Surgery

A $34$-year-old man is evaluated in the trauma bay following a high-velocity motorcycle collision. He is hemodynamically stable. Examination reveals lower abdominal guarding, diffuse tenderness, and a displaced pelvic ring fracture. Retrograde urethrography demonstrates an intact urethra, allowing for the safe placement of a urethral catheter, which yields $300\text{ mL}$ of frankly bloody urine. A subsequent retrograde CT cystography demonstrates contrast extravasation into the paracolic gutters and outlining loops of small bowel.

Arrange the following surgical management steps in the most appropriate chronological sequence for this patient.

Match each patient's postoperative clinical presentation with the most appropriate next step in management.

A forestry worker is airlifted to a regional trauma center after his leg was crushed under a fallen tree. Due to the remote location and complex extrication, the total time from the moment of injury to hospital arrival is seven and a half hours. Upon arrival, the patient is hemodynamically stable. The primary survey is otherwise clear, but the secondary survey reveals a grossly deformed left knee with an open, highly comminuted distal femur fracture (Gustilo-Anderson IIIB). The left foot is pale, poikilothermic, and cold, with absent dorsalis pedis and posterior tibial pulses. Capillary refill is completely absent. A rapid on-table angiogram in the hybrid operating room demonstrates a complete transection of the popliteal artery with no distal flow. The trauma and orthopedic surgery teams prepare for immediate combined surgical intervention.

Arrange the following operative steps in the most appropriate chronological sequence for this patient's limb salvage.

A 28-year-old woman is brought to the emergency department 20 minutes after being involved in a high-speed motor vehicle collision. She is in severe respiratory distress and complains of sharp, right-sided chest pain. Her blood pressure is 70/40 mmHg, pulse is 135/min, and respirations are 32/min. Pulse oximetry shows an oxygen saturation of 84% on room air. Physical examination reveals a deviated trachea to the left, markedly distended neck veins, and absent breath sounds over the right hemithorax. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation with the most likely underlying pathophysiologic diagnosis.

A 52-year-old man is brought to the emergency department complaining of agonizing mid-back pain that has progressively worsened over the last week. This morning, he developed weakness in both legs and has been unable to urinate for the past 12 hours. He has a history of type 2 diabetes mellitus and had a central venous catheter placed during a hospitalization two weeks ago. His temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure is $118/76\text{ mmHg}$, and heart rate is $105/\text{min}$. Neurologic examination shows $2/5$ strength in the bilateral lower extremities, patellar hyperreflexia, a sensory loss below the umbilicus, and a palpably distended bladder.

Arrange the following management steps in the most appropriate sequential order for this patient:

Match each clinical presentation with the most likely corresponding vascular diagnosis.

An emergency medicine physician is evaluating a 54-year-old woman complaining of severe right-sided back pain, rigors, and vomiting that began 12 hours ago. Her temperature is 39.2°C (102.6°F), blood pressure is 88/55 mmHg, and pulse is 115/min. Physical examination reveals exquisite right costovertebral angle tenderness. Laboratory testing shows a leukocyte count of 18,000/mm³. Arrange the following management steps in the most appropriate chronological sequence for this patient.

During a routine health maintenance examination, a 64-year-old African American male reports waking up twice a night to urinate but denies any dysuria, gross hematuria, or bone pain. His past medical history is notable for hypertension managed with lisinopril. Vital signs are within normal limits. Digital rectal examination reveals a distinctly firm, irregularly shaped nodule on the left posterior lobe of the prostate gland. Laboratory studies show a serum prostate-specific antigen (PSA) level of 7.8 ng/mL. Which of the following is the most appropriate next step in the management of this patient?

A $45$-year-old man is brought to the emergency department by his partner due to the sudden onset of an excruciating headache that began $2$ hours ago. He also reports blurred vision and extreme dizziness upon standing. The patient's medical history is significant for a known $2.5\text{-cm}$ nonfunctioning pituitary macroadenoma, which was being evaluated for elective surgical resection. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $82/50\text{ mmHg}$, pulse is $118/\text{min}$, and respirations are $16/\text{min}$. Physical examination reveals bitemporal hemianopsia and a dilated, unresponsive right pupil with a "down and out" gaze deviation. The patient is lethargic but oriented. Which of the following is the most appropriate next step in the management of this patient?

Match the following classic clinical presentations with their most likely vascular surgical diagnosis.

An overweight 13-year-old boy is brought to the outpatient clinic by his parents. He has been complaining of left knee and anterior thigh pain for the past four weeks. The pain is described as a dull ache that worsens with physical activity such as walking or climbing stairs. There is no history of recent trauma, falls, or fever. His temperature is 36.8°C (98.2°F), blood pressure is 112/72 mm Hg, pulse is 76/min, and respirations are 14/min. His body mass index is 31 kg/m². Upon physical evaluation, the left knee shows no evidence of erythema, swelling, or localized tenderness, and ligamentous testing is normal. However, examination of the left hip reveals restricted internal rotation. Furthermore, when the clinician passively flexes the patient's left hip, the thigh obligatorily rotates outward. Motor strength and sensory examinations in the lower extremities are unremarkable. Distal pulses are palpable and equal bilaterally.

Which of the following is the most appropriate next step in management?

A 75-year-old woman is evaluated in the emergency department for severe right leg pain. She was found on the floor of her apartment after a fall and was last known to be in her usual state of health 36 hours ago. Medical history is significant for hypertension, prior myocardial infarction, and paroxysmal atrial fibrillation for which she has not been taking anticoagulation. Her temperature is 37.1°C (98.8°F), blood pressure is 142/86 mmHg, and heart rate is 112/min and irregularly irregular. On physical examination, the right lower extremity is pale, cold to the touch, and mottled from the toes extending up to the mid-thigh. There is complete absence of sensation below the right knee. The patient is unable to move her right ankle or toes, and the calf muscles are remarkably firm and rigid to palpation. Handheld Doppler ultrasound evaluation reveals absent arterial and venous signals in the right popliteal, dorsalis pedis, and posterior tibial vessels. Which of the following is the most appropriate next step in management?

A 50-year-old woman presents to the surgery clinic for evaluation of a right-sided neck swelling. She first noticed the lump 6 months ago, and it has slowly enlarged. She denies dysphagia, hoarseness, palpitations, or weight changes. Vital signs are within normal limits. Physical examination reveals a 3.5-cm, firm, mobile, non-tender nodule in the right lobe of the thyroid gland. There is no cervical lymphadenopathy. Laboratory studies show a serum thyroid-stimulating hormone (TSH) level of 2.1 mU/L (normal: 0.4-4.0 mU/L). Neck ultrasound demonstrates a 3.5-cm solid, isoechoic nodule with smooth margins and a thin hypoechoic halo. A fine-needle aspiration (FNA) biopsy is performed. Cytology reveals a hypercellular aspirate composed of microfollicles with scant colloid, and the pathologist reports the lesion as a 'follicular neoplasm'. What is the most appropriate next step in the management of this patient?

Following a three-day hospitalization for conservative management of a small bowel obstruction, a $72$-year-old man undergoes acute clinical deterioration. He initially presented with colicky abdominal pain, profound abdominal distension, and failure to pass flatus. His medical history includes paroxysmal atrial fibrillation, for which he takes apixaban, and his surgical history includes a sigmoid colectomy performed a decade ago for complicated diverticulitis. During the first $48$ hours of admission, he remained afebrile and was managed with a nasogastric tube and intravenous crystalloid therapy.

Over the past $2$ hours, the patient's nurse reports that he has become increasingly lethargic and is now complaining of a new, relentless, severe aching pain centered in the periumbilical region.

Current vital signs demonstrate a temperature of $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), a blood pressure of $92/54\text{ mmHg}$, a pulse of $122/\text{min}$, and respirations of $24/\text{min}$.

Physical examination reveals a markedly distended, rigid abdomen with absent bowel sounds. Palpation elicits involuntary muscle spasm and severe pain upon quick release of the examining hand.

Laboratory evaluation reveals:
Leukocyte count: $18,200/\text{mm}^3$ ($85\%$ neutrophils, $10\%$ bands)
Serum bicarbonate: $16\text{ mEq/L}$
Lactate: $4.2\text{ mmol/L}$

Which of the following is the most appropriate next step in the management of this patient?

Match the following common musculoskeletal injuries with their classic, diagnostic physical examination findings.

Following a high-velocity motorcycle collision, a 26-year-old male driver is evaluated in the trauma resuscitation unit. He was intubated at the scene for a Glasgow Coma Scale score of 7. On arrival, his temperature is $35.2^\circ\text{C}$ ($95.4^\circ\text{F}$), blood pressure is $85/50 \text{ mm Hg}$, and heart rate is $132\text{/min}$. Primary survey reveals decreased breath sounds on the right. A tube thoracostomy is performed, yielding a large rush of air and $50 \text{ mL}$ of blood; his oxygen saturation improves to 94%, but his blood pressure remains $90/55 \text{ mm Hg}$ despite the rapid infusion of $2 \text{ L}$ of warmed crystalloids. The focused assessment with sonography for trauma (FAST) is negative. A pelvic radiograph shows no fractures. Examination of the extremities reveals a grossly deformed and swollen right thigh with intact overlying skin. Dorsalis pedis and posterior tibial pulses are palpable and symmetric. A portable chest radiograph shows bilateral patchy infiltrates and a right-sided chest tube in good position. A radiograph of the right femur confirms a comminuted diaphyseal fracture. Arterial blood gas analysis reveals a pH of $7.21$, $\text{PaCO}_2$ of $48 \text{ mm Hg}$, $\text{PaO}_2$ of $65 \text{ mm Hg}$, and a lactate level of $5.2 \text{ mmol/L}$. Which of the following is the most appropriate next step in the management of this patient's femur fracture?

A 62-year-old male arrives at the urgent care clinic reporting sudden, agonizing pain in his left lower extremity that started two hours prior. His medical background is significant for an anterior wall myocardial infarction three weeks ago. Vital signs are within normal limits. Examination of the left lower extremity reveals a pale, cool leg distal to the knee. While the left femoral pulse is easily palpable, both popliteal and pedal pulses are absent. The patient exhibits a newly developed inability to dorsiflex his left foot and reports numbness over the dorsal aspect. Bedside handheld continuous-wave Doppler demonstrates absent arterial signals in the distal left leg. An intravenous heparin infusion is promptly started. Which of the following is the most appropriate next step in management?

During a high school basketball game, a $16$-year-old adolescent boy suddenly experiences excruciating left-sided scrotal pain and collapses on the court. He is immediately transported to the hospital by his coach. The patient reports severe, unrelenting pain radiating to his lower abdomen and has vomited twice in the triage area. He is otherwise healthy and takes no medications. Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $130/85\text{ mm Hg}$, and a pulse of $110/\text{min}$. Physical examination reveals a swollen, exquisitely tender left hemiscrotum. The left testicle is firm, positioned higher than the right, and lies in a transverse orientation. The cremasteric reflex is absent on the left side but intact on the right. There is no relief of pain upon manual elevation of the scrotum. Which of the following is the most appropriate next step in the management of this patient?

A rapid response is called for a $65$-year-old man on the medical ward due to acute hemodynamic deterioration. Two days prior, he was admitted for severe right flank pain. A non-contrast computed tomography (CT) scan at admission demonstrated a $9$-mm calculus in the proximal right ureter with moderate hydroureteronephrosis. At that time, he was afebrile and hemodynamically stable. A urine culture was obtained, and he was started on intravenous normal saline and empirical ceftriaxone.

Currently, his temperature is $39.6^\circ\text{C}$ ($103.3^\circ\text{F}$), blood pressure is $82/50$ mm Hg, and pulse is $128$/min. He is lethargic, diaphoretic, and minimally responsive. Physical examination reveals exquisite right costovertebral angle tenderness. Laboratory studies show a leukocyte count of $22,000/\text{mm}^3$ with $15\%$ bandemia. The admission urine culture has just resulted, demonstrating $>10^5$ CFU/mL of *Escherichia coli*. Susceptibility testing indicates the organism is sensitive to cefazolin, ceftriaxone, and ciprofloxacin, but resistant to ampicillin. He is receiving aggressive intravenous fluid resuscitation.

Which of the following is the most appropriate next step in management?