Surgery

A $68$-year-old man presents to the emergency department complaining of severe, progressively worsening mid-back pain over the past $2$ weeks. He has a history of advanced prostate cancer treated with androgen deprivation therapy. Over the past $24$ hours, he has developed difficulty walking and states his legs feel "heavy." He also reports an inability to urinate since early this morning. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $142/88\text{ mm Hg}$, and pulse is $88\text{/min}$. On physical examination, there is exquisite point tenderness to palpation over the T10 spinous process. Neurologic examination reveals $3/5$ motor strength in the lower extremities bilaterally. There is decreased sensation to pinprick and temperature below the umbilicus. Deep tendon reflexes are $3+$ at the patellae and ankles, with bilateral upgoing plantar responses. Post-void residual ultrasound shows $550\text{ mL}$ of urine in the bladder. Which of the following is the most appropriate initial step in the management of this patient?

A $44$-year-old woman is evaluated on postoperative day $3$ following a complicated total abdominal hysterectomy for severe endometriosis. She reports new-onset right-sided flank pain and nausea. Her temperature is $38.2^{\circ}\text{C}$ ($100.8^{\circ}\text{F}$). Physical examination reveals right costovertebral angle tenderness. The pelvic surgical drain has abruptly started outputting a high volume of clear, watery fluid. Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order for managing this patient's suspected urologic complication.

A 24-year-old man is brought to the emergency department via ambulance after diving into a shallow lake and striking his head on the bottom. He is conscious but reports an inability to move his arms or legs. His blood pressure is 78/40 mm Hg, heart rate is 52/min, and respiratory rate is 22/min. Oxygen saturation is 94% on room air. He has flaccid paralysis and absent reflexes in all four extremities. Arrange the following steps in the optimal sequence for the management of this patient, from initial presentation to definitive treatment.

An unrestrained 24-year-old male driver is transported to the emergency department following a severe front-end motor vehicle collision. Primary survey reveals a hemodynamically stable patient with an isolated right lower extremity injury. The right leg is visibly shortened, adducted, and internally rotated. The patient complains of intense right hip pain and an inability to feel the top of his right foot. Subsequent imaging during his care reveals an incongruent joint space requiring definitive operative intervention. Arrange the following steps in the correct chronological order for the optimal, evidence-based management of this patient's injury.

A 24-year-old man is admitted to the hospital after sustaining a closed midshaft femur fracture in a motor vehicle collision. The fracture is temporarily immobilized in a traction splint, and he is scheduled for operative fixation the following morning. Twelve hours after admission, he develops sudden-onset shortness of breath, confusion, and a new petechial rash over his chest and anterior neck. Vital signs show a temperature of 37.6°C (99.7°F), blood pressure of 122/78 mmHg, pulse of 118/min, and respirations of 26/min. Oxygen saturation is 86% on room air. Auscultation of the lungs reveals scattered bilateral crackles. Which of the following is the most likely diagnosis?

A 46-year-old female patient is referred for surgical evaluation of an asymptomatic neck mass. She noticed the swelling while looking in the mirror two weeks ago. She denies any recent changes in weight, bowel habits, or temperature tolerance. Vital signs are within normal limits. Neck palpation confirms a $2.8\text{-cm}$, firm, well-circumscribed mass localized to the right thyroid lobe. The remainder of the gland is normal, and there is no palpable cervical lymphadenopathy. Laboratory results are as follows:

Thyroid-stimulating hormone (TSH): $0.02\text{ }\mu\text{U/mL}$ (Reference: $0.4-4.0\text{ }\mu\text{U/mL}$)
Free thyroxine (T4): $1.5\text{ ng/dL}$ (Reference: $0.9-1.7\text{ ng/dL}$)
Triiodothyronine (T3): $3.1\text{ pg/mL}$ (Reference: $2.3-4.2\text{ pg/mL}$)

Which of the following is the most appropriate next step in evaluating this patient's condition?

An $82$-year-old woman is evaluated in the emergency department due to a $48$-hour history of worsening abdominal distension, failure to pass flatus, and multiple episodes of dark green emesis. She resides in a skilled nursing facility and has a medical history significant for Alzheimer dementia, coronary artery disease, and an open appendectomy performed three decades ago. On presentation, she appears lethargic and moans during the examination. Temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), pulse is $124/\text{min}$, blood pressure is $88/54\text{ mm Hg}$, and respirations are $24/\text{min}$. Physical examination reveals a markedly distended abdomen that is rigid, with diffuse rebound tenderness and absent bowel sounds.

Laboratory results:
Leukocyte count: $18,200/\text{mm}^3$ with $15\%$ bands
Serum lactate: $5.4\text{ mmol/L}$
Creatinine: $1.8\text{ mg/dL}$

An upright chest radiograph reveals no free air under the diaphragm. A supine abdominal radiograph demonstrates multiple dilated loops of small bowel with prominent air-fluid levels and a paucity of colonic gas. After initiating aggressive intravenous fluid resuscitation, the patient's blood pressure remains $90/56\text{ mm Hg}$.

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

A 42-year-old woman is brought to the emergency department after tripping over a rug and falling onto her right arm. She reports severe, sharp pain and an inability to move her right arm. Vital signs are within normal limits. Physical examination reveals an obvious deformity and significant swelling over the middle-to-distal aspect of the right arm. Upon initial neurologic evaluation, the patient has full active extension of the right wrist and fingers, and sensation is intact to light touch over the dorsum of the hand. Radial and ulnar pulses are 2+ and capillary refill is less than 2 seconds. Radiographs of the right upper extremity demonstrate a displaced, spiral fracture of the distal third of the humeral shaft. An orthopedic surgery resident performs a closed reduction in the emergency department, and a coaptation splint is applied. Post-reduction radiographs confirm acceptable alignment of the fracture fragments. Thirty minutes later, during a routine neurovascular reassessment, the patient is unable to actively extend her right wrist or digits. Sensation to light touch is now decreased over the dorsal web space between the thumb and index finger. Distal pulses remain 2+. Which of the following is the most appropriate next step in management?

A 64-year-old man is evaluated in the emergency department for severe perineal and scrotal pain that has progressively worsened over the past 3 days. He has a history of poorly controlled type 2 diabetes mellitus and hypertension. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), pulse is $118/\text{min}$, respirations are $22/\text{min}$, and blood pressure is $88/54\text{ mmHg}$. Physical examination reveals a markedly swollen, tense, and erythematous scrotum with areas of dusky discoloration. Palpation of the scrotum and perineum elicits exquisite tenderness, and distinct crepitus is felt within the subcutaneous tissues. Laboratory studies show a leukocyte count of $24,000/\text{mm}^3$ and a serum glucose of $310\text{ mg/dL}$. Which of the following is the most appropriate next step in the management of this patient?

Match each of the following patient clinical presentations and breast biopsy findings with the most appropriate definitive surgical management.

An 80-year-old female resident of a nursing facility is brought to the emergency department due to a sudden onset of generalized, severe abdominal pain. She has a history of persistent atrial fibrillation and is not taking anticoagulants due to a prior gastrointestinal bleed. On examination, her blood pressure is $75/45 \text{ mmHg}$, heart rate is $125/\text{min}$ and irregular, and respiratory rate is $24/\text{min}$. Her abdomen is rigid with diffuse involuntary guarding and rebound tenderness. Arterial blood gas shows a pH of $7.15$, $\text{pCO}_2$ of $30 \text{ mmHg}$, and calculated bicarbonate of $10 \text{ mEq/L}$. Serum lactate is $8.5 \text{ mmol/L}$. Which of the following is the most appropriate next step in the management of this patient?

A $29$-year-old primigravida at $15$ weeks of gestation is referred to the surgery clinic for evaluation of a prominent neck lump. The patient noticed the swelling three weeks ago. She reports mild heat intolerance and fatigue but feels otherwise well. Her pregnancy has been uncomplicated. Vital signs show a blood pressure of $118/74\text{ mmHg}$ and a pulse of $92\text{/min}$. Physical examination reveals a palpable, firm, $2.4\text{-cm}$ nodule in the right thyroid lobe that moves with swallowing. No cervical lymphadenopathy is present.

Laboratory results are as follows:
Thyroid-stimulating hormone (TSH): $0.05\text{ \mu U/mL}$ (Reference: $0.4\text{--}4.0\text{ \mu U/mL}$)
Free thyroxine (T4): $1.9\text{ ng/dL}$ (Reference: $0.8\text{--}1.8\text{ ng/dL}$)

An ultrasound of the neck shows a $2.4\text{-cm}$ completely solid, hypoechoic nodule with irregular borders and internal microcalcifications in the right lobe.

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

A 68-year-old man is evaluated on postoperative day 2 following an elective open repair of a 6.5-cm infrarenal abdominal aortic aneurysm. The surgical note indicates that the inferior mesenteric artery was ligated during the procedure. Today, the patient reports the sudden onset of left lower quadrant abdominal pain. Two hours later, he passes a large volume of bright red blood mixed with stool. His temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $135/85\text{ mmHg}$, heart rate is $98/\text{min}$, and respiratory rate is $16/\text{min}$. Physical examination reveals a soft abdomen with tenderness to deep palpation in the left lower quadrant. There is no rebound tenderness, guarding, or rigidity. The midline laparotomy incision is clean and intact. Laboratory studies show a leukocyte count of $14,500/\text{mm}^3$ and a serum lactate level of $1.8\text{ mmol/L}$ (normal: $0.5-2.2\text{ mmol/L}$). Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation and imaging findings of an adrenal mass with the most appropriate definitive surgical and perioperative management plan.

Match the following distinct clinical presentations of urologic conditions to their most appropriate definitive surgical management.

A 32-year-old female arrives at the emergency department via ambulance following a high-speed motorcycle collision. She has an obvious deformity of her right lower leg with a 5-centimeter laceration over the anterior tibia exposing the underlying bone. Active oozing of blood is noted. Her pulse is 110/min, and blood pressure is 115/75 mm Hg. Arrange the following initial management steps in the most appropriate chronological sequence for this patient.

A $59$-year-old man is brought to the emergency department by his partner due to severe, worsening perineal pain and fever for the past $24\text{ hours}$. He has a $15$-year history of type 2 diabetes mellitus complicated by peripheral neuropathy and nephropathy. His temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $84/52\text{ mmHg}$, pulse is $124/\text{min}$, and respirations are $22/\text{min}$. Physical examination demonstrates marked edema, erythema, and induration of the perineum extending to the scrotum. There are several dark, necrotic bullae on the scrotal skin. Palpation of the affected area elicits exquisite pain and a crackling sensation beneath the skin. Laboratory evaluation reveals a leukocyte count of $26,000/\text{mm}^3$ and serum glucose of $480\text{ mg/dL}$. Aggressive intravenous fluid resuscitation and broad-spectrum antibiotics are initiated. Which of the following is the most appropriate next step in management?

A 45-year-old woman is brought to the emergency department by her partner after developing a sudden-onset, excruciating headache that she describes as the 'worst of my life.' The headache began abruptly 2 hours ago while she was moving heavy furniture. She reports associated nausea, photophobia, and neck stiffness. Her temperature is 37.2°C (99.0°F), blood pressure is 168/94 mm Hg, and heart rate is 92/min. Neurological examination reveals intact cranial nerves, normal symmetric strength, and marked nuchal rigidity. Arrange the following steps in the correct sequential order for the standard diagnostic workup and definitive management of this patient, assuming the initial head imaging does not demonstrate an acute hemorrhage.

Match each specific orthopedic injury with the most likely corresponding acute neurovascular physical exam finding.

A $58$-year-old right-handed woman is evaluated in the neurosurgical intensive care unit for new-onset neurological deficits. Six days ago, she underwent successful surgical clipping of a ruptured left middle cerebral artery aneurysm. Her postoperative course had been uncomplicated, and she was alert and fully oriented this morning. Over the past hour, the nurse noted that the patient developed right-sided hemiparesis and severe expressive aphasia.

Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate is $82 \text{ /min}$, blood pressure is $112/74 \text{ mmHg}$, and respirations are $14 \text{ /min}$. A stat noncontrast head computed tomography scan shows expected postsurgical changes with no evidence of new hemorrhage, cerebral edema, or hydrocephalus. Continuous electroencephalography reveals no epileptiform activity.

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