Surgery

A $53$-year-old woman comes to the breast surgery clinic due to a $4$-week history of right breast swelling, redness, and heaviness. She has no history of trauma, breast disease, or family history of cancer. She is postmenopausal. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$). Physical examination of the right breast reveals diffuse erythema, warmth, and marked skin edema with prominent pores, giving the skin a dimpled appearance. The breast is firm and enlarged, but no discrete, fluctuant mass is palpable. Firm, mobile right axillary lymph nodes are present. A $10$-day course of oral cephalexin prescribed by her primary care physician resulted in no clinical improvement. Diagnostic mammography and ultrasonography obtained prior to the visit show diffuse skin thickening and stromal edema, but no underlying localized mass or fluid collection. Which of the following is the most appropriate next step in management?

A $5$-year-old boy is brought to the emergency department by his parents because he has been refusing to walk since this morning. The parents report that he had a subjective fever at home yesterday but otherwise has been healthy. His immunizations are up to date. His temperature is $38.9^\circ\text{C}$ ($102^\circ\text{F}$), blood pressure is $100/60\text{ mmHg}$, pulse is $115/\text{min}$, and respirations are $22/\text{min}$. Physical examination reveals a distressed child who cries when the right leg is touched. The right hip is held in a position of flexion, abduction, and external rotation. Any attempted passive range of motion of the right hip elicits severe pain. Laboratory studies show a leukocyte count of $16,500/\text{mm}^3$ and an erythrocyte sedimentation rate (ESR) of $55\text{ mm/hr}$. Radiographs of the pelvis and bilateral hips demonstrate no fractures or structural abnormalities. Which of the following is the most appropriate next step in management?

A 58-year-old right-handed female visits her primary care physician due to recurrent episodes of lightheadedness, blurred vision, and unsteady gait. She noticed these episodes over the past three months, specifically mentioning they occur when she spends extended time brushing her hair or organizing items on high shelves. Once she rests her arms, the symptoms resolve within minutes. Medical history includes type 2 diabetes mellitus, hypercholesterolemia, and a 30-pack-year smoking habit. Current medications are metformin and atorvastatin. Vital signs show a heart rate of 78/min and a respiratory rate of 14/min. Blood pressure is 148/90 mmHg in the right upper extremity and 112/74 mmHg in the left upper extremity. Palpation of the radial pulses reveals a delayed and diminished pulse on the left compared to the right. Auscultation of the left supraclavicular fossa demonstrates a harsh systolic murmur. Neurological examination is unremarkable at rest. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

A 72-year-old man is brought to the emergency department by emergency medical services due to the sudden onset of massive, painless hematochezia that began 2 hours ago. His past medical history includes hypertension, hyperlipidemia, and coronary artery disease. On arrival, he is pale and diaphoretic. His temperature is 37.1°C (98.8°F), heart rate is 132/min, blood pressure is 82/50 mmHg, and respiratory rate is 22/min. Physical examination reveals a soft, non-tender, and non-distended abdomen. Digital rectal examination demonstrates gross bright red blood without palpable masses. Initial laboratory studies show a hemoglobin of 7.8 g/dL (baseline 13.5 g/dL), blood urea nitrogen (BUN) of 42 mg/dL, and serum creatinine of 1.1 mg/dL.

Arrange the following interventions in the most appropriate sequential order for the optimal algorithmic management of this patient's acute presentation.

Correlate the following clinical scenarios with their most likely intracranial hemorrhage diagnosis.

A 75-year-old woman with a history of heart failure and atrial fibrillation is brought to the emergency department due to the sudden onset of severe, diffuse abdominal pain. She reports nausea and one episode of non-bloody emesis. Her temperature is 37.8°C (100.0°F), blood pressure is 135/85 mmHg, pulse is 115/min and irregularly irregular, and respiratory rate is 18/min. On physical examination, her abdomen is soft, non-distended, and mildly tender to deep palpation, without rebound tenderness or guarding. Bowel sounds are decreased. Laboratory studies reveal a leukocyte count of 18,000/mm³ and a serum lactate level of 4.5 mmol/L. Arrange the following steps in the most appropriate chronological sequence for the definitive management of this patient.

An ambulatory 61-year-old man presents to his primary care provider reporting a persistent feeling of heaviness and a dull ache in his right scrotum that he first noticed three weeks ago. He denies any history of scrotal trauma, dysuria, gross hematuria, urgency, or fevers. His medical history includes essential hypertension and hyperlipidemia, both well-controlled with medication. He has a 40-pack-year smoking history. His temperature is 37.1°C (98.8°F), blood pressure is 138/86 mmHg, and pulse is 76/min. Physical examination of the genitalia reveals a soft, irregular, tortuous mass in the right hemiscrotum that feels like a 'bag of worms.' When the patient is asked to lie in the supine position, the mass does not decrease in size. Both testicles are palpable, symmetric, and without firm nodules. Transillumination of the scrotum is negative. Which of the following is the most appropriate next step in management?

Emergency medical services transport a 32-year-old female to the hospital due to altered mental status and intractable vomiting. According to her husband, she developed a relentless, diffuse headache yesterday, which has progressively worsened. Her past medical history is notable for congenital hydrocephalus secondary to aqueductal stenosis, managed with a ventriculoperitoneal shunt that was last revised 15 years ago. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $165/95\text{ mm Hg}$, and pulse is $52/\text{min}$. On physical examination, the patient is somnolent but arouses to loud verbal stimuli. Pupils are sluggishly reactive to light, and fundoscopy reveals bilateral papilledema. She exhibits an inability to look upward. Which of the following is the most appropriate next step in management?

Brain herniation syndromes occur when elevated intracranial pressure forces brain parenchyma across rigid intracranial structures. Based on the clinical features provided, match each clinical presentation to its corresponding specific brain herniation syndrome.

An $18$-year-old man is brought to the emergency department due to severe, sudden-onset left scrotal pain that woke him from sleep $4$ hours ago. The pain is continuous and radiates to his left lower abdomen. He reports one episode of vomiting and significant nausea. One month ago, he had a similar episode of left-sided scrotal pain that resolved spontaneously after $30$ minutes. He has no significant past medical history and is not sexually active. His temperature is $37.2^\circ$ C ($99.0^\circ$ F), blood pressure is $135/85$ mm Hg, and pulse is $108$/min. On physical examination, the left hemiscrotum is swollen, erythematous, and exquisitely tender to palpation. The left testis is positioned higher in the scrotum compared to the right and has a transverse orientation. The cremasteric reflex is absent on the left side but intact on the right. Elevation of the left testis exacerbates the pain. Urinalysis reveals $8$ WBCs/hpf, $0$ RBCs/hpf, and negative leukocyte esterase and nitrites. Which of the following is the most appropriate next step in management?

Match each of the following orthopedic physical examination maneuvers with the underlying structural injury it is most specifically designed to evaluate.

Various urologic conditions present with specific symptoms and physical findings that dictate precise clinical algorithms. Which surgical intervention or initial operative management is most appropriate for each of the following patient profiles?

A 35-year-old man is evaluated in the surgical oncology clinic after a painless neck mass was discovered during a routine physical examination. Ultrasound of the neck reveals a 2.5-cm solid, hypoechoic nodule in the right thyroid lobe. Subsequent fine-needle aspiration biopsy of the nodule demonstrates sheets of polygonal cells in an amyloid stroma, confirming medullary thyroid carcinoma. During the interview, the patient reports a 6-month history of episodic severe headaches, profuse sweating, and palpitations. His vital signs show a blood pressure of 168/98 mmHg and a heart rate of 110/min. His family history is notable for a father who died of a hypertensive stroke at age 45. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for this patient's management.

A 54-year-old woman is brought to the emergency department for severe right flank pain, nausea, and chills over the past 24 hours. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $86/52 \text{ mmHg}$, pulse is $122/\text{min}$, and respirations are $22/\text{min}$. Physical examination demonstrates marked right costovertebral angle tenderness. Laboratory studies reveal a leukocyte count of $19,500/\text{mm}^3$ and a serum creatinine of $1.8 \text{ mg/dL}$. A non-contrast computed tomography scan of the abdomen and pelvis demonstrates an $8\text{-mm}$ calculus in the proximal right ureter with associated moderate hydronephrosis and perinephric fat stranding. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A $56$-year-old postmenopausal woman is evaluated in the clinic after a routine metabolic panel showed an elevated serum calcium level. She has no history of nephrolithiasis, bone fractures, abdominal pain, or psychiatric symptoms. She takes no medications and has no family history of significant medical conditions. Her vital signs are within normal limits. Physical examination reveals no palpable neck masses or other abnormalities.

Laboratory results are as follows:
Serum calcium: $11.2\text{ mg/dL}$ (normal: $8.4-10.2\text{ mg/dL}$)
Serum albumin: $4.0\text{ g/dL}$ (normal: $3.5-5.0\text{ g/dL}$)
Serum phosphorus: $2.3\text{ mg/dL}$ (normal: $2.5-4.5\text{ mg/dL}$)
Intact parathyroid hormone: $92\text{ pg/mL}$ (normal: $10-65\text{ pg/mL}$)
Serum creatinine: $0.9\text{ mg/dL}$ (normal: $0.6-1.2\text{ mg/dL}$)
$25$-hydroxyvitamin D: $35\text{ ng/mL}$ (normal: $20-50\text{ ng/mL}$)

A dual-energy x-ray absorptiometry (DEXA) scan reveals a T-score of $-2.6$ at the lumbar spine and $-1.8$ at the femoral neck.

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

A $68$-year-old man is brought to the emergency department complaining of sudden, severe left flank pain that began two hours ago. He also reports a brief episode of lightheadedness just prior to arrival. His medical history is significant for essential hypertension, type 2 diabetes mellitus, and a $40$-pack-year smoking history. Initially, his temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), pulse is $98/\text{min}$, blood pressure is $112/74\text{ mmHg}$, and respirations are $18/\text{min}$. Physical examination reveals a palpable, slightly tender, pulsatile mass in the periumbilical region. A focused assessment with sonography for trauma (FAST) demonstrates a $6.5\text{-cm}$ dilation of the infrarenal abdominal aorta and free fluid in the hepatorenal recess. Ten minutes later, the patient becomes progressively lethargic; his repeat blood pressure is $68/42\text{ mmHg}$, and his pulse is $132/\text{min}$. Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old male is brought to the emergency department after a high-speed motor vehicle collision. His initial Glasgow Coma Scale score is 6 (E1, V1, M4), and he is promptly intubated for airway protection. A non-contrast head CT demonstrates extensive traumatic subarachnoid hemorrhage, a large right-sided acute subdural hematoma, and significant midline shift. The neurosurgery team discusses the risk of various herniation syndromes based on the imaging findings. Match the following brain herniation syndromes with their classic neurologic or vascular consequences.

Emergency medical services arrive with a 68-year-old male patient who experienced the sudden onset of severe, sharp chest pain radiating to his back approximately 45 minutes ago. Shortly after the pain began, the patient developed profound shortness of breath. His wife reports his medical history is significant for poorly controlled hypertension and severe chronic obstructive pulmonary disease (COPD), managed with a daily tiotropium inhaler.

Upon arrival in the resuscitation bay, he is in severe respiratory distress and utilizing accessory muscles to breathe. His temperature is 37.0°C (98.6°F), blood pressure is 88/50 mm Hg in the right arm and 112/68 mm Hg in the left arm, pulse is 118/min, and respirations are 28/min. Pulse oximetry shows 87% on room air.

Physical examination reveals markedly elevated jugular venous pressure. Lung auscultation demonstrates diffuse bilateral crackles and prominent expiratory wheezing. Cardiac auscultation reveals a prominent, early decrescendo diastolic murmur heard best at the right second intercostal space. A bedside chest radiograph shows a widened mediastinum and bilateral alveolar infiltrates.

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

A 42-year-old man is brought to the emergency department after a high-speed head-on motor vehicle collision. He complains of severe chest and mid-back pain. His blood pressure is 165/90 mm Hg, pulse is 112/min, and respirations are 22/min. Oxygen saturation is 96% on room air. The primary survey is complete; his airway is patent, and breath sounds are equal bilaterally. There is a visible seatbelt sign across his chest. Arrange the following steps in the most appropriate chronological sequence for diagnosing and managing this patient's suspected blunt thoracic aortic injury.

Match each clinical presentation to the most appropriate cardiothoracic or vascular diagnosis.