Surgery

A 55-year-old woman presents to the surgical clinic for evaluation of a neck mass that she noticed two weeks ago while swallowing. She reports a 6-month history of profound fatigue, cold intolerance, dry skin, and a 4.5-kg (10-lb) weight gain. Her past medical history is significant for a severe postpartum hemorrhage requiring multiple blood transfusions 20 years ago. She takes no daily medications. Her temperature is 36.5°C (97.7°F), blood pressure is 110/70 mmHg, and pulse is 58/min. Physical examination reveals a 2.5-cm, firm, non-tender, mobile nodule in the right lobe of the thyroid gland. There is no cervical lymphadenopathy.

Ultrasound of the neck demonstrates a 2.5-cm solid, markedly hypoechoic nodule with irregular margins in the right thyroid lobe. Which of the following is the most appropriate next step in the management of this patient's thyroid nodule?

Emergency medical services arrive at the trauma bay with a 78-year-old man who developed sudden, excruciating, and diffuse abdominal pain two hours ago. He has a known history of severe coronary artery disease and noncompliant medication management for atrial fibrillation. Upon arrival, he appears ashen, profoundly lethargic, and diaphoretic. Vital signs include a temperature of 37.8°C, an irregularly irregular pulse of 132/min, a blood pressure of 82/50 mm Hg, and respirations of 24/min. Abdominal examination demonstrates striking rigidity with widespread guarding and rebound tenderness in all four quadrants. Initial point-of-care testing reveals a serum lactate of 9.4 mmol/L and a marked leukocytosis of 22,000/mm³. An electrocardiogram shows atrial fibrillation with rapid ventricular response. Arrange the following interventions in the most appropriate chronological sequence for the definitive management of this patient.

A $62$-year-old postmenopausal woman is evaluated in the clinic for hypercalcemia found on routine laboratory screening. She is entirely asymptomatic and has no history of nephrolithiasis, fragility fractures, or abdominal pain. Her serum calcium is $10.9$ mg/dL (normal range: $8.4-10.2$ mg/dL), albumin is $4.0$ g/dL, and intact parathyroid hormone (PTH) is $115$ pg/mL (normal range: $10-65$ pg/mL). Renal function is normal. Arrange the following steps in the most appropriate chronological sequence for the diagnostic workup and surgical management of this patient.

Following a high-speed motorcycle collision, a male patient in his mid-twenties arrives at the trauma resuscitation bay. He is lethargic and responds only to painful stimuli. Vital signs include a blood pressure of $76/40\text{ mmHg}$, heart rate of $135/\text{min}$, respiratory rate of $26/\text{min}$, and temperature of $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$). Physical assessment reveals profound ecchymosis over the suprapubic and perineal areas, accompanied by visible blood at the urethral meatus. Gentle anteroposterior compression of the iliac crests demonstrates gross mechanical instability of the pelvic ring. A bedside focused assessment with sonography for trauma (FAST) shows no anechoic fluid in the peritoneal spaces. Massive transfusion protocol is initiated via two large-bore peripheral intravenous catheters. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation of urolithiasis with the most appropriate definitive surgical or procedural management.

A triage nurse immediately calls a surgical code for a patient who just collapsed in the hospital waiting room. The patient, a 72-year-old male with a history of hypertension and tobacco use, was initially presenting for evaluation of sudden, tearing flank pain. Vital signs on the monitor show a heart rate of 128/min and a blood pressure of 72/38 mm Hg. The patient is confused and visibly diaphoretic. Physical examination reveals a large, expansile periumbilical mass. Arrange the following steps in the most appropriate chronological sequence for the optimal management of this hemodynamically unstable patient's condition.

A 52-year-old woman is evaluated in the neurosurgical intensive care unit for new-onset neurological deficits. Six days ago, she was admitted for a subarachnoid hemorrhage and underwent successful endovascular coiling of a ruptured anterior communicating artery aneurysm. Her postoperative course was initially uncomplicated, and she has been receiving standard medical therapy. Over the past 2 hours, she has become increasingly lethargic and developed right-sided weakness. Her temperature is 37.2°C (99.0°F), blood pressure is 112/72 mm Hg, and pulse is 84/min. Physical examination confirms right-sided hemiparesis and expressive aphasia. A noncontrast CT scan of the head reveals the coiled aneurysm with no new bleeding, hydrocephalus, or territorial infarction. Which of the following is the most appropriate next step in management?

A 28-year-old man is brought to the emergency department 30 minutes after sustaining a stab wound to his right medial thigh. He reports excruciating pain in his right leg. His blood pressure is $118/76$ mm Hg, and his heart rate is $102$/min. Physical examination reveals a 3-cm linear laceration over the right anteromedial thigh. There is a rapidly expanding, pulsatile hematoma surrounding the wound. Palpation of the right lower extremity reveals absent dorsalis pedis and posterior tibial pulses, whereas the left lower extremity pulses are normal and symmetric. The right foot is pale and cool to the touch compared to the left. Which of the following is the most appropriate next step in the management of this patient?

A 34-year-old man presents to the emergency department with a painful, persistent erection that began 8 hours ago without sexual stimulation. He has a history of sickle cell trait. Physical examination reveals fully rigid, exquisitely tender corpora cavernosa and a flaccid glans penis. Arrange the following diagnostic and therapeutic steps in the optimal chronological sequence for managing this acute urologic emergency, progressing from initial evaluation to definitive refractory management.

A 51-year-old woman is admitted to the surgical ward with a 24-hour history of severe abdominal pain, nausea, and obstipation. She has not passed flatus since the symptoms began. Her past medical history is significant for an open appendectomy for perforated appendicitis 15 years ago. The pain was initially intermittent and crampy but transitioned to a continuous, dull ache over the past 4 hours. Temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $138/82\text{ mmHg}$, pulse is $92/\text{min}$, and respiratory rate is $16/\text{min}$. On physical examination, the abdomen is moderately distended and tympanitic. There is focal tenderness to deep palpation in the right lower quadrant, but no rebound tenderness, rigidity, or guarding. Bowel sounds are high-pitched and tinkling. Laboratory studies show a leukocyte count of $10,500/\text{mm}^3$ and a serum lactate level of $1.5\text{ mmol/L}$ (normal: $0.5-2.2\text{ mmol/L}$). An intravenous contrast-enhanced CT scan of the abdomen and pelvis reveals a transition point in the distal ileum. Proximal to this point, a distinct, radially distributed, C-shaped cluster of fluid-filled small bowel loops is visualized. The mesenteric vessels supplying this segment demonstrate a converging, twisted configuration. The bowel wall of the involved segment shows normal contrast enhancement, and there is no pneumatosis intestinalis. Which of the following is the most appropriate next step in management?

A $55$-year-old woman is evaluated on postoperative day $4$ following an open low anterior resection for locally advanced rectal cancer. She reports new-onset, constant, right-sided flank pain and mild nausea that began yesterday. Her temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $125/75\text{ mmHg}$, and pulse is $92/\text{min}$. Physical examination reveals a clean midline abdominal incision with normal, active bowel sounds. There is distinct right costovertebral angle tenderness, but no rebound tenderness or guarding. A urethral Foley catheter was removed on postoperative day $2$, and the patient has since been voiding spontaneously with an output of approximately $450\text{ mL}$ every $8$ hours. Laboratory studies show a serum creatinine of $0.9\text{ mg/dL}$ (baseline $0.8\text{ mg/dL}$) and a leukocyte count of $12,500/\mu\text{L}$. Urinalysis shows $2$-$3$ white blood cells/hpf and no bacteria. Which of the following is the most appropriate next step in management?

Match each clinical vignette describing a mechanism of injury, physical exam finding, and radiographic pattern with the correct upper extremity orthopedic diagnosis.

A $76$-year-old man presents to the emergency department with the sudden onset of agonizing, diffuse abdominal pain that began $2\text{ hours}$ ago. He has a history of paroxysmal atrial fibrillation and recently stopped taking his apixaban. On physical examination, his temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $145/88\text{ mm Hg}$, pulse is $120/\text{min}$ and irregularly irregular, and respirations are $22/\text{min}$. His abdomen is soft, non-distended, and remarkably exhibits only mild tenderness to deep palpation, without guarding, rebound, or rigidity. Bowel sounds are hypoactive. Laboratory studies show a leukocyte count of $19,000/\text{mm}^3$ and a serum lactate level of $4.2\text{ mmol/L}$. Arrange the following steps in the most appropriate chronological sequence for the optimal diagnosis and management of this patient's condition.

A 28-year-old woman with a history of a ventriculoperitoneal (VP) shunt placed for communicating hydrocephalus presents to the emergency department with a severe headache, nausea, and projectile vomiting. Over the last hour, she has become increasingly lethargic. Her temperature is 37.1°C (98.8°F), heart rate is 52/min, respiratory rate is 10/min, and blood pressure is 165/95 mmHg. Physical examination shows bilateral papilledema and sluggishly reactive pupils. The emergency physician suspects an acute shunt malfunction leading to critically elevated intracranial pressure.

Arrange the following steps in the most appropriate sequential order for the evaluation and definitive management of this patient's condition.

A 45-year-old woman is referred to the surgery clinic for evaluation of an enlarging anterior neck mass. Over the past 6 months, she has noticed a lump in her lower neck. During this time, she has also experienced worsening fatigue, constipation, cold intolerance, and a 4.5-kg (10-lb) weight gain. She has not had any difficulty swallowing or breathing. Her menstrual periods ceased one year ago. Physical examination reveals a non-tender, 3.5-cm, firm, mobile nodule in the right lobe of the thyroid gland. No cervical lymphadenopathy is present.

Laboratory studies show:

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

A 68-year-old woman is brought to the emergency department due to the sudden onset of severe right leg pain that began 2 hours ago. She has a history of permanent atrial fibrillation and was instructed to stop her apixaban three weeks ago prior to a dental extraction, but she never resumed the medication. On physical examination, the right leg is pale and cool to the touch below the knee. The right femoral pulse is palpable, but the popliteal, dorsalis pedis, and posterior tibial pulses are not palpable. She has intact sensation to light touch in her foot and normal toe movement. Arrange the following steps in the most appropriate chronological sequence for the evaluation and management of this patient.

A 48-year-old woman is evaluated for right-sided flank pain and nausea on postoperative day 2 following a total abdominal hysterectomy for symptomatic uterine leiomyomata. She reports the pain is constant and severe. Her temperature is $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$), blood pressure is $128/78\text{ mm Hg}$, and pulse is $86/\text{min}$. Physical examination reveals exquisite right costovertebral angle tenderness. The surgical incision is clean, dry, and intact without erythema or induration. Laboratory results are as follows:

Blood urea nitrogen: $28\text{ mg/dL}$
Serum creatinine: $1.8\text{ mg/dL}$ (baseline: $0.8\text{ mg/dL}$)

Urinalysis:
Leukocyte esterase: negative
Nitrites: negative
WBC: $1-2/\text{hpf}$
RBC: $10-15/\text{hpf}$

Renal ultrasonography demonstrates moderate right-sided hydronephrosis. The left kidney appears normal. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation with the most appropriate definitive surgical intervention or management step.

An $82$-year-old woman residing in an assisted living facility is brought to the emergency center after developing bilious emesis and progressive abdominal bloating over the past two days. Her medical history includes an open cholecystectomy and atrial fibrillation. For the last $12\text{ hours}$, her previously colicky cramping has transitioned into a constant, severe ache. Her temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $102/60\text{ mm Hg}$, and pulse is $115/\text{min}$ and irregularly irregular. Physical evaluation shows marked abdominal distension. Bowel sounds are absent. Light palpation produces significant guarding and rigidity localized to the periumbilical region. Laboratory values show a leukocyte count of $16,500/\text{mm}^3$ with $12\%$ bands, a hemoglobin of $13.2\text{ g/dL}$, and a venous lactate of $4.2\text{ mmol/L}$. An acute abdominal series reveals dilated central bowel loops, prominent mucosal folds extending entirely across the lumen, and multiple air-fluid levels. There is no free intraperitoneal air. Which of the following is the most appropriate management for this patient's current condition?

A 46-year-old male with a history of an uncorrected right-to-left cardiac shunt is evaluated in the neurology unit for a progressively worsening, severe global headache over the past week. This morning, he developed new-onset weakness in his left arm and leg. His temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $145/90\text{ mm Hg}$, and heart rate is $88\text{/min}$. Neurologic examination reveals $3/5$ motor strength in the left upper and lower extremities and a left homonymous hemianopia. Fundoscopic examination shows bilateral optic disc swelling with blurred margins. A contrast-enhanced MRI of the brain demonstrates a $3.8\text{-cm}$ solitary ring-enhancing lesion with a necrotic core in the right frontoparietal lobe, surrounded by substantial vasogenic edema and a $7\text{-mm}$ midline shift. Which of the following is the most appropriate next step in management?