Surgery

Identify the most appropriate definitive surgical or procedural intervention for each of the described male genitourinary pathologies.

Match each clinical presentation of an acute orthopedic injury to its most likely associated neurological examination deficit.

A 52-year-old woman is evaluated on postoperative day 10 following an exploratory laparotomy and extensive lysis of adhesions for recurrent small bowel obstruction. Over the past 48 hours, she has developed drainage of feculent fluid through the mid-portion of her healing midline incision. The output is currently measured at 900 mL/day. She is afebrile with a heart rate of 88/min and blood pressure of 110/70 mmHg. Her abdomen is soft and non-tender, but the skin surrounding the drainage site is rapidly becoming severely erythematous and excoriated. Arrange the following management steps in the standard evidence-based chronological sequence for the treatment of a newly diagnosed high-output enterocutaneous fistula, proceeding from the immediate phase to definitive care.

A 74-year-old man develops progressive, massive abdominal distension 4 days after undergoing a coronary artery bypass graft. He reports mild nausea but no significant abdominal pain. His vital signs are within normal limits. Physical examination reveals a markedly distended, tympanitic abdomen with no guarding or rebound tenderness. Laboratory studies show normal potassium and magnesium levels. An abdominal radiograph reveals a diffusely dilated colon with the cecum measuring 11.5 cm in diameter, without evidence of a transition point or pneumoperitoneum. Assuming each subsequent intervention fails to resolve the patient's condition, arrange the following management steps in the correct sequential order.

A 72-year-old woman with a history of persistent atrial fibrillation and nonadherence to her oral anticoagulant therapy presents to the emergency department with sudden, excruciating pain in her right leg that began 3 hours ago. On physical examination, the right lower extremity is pale and cool to the touch. No pulses are palpable distal to the femoral artery. She reports numbness over the dorsum of her right foot and is unable to actively dorsiflex her toes. Arrange the following interventions in the most appropriate chronological sequence for the optimal management of this patient.

A 15-year-old boy is brought to the emergency department by his parents due to the sudden onset of excruciating left-sided scrotal pain that woke him from sleep 3 hours ago. The pain is constant and accompanied by nausea and one episode of non-bilious emesis. He reports no dysuria, hematuria, urethral discharge, or recent flank pain. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $128/82\text{ mmHg}$, and heart rate is $110\text{ /min}$. On physical examination, the left hemiscrotum is edematous, erythematous, and exquisitely tender to palpation. The left testicle is positioned higher than the right and lies horizontally. The cremasteric reflex is absent on the left side but intact on the right side. Which of the following is the most appropriate next step in management for this patient?

Match each neurosurgical emergency or traumatic brain injury with its characteristic pathophysiologic mechanism and classic neuroimaging findings.

During morning rounds, the orthopedic team evaluates a 24-year-old male who was admitted overnight following a closed mid-shaft right tibia fracture sustained during a soccer match. He was treated with closed reduction and application of a long-leg cast $8$ hours ago. The patient is now highly agitated, reporting severe, throbbing pain in his right leg that has worsened significantly despite escalating doses of intravenous hydromorphone. His medical history is notable for opioid use disorder, for which he takes daily methadone. Vital signs are within normal limits. Physical examination reveals a pink, warm right foot with a capillary refill time of $2$ seconds. Dorsalis pedis and posterior tibial pulses are easily palpable. However, passive plantar flexion of the toes elicits excruciating pain in the anterior shin, and the patient reports decreased sensation in the first dorsal web space. Which of the following is the most appropriate next step in management?

An 81-year-old woman is brought to the emergency department by her daughter due to the sudden onset of severe abdominal pain that began 5 hours ago. The patient has a medical history of hypertension, type 2 diabetes mellitus, and paroxysmal atrial fibrillation. She routinely takes metoprolol, lisinopril, and apixaban, but she discontinued apixaban three weeks ago prior to a dental extraction. Her daughter reports that the patient initially complained of generalized, agonizing pain and was writhing in agony, but over the last hour, she has become increasingly lethargic and now lies completely motionless on the stretcher. Her temperature is 38.4°C (101.1°F), blood pressure is 84/52 mm Hg, pulse is 128/min and irregularly irregular, and respirations are 24/min. Physical examination reveals a moderately distended abdomen. There is diffuse, severe pain on light palpation with board-like rigidity and involuntary guarding. Bowel sounds are absent. Laboratory studies show a leukocyte count of 21,500/mm³ and a serum lactate level of 6.4 mmol/L. Which of the following is the most appropriate next step in management?

Match each clinical presentation with the most appropriate next step in management or definitive surgical intervention.

Match each specific post-gastric surgery complication with its classic clinical presentation or underlying pathophysiology.

Match each patient presentation involving a peripheral vascular pathology or injury with the most appropriate immediate next step in management.

A male patient, aged 45, presents to the emergency room with a 7-day history of escalating mid-thoracic back pain and subjective fevers. He has a known medical history of intravenous substance use disorder. Over the last 24 hours, he noted rapidly progressive weakness in both legs and an inability to void urine. Vital signs show a temperature of 38.9°C (102°F), heart rate of 110/min, and blood pressure of 122/78 mm Hg. Neurologic examination reveals 2/5 motor strength in the bilateral lower extremities, a distinct loss of pain and temperature sensation below the umbilicus, and 3+ patellar reflexes with bilateral Babinski signs. Bladder ultrasound reveals a post-void residual volume of 650 mL. Empiric intravenous vancomycin and ceftriaxone are promptly initiated. Magnetic resonance imaging of the spine demonstrates a peripherally enhancing anterior epidural collection spanning T9-T11, causing severe compression of the spinal cord. Which of the following is the most appropriate next step in management?

Following a two-day history of escalating groin discomfort, a 54-year-old male with poorly controlled type 2 diabetes mellitus arrives at the emergency department. His spouse notes he has been increasingly lethargic and shivering since this morning. Vital signs demonstrate a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), pulse of $122/\text{min}$, and blood pressure of $86/52\text{ mmHg}$. Genitourinary examination reveals significant edema, poorly defined erythema, and a putrid odor emanating from the perineum. There is palpable crepitus extending from the base of the scrotum to the perianal region. Initial laboratory analysis yields a leukocyte count of $26,000/\text{mm}^3$ with $15\%$ bands. Fluid resuscitation is currently underway. Which of the following is the most appropriate next step in the management of this patient?

A 5-year-old girl is brought to the emergency department with a 24-hour history of high fever ($39.2^\circ\text{C}$ or $102.6^\circ\text{F}$) and refusal to bear weight on her right leg. On examination, her right hip is exquisitely tender and held rigidly in flexion, abduction, and external rotation. Any attempted passive range of motion elicits severe distress. Assuming all subsequent diagnostic findings support a diagnosis of acute septic arthritis, arrange the following clinical management steps in the most appropriate chronological sequence.

A 28-year-old man is brought to the emergency department after a high-speed motorcycle collision. In the field, his Glasgow Coma Scale (GCS) score was 6, and he was immediately intubated. On arrival, his blood pressure is 170/100 mm Hg, and his heart rate is 50/min. His right pupil is 7 mm and nonreactive to light, while his left pupil is 3 mm and briskly reactive. Extensor posturing is noted on the left side in response to painful stimuli. A stat non-contrast head CT reveals a large right-sided acute subdural hematoma with a 15-mm midline shift. Arrange the following interventions in the most appropriate chronological sequence for managing this patient's condition, from the most immediate initial bedside action to definitive ongoing care.

Match each clinical vignette describing a patient's physical examination and historical findings with the most accurate description of the underlying vascular pathology.

An otherwise healthy 7-year-old boy arrives at the trauma bay 45 minutes after falling from a playground structure onto his outstretched right hand. He complains of excruciating elbow pain and refuses to move his arm. Vital signs are within normal limits for his age. On physical examination, the right elbow is markedly swollen with an S-shaped deformity. The skin over the antecubital fossa is intact, taut, and slightly ecchymotic. Neurologic evaluation reveals an inability to flex the distal interphalangeal joints of the index finger and thumb to make an "OK" sign, though wrist extension and finger abduction are intact. The radial pulse is non-palpable and cannot be detected with a handheld Doppler ultrasound. However, the right hand is warm and pink, with a capillary refill time of 2 seconds. Radiographs of the right elbow reveal a completely displaced extension-type supracondylar humerus fracture. Which of the following is the most appropriate next step in management?

A 23-year-old male presents to the urgent care clinic with right wrist pain after falling on an outstretched hand while snowboarding. Physical examination reveals focal swelling and significant tenderness to palpation in the anatomic snuffbox. Initial anteroposterior, lateral, and scaphoid-view plain radiographs of the right wrist demonstrate no obvious fracture, dislocation, or joint effusion. Arrange the following management steps in the most appropriate chronological order for this patient.

A 79-year-old woman is admitted to the surgical ward with a 3-day history of intermittent, severe abdominal cramps and frequent vomiting of green-tinged fluid. She has not had a bowel movement or passed flatus for the past 48 hours. Her past medical history includes essential hypertension, osteoarthritis, and several episodes of self-resolving right upper quadrant pain over the last decade. She has never undergone any surgical procedures. On admission, her temperature is 37.4°C (99.3°F), blood pressure is 105/65 mmHg, and heart rate is 108/min. The abdomen is significantly distended, tympanitic to percussion, and diffusely tender without guarding or rebound. Bowel sounds are hyperactive and high-pitched. Laboratory evaluation shows a leukocyte count of 11,200/mm³ and serum creatinine of 1.6 mg/dL (baseline 0.9 mg/dL). Cross-sectional abdominal imaging with contrast reveals markedly dilated loops of small bowel up to the terminal ileum, where a 3.5-cm radiopaque structure is lodged. There is also air visible within the biliary tree. After initial fluid resuscitation, which of the following is the most appropriate next step in management?