Surgery

Match each patient's clinical presentation of an orthopedic injury with the most likely associated neurovascular complication or mandatory physical examination finding.

A 35-year-old man is brought to the emergency department complaining of a severely painful and rigid erection that has lasted for 10 hours without any sexual stimulation. He recently began taking trazodone for major depressive disorder. On physical examination, the corpora cavernosa are extremely tense and tender to palpation, while the glans penis and corpus spongiosum remain soft and flaccid. Arrange the following therapeutic interventions in the correct sequential order for managing this patient's condition, proceeding from the initial appropriate step to the most advanced surgical option.

A 13-year-old boy is brought to the clinic by his parents due to left knee pain and a limp that has progressively worsened over the past month. Yesterday, the pain became significantly more severe after he jumped down from a small wall. He has no history of direct trauma to the knee, fever, or prior medical conditions. His BMI is $34 \text{ kg/m}^2$. Vital signs are within normal limits. Physical examination of the left knee reveals no effusion, joint line tenderness, or ligamentous laxity. During examination of the left hip, flexion of the hip results in obligatory external rotation of the thigh. Internal rotation of the left hip is severely limited and elicits pain. Radiographs of the hip confirm the diagnosis. Which of the following is the most appropriate next step in management?

A $65$-year-old man is evaluated in the intensive care unit for sudden-onset dyspnea and lightheadedness. The patient is currently on postoperative day $3$ following a three-vessel coronary artery bypass grafting. His recovery had been uncomplicated until $30$ minutes ago. Temperature is $37.1^\circ \text{C}$ ($98.8^\circ \text{F}$), blood pressure is $82/65\text{ mm Hg}$, pulse is $122/\text{min}$, and respirations are $24/\text{min}$. Physical examination reveals elevated jugular venous pressure and muffled heart sounds. The lungs are clear to auscultation bilaterally. Review of the patient's drains shows that the mediastinal chest tubes, which had been draining approximately $100\text{ mL/hr}$ of serosanguinous fluid, have drained less than $10\text{ mL}$ over the past $3$ hours. Electrocardiogram demonstrates sinus tachycardia with low-voltage QRS complexes. Which of the following is the most appropriate next step in management?

A 42-year-old man presents to the emergency department with a 5-day history of progressively worsening abdominal pain. Initially, the pain was dull and periumbilical, but it is now sharp and localized to the right lower quadrant. He reports subjective fevers, chills, and significant anorexia. His temperature is 38.8°C (101.8°F), heart rate is 110/min, blood pressure is 115/75 mmHg, and respiratory rate is 18/min. Physical examination reveals a palpable, tender mass in the right lower quadrant with localized guarding. Laboratory studies show a leukocyte count of 18,500/mm³ with a prominent left shift. Arrange the following management steps in the most appropriate sequential order for this patient.

Correlate each pediatric or adolescent patient's musculoskeletal presentation with the most accurate orthopedic diagnosis.

A 28-year-old male is evaluated in the surgical triage area after experiencing sudden, severe genital pain. He reports that approximately two hours ago, during vigorous sexual intercourse, he heard a distinct 'snapping' sound from his groin, which was immediately followed by a rapid loss of erection. Since then, he has noticed progressive swelling and discoloration. His vital signs are within normal limits. Physical examination reveals a markedly edematous and ecchymotic penile shaft that is deviated to the left side. The patient states he was able to urinate normally just prior to arrival, and the urine was clear. There is no blood visible at the urethral meatus. Which of the following is the most appropriate next step in the management of this patient?

Paramedics bring a 68-year-old female to the acute care clinic for evaluation of intractable vomiting and generalized abdominal swelling that began 24 hours ago. The patient reports that the emesis is dark green and bitter. She has been unable to pass any gas or stool since the symptoms started. Her surgical history is notable for a total abdominal hysterectomy performed 12 years ago.

Current vital signs are temperature 38.4°C (101.1°F), pulse 118/min, blood pressure 100/60 mmHg, and respirations 22/min. On examination, the abdomen is tensely distended and tympanic to percussion. There is exquisite tenderness with involuntary muscle spasm upon palpation of the lower quadrants. Bowel sounds are absent.

Initial laboratory studies reveal:
- Leukocyte count: 17,500/mm³
- Serum bicarbonate: 16 mEq/L
- Serum lactate: 4.1 mmol/L

A portable upright radiograph reveals multiple dilated small bowel loops with air-fluid levels and an absence of distal colonic gas.

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

A 25-year-old man is brought to the emergency department after a skiing accident in which he fell directly onto his right shoulder. He complains of severe shoulder pain and an inability to move his arm. Vital signs are within normal limits. On physical examination, the right arm is held in slight abduction and external rotation. There is a prominent acromion and a loss of the normal rounded contour of the shoulder. He has decreased sensation to pinprick over the lateral aspect of the right shoulder. Radial and brachial pulses are 2+ and symmetric. Capillary refill is less than 2 seconds. Anteroposterior and axillary lateral radiographs of the right shoulder demonstrate an anterior, subcoracoid dislocation of the humeral head. The patient undergoes closed reduction in the emergency department using procedural sedation. Post-reduction radiographs confirm anatomic alignment of the glenohumeral joint. However, upon repeat physical examination, the patient is able to actively abduct the arm to 15 degrees, but is unable to actively abduct it any further. The decreased sensation over the lateral shoulder persists. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation of urothelial carcinoma with its most appropriate definitive surgical or procedural management.

A 28-year-old man is brought to the emergency department after sustaining a stab wound to the right lower chest during an altercation. On arrival, his blood pressure is 115/75 mmHg, heart rate is 105/min, and respiratory rate is 22/min. Oxygen saturation is 94% on room air. Primary survey reveals a 2-cm laceration in the right fifth intercostal space at the midaxillary line. The trachea is midline. Breath sounds are decreased over the right hemithorax, and dullness to percussion is noted at the right lung base. An extended bedside focused assessment with sonography for trauma (eFAST) confirms a moderate right-sided hemothorax. Two large-bore intravenous lines are established, and fluid resuscitation is initiated.

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

Following a fall onto an outstretched hand during a snowboarding competition, a collegiate athlete presents with worsening right wrist discomfort. The patient specifically notes a deep ache near the base of the thumb that is exacerbated by gripping objects. On physical examination, there is mild edema and focal tenderness when palpating the depression between the extensor pollicis longus and the extensor pollicis brevis tendons. Range of motion at the radiocarpal joint is slightly limited by pain. Standard four-view radiographs of the wrist reveal no cortical step-offs, radiolucent lines, or malalignment. Which of the following is the most appropriate next step in management?

Five days after undergoing an elective right hemicolectomy with primary anastomosis for colon adenocarcinoma, a $65$-year-old patient suddenly experiences severe, worsening abdominal pain and bilious vomiting. Over the past $12$ hours, his condition has significantly deteriorated. He has not had any bowel movements or passed flatus since the surgery. His temperature is now $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure has dropped to $90/55\text{ mmHg}$, pulse is $122/\text{min}$, and respirations are $24/\text{min}$. The patient appears diaphoretic and is lying completely still in bed. Physical examination reveals a markedly distended abdomen that is diffusely tender to palpation, with prominent guarding and rebound tenderness in all four quadrants. Auscultation reveals absent bowel sounds. The surgical incision site appears clean, dry, and intact. Laboratory tests demonstrate a leukocyte count of $21,000/\text{mm}^3$ with $15\%$ band forms and a serum lactate concentration of $4.2\text{ mmol/L}$. Which of the following are the most appropriate next steps in the management of this patient? (Select 2)

A 28-year-old male warehouse worker is brought to the emergency department after being crushed laterally against a wall by a moving forklift. Upon arrival, he is confused and diaphoretic. Vital signs are temperature 36.2°C, heart rate 132/min, blood pressure 78/50 mmHg, and respiratory rate 22/min. Oxygen saturation is 96% on room air. Primary survey reveals a patent airway and equal breath sounds bilaterally. The abdomen is soft and non-distended with no peritoneal signs. Palpation of the pelvis reveals gross mechanical instability. Genitourinary examination shows marked scrotal ecchymosis, and digital rectal examination reveals a high-riding prostate. An anteroposterior pelvic radiograph confirms a severely displaced open-book pelvic ring fracture. A pelvic binder is immediately applied, and the patient is resuscitated with 2 units of uncrossmatched packed red blood cells. Following this intervention, his blood pressure remains 80/52 mmHg. A focused assessment with sonography for trauma (FAST) scan is performed and shows no free intraperitoneal or pericardial fluid. Which of the following is the most appropriate next step in management?

A 22-year-old male is evaluated in the surgical intensive care unit for sudden-onset, severe abdominal pain. Three days ago, he was involved in a high-speed motorcycle collision, during which he was thrown forward and struck his upper abdomen against the handlebars. His initial trauma evaluation in the emergency department demonstrated stable hemodynamics, and a computed tomography scan of the abdomen and pelvis showed a non-expanding Grade II splenic laceration without active contrast extravasation. He was admitted for nonoperative management and had been clinically stable until this morning.

Current vital signs include a temperature of 38.6°C (101.5°F), a heart rate of 135/min, a respiratory rate of 24/min, and a blood pressure of 82/48 mm Hg. Physical examination reveals a distended abdomen with diffuse rigidity, involuntary guarding, and severe rebound tenderness in all four quadrants. Bowel sounds are absent. Following the rapid infusion of 2 L of isotonic crystalloid, his blood pressure remains 86/50 mm Hg.

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

A $29$-year-old woman, G2P1, at $32$ weeks gestation is brought to the emergency department via ambulance following a motor vehicle collision. She was the restrained driver of a sedan that was struck on the driver's side by a commercial truck. On arrival, she is immobilized on a backboard with a cervical collar. She appears confused and is diaphoretic. Temperature is $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), blood pressure is $78/45\text{ mmHg}$, heart rate is $132\text{/min}$, and respiratory rate is $24\text{/min}$. Pulse oximetry is $96\%$ on $15\text{ L/min}$ oxygen via a nonrebreather mask. The airway is patent, and breath sounds are equal bilaterally. The uterus is palpated above the umbilicus. The abdomen is diffusely tender to palpation with involuntary guarding. There is no external vaginal bleeding. A focused assessment with sonography for trauma (FAST) reveals a large amount of free fluid in the hepatorenal space (Morison's pouch). Fetal heart tones are $140\text{/min}$. Two large-bore intravenous lines are established, and administration of warmed crystalloid fluids is initiated. Which of the following is the best next step in management?

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

During morning rounds, a $64$-year-old woman is evaluated for a newly elevated temperature. She is currently on her sixth postoperative day following a low anterior resection with a primary colorectal anastomosis for rectal adenocarcinoma. Her postoperative course was initially uncomplicated, and a transurethral bladder catheter was removed $3$ days ago. Over the past $24$ hours, the patient has developed suprapubic pressure, frequent voiding of small urine volumes, and three episodes of loose, watery stool.

Her temperature is $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$), blood pressure is $122/78$ mmHg, pulse is $110$/min, and respirations are $18$/min. Physical examination reveals a dry and intact midline laparotomy incision with no surrounding erythema or fluctuance. Palpation of the lower abdomen elicits moderate deep tenderness, but there is no involuntary guarding or rebound tenderness.

Laboratory results are as follows:
Leukocyte count: $16,500/\text{mm}^3$
Urinalysis:
Color: Yellow
Appearance: Cloudy
Specific gravity: $1.015$
Leukocyte esterase: Positive
Nitrites: Negative
WBCs: $30$-$40$/hpf
Bacteria: None

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

A 62-year-old female is evaluated in the emergency department for severe, diffuse abdominal pain that worsened abruptly over the last four hours. Her medical history is notable for a total abdominal hysterectomy ten years ago. She has not had a bowel movement or passed flatus in two days. On physical examination, the patient appears diaphoretic and in severe distress. Temperature is 39.2°C (102.6°F), pulse is 130/min, respirations are 24/min, and blood pressure is 80/50 mm Hg. Abdominal examination reveals a rigid, board-like abdomen with severe diffuse guarding and rebound tenderness. Laboratory studies show a leukocyte count of 22,000/mm³ and an elevated serum lactate. Which of the following is the most appropriate next step in the management of this patient?

A 19-year-old male is brought to the emergency department after colliding with a tree while snowboarding. On arrival, he complains of severe left upper quadrant abdominal pain and left shoulder pain. Initial vital signs include a blood pressure of 115/70 mm Hg, heart rate of 105/min, and respiratory rate of 18/min. A Focused Assessment with Sonography for Trauma (FAST) exam shows a moderate amount of free fluid in the splenorenal recess. Because the patient is hemodynamically stable, a computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast is performed, which reveals a deep splenic laceration with active contrast extravasation. Shortly after returning to the trauma bay, the patient becomes confused and diaphoretic. Repeat vital signs show a blood pressure of 82/45 mm Hg and a heart rate of 138/min. The patient is rapidly transfused with 1 unit of uncrossmatched packed red blood cells, but his blood pressure remains 84/48 mm Hg. Which of the following is the most appropriate next step in management?