Surgery

Match each post-bariatric surgery clinical presentation with the most likely diagnosis or surgical complication.

A 45-year-old man is brought to the emergency department 30 minutes after falling from a 3-story building. He is confused and moaning in pain. His temperature is 36.2°C (97.2°F), blood pressure is 75/40 mm Hg, heart rate is 135/min, and respiratory rate is 24/min. The airway is patent, and breath sounds are clear and equal bilaterally. A portable chest radiograph is unremarkable. A portable pelvic radiograph demonstrates a 4.5-cm diastasis of the pubic symphysis. A pelvic binder is immediately applied and secured appropriately. Focused assessment with sonography for trauma (FAST) demonstrates a large volume of anechoic fluid in the hepatorenal and splenorenal recesses. The patient receives 2 units of uncrossmatched packed red blood cells and 2 units of fresh frozen plasma via a rapid infusion device. Following the transfusion, his blood pressure is 78/42 mm Hg and heart rate is 130/min. Which of the following is the most appropriate next step in management?

A 68-year-old woman is recovering in the surgical intensive care unit shortly after undergoing a pancreaticoduodenectomy. Due to poor peripheral venous access, the surgical resident places a right internal jugular central venous catheter. Ten minutes after the procedure, the patient suddenly develops severe shortness of breath. Her temperature is 37.1°C, blood pressure is 76/40 mm Hg, heart rate is 138/min, and respiratory rate is 32/min. Oxygen saturation is 82% on room air. Physical examination reveals distended neck veins, absent breath sounds over the right lung field, and deviation of the trachea to the left side. Arrange the following management steps in the most appropriate chronological sequence for this patient.

Match each postoperative clinical presentation following abdominal surgery to the most likely diagnosis.

A 42-year-old woman presents to the emergency department with steady, severe right upper quadrant abdominal pain that radiates to her right scapula. The pain began 6 hours ago after eating a large, fatty meal. She reports nausea and two episodes of vomiting. Her temperature is 38.2°C (100.8°F), blood pressure is 130/80 mmHg, and heart rate is 92/min. Physical examination reveals tenderness to palpation in the right upper quadrant with inspiratory arrest (positive Murphy sign). Arrange the following steps in the most appropriate chronological sequence for the evaluation and management of this patient.

A 50-year-old construction worker is evacuated by helicopter to the trauma center following a localized industrial explosion. The patient weighs $80\text{ kg}$. Paramedics report the incident occurred exactly $2\text{ hours}$ prior to arrival. Primary survey reveals a patent airway with no signs of inhalation injury, clear breath sounds bilaterally, and a heart rate of $115\text{ beats/min}$. Secondary survey is notable for deep partial-thickness and full-thickness thermal burns covering the entirety of his posterior trunk (including buttocks), his entire left lower extremity, and his entire right upper extremity. Superficial (first-degree) burns are noted on his face but are not blistering. Large-bore intravenous access is established. The trauma team initiates fluid resuscitation using lactated Ringer solution according to current Advanced Trauma Life Support (ATLS) guidelines ($2\text{ mL/kg/\%TBSA}$ for adult thermal burns).

What should be the initial rate of the fluid infusion (in $\text{mL/hr}$) programmed on the intravenous pump for the time remaining in the first 8-hour post-injury window?

A 34-year-old man is brought to the emergency department 20 minutes after a high-speed motor vehicle collision. He was the restrained driver of a vehicle that struck a concrete barrier. On arrival, the patient is confused and diaphoretic. His temperature is 36.5°C (97.7°F), blood pressure is 78/45 mm Hg, pulse is 135/min, and respirations are 24/min. Pulse oximetry shows 97% on room air. The airway is patent, and breath sounds are equal bilaterally. A focused assessment with sonography for trauma (FAST) reveals a large amount of free fluid in the hepatorenal recess (Morison pouch) and splenorenal recess. Which of the following is the most appropriate next step in management?

A $71$-year-old woman is assessed by the rapid response team five days after undergoing an elective sigmoid resection with primary anastomosis for recurrent complicated diverticulitis. The nursing staff activated the response due to acute mental status changes and hypotension. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $78/48\text{ mm Hg}$, pulse is $132/\text{min}$, and respirations are $26/\text{min}$. Pulse oximetry shows $93\%$ on room air. The patient is lethargic and oriented only to person. Abdominal examination reveals a rigid, board-like abdominal wall with severe diffuse tenderness and absent bowel sounds. A closed-suction pelvic drain, which had been outputting minimal clear fluid, has abruptly filled with $200\text{ mL}$ of dark, foul-smelling, turbid liquid. Electrocardiography demonstrates sinus tachycardia alongside $2\text{-mm}$ ST-segment depressions in leads II, III, and aVF. Laboratory studies reveal a leukocyte count of $22,000/\text{mm}^3$, a serum lactate level of $5.4\text{ mmol/L}$, and a serum troponin I concentration of $0.8\text{ ng/mL}$ (normal: $<0.04\text{ ng/mL}$). Intravenous crystalloid resuscitation is initiated. Which of the following is the most appropriate next step in the management of this patient?

A $35$-year-old man weighing $70 \text{ kg}$ is brought to the emergency department $2 \text{ hours}$ after being rescued from a structural fire. On examination, he is hemodynamically stable, and his airway is secure with no evidence of inhalational injury. He has sustained deep partial-thickness and full-thickness burns involving his anterior chest, anterior abdomen, entire right arm, and the anterior aspect of his left leg. The remainder of his skin is intact. Intravenous access is obtained. According to current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns, what should be the initial rate of intravenous lactated Ringer solution administration for this patient? (Enter the value in $\text{mL/hr}$)

Eighteen hours into resuscitation for severe thermal injuries, a $42$-year-old male patient exhibits acute clinical deterioration in the intensive care unit. He initially presented following an industrial fire with full-thickness burns covering $55\%$ of his total body surface area, localized exclusively to his back and bilateral lower extremities. He was intubated upon arrival, and standard Parkland formula-based crystalloid infusion was initiated.

Current assessment reveals a precipitous drop in urine output to $10 \text{ mL/hr}$. Vital signs show a temperature of $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure of $82/50 \text{ mm Hg}$, and a heart rate of $135\text{/min}$. The central venous pressure is elevated at $18 \text{ mm Hg}$. The mechanical ventilator repeatedly triggers high-pressure alarms, with peak airway pressures rising acutely from $25 \text{ cm H}_2\text{O}$ to $48 \text{ cm H}_2\text{O}$. On physical examination, the abdomen is tensely distended. Transducer measurement via the urinary catheter demonstrates an intravesical pressure of $34 \text{ mm Hg}$. Which of the following is the most appropriate next step in management?

A 35-year-old man presents to the emergency department complaining of severe, crampy periumbilical pain and worsening abdominal bloating for the past two days. He has had multiple episodes of bilious emesis over the last 12 hours. His last bowel movement was 3 days ago, and he has not passed flatus for 24 hours. His surgical history is significant for an open appendectomy for ruptured appendicitis 8 years ago.

Temperature is 37.8°C (100.0°F), blood pressure is 135/85 mm Hg, pulse is 98/min, and respirations are 18/min. Physical examination reveals a distended and tympanitic abdomen. High-pitched, tinkling bowel sounds are auscultated. There is diffuse, mild tenderness to deep palpation, but no rebound tenderness, rigidity, or involuntary guarding.

Laboratory results:
- Leukocyte count: $11,500/\text{mm}^3$
- Hemoglobin: $15.2 \text{ g/dL}$
- Blood urea nitrogen: $28 \text{ mg/dL}$
- Serum creatinine: $1.2 \text{ mg/dL}$
- Serum lactate: $1.2 \text{ mmol/L}$ (normal: $0.5-2.2 \text{ mmol/L}$)

An abdominal CT scan with oral and intravenous contrast demonstrates dilated proximal small bowel loops measuring up to $4.5 \text{ cm}$ in diameter. A distinct transition point is seen in the distal ileum. Contrast is visualized within the cecum. There is no bowel wall thickening, pneumatosis intestinalis, mesenteric fat stranding, or free intraperitoneal fluid.

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

A 65-year-old man presents to the outpatient surgical clinic 6 days after undergoing an emergency laparotomy and omental patch repair for a perforated duodenal ulcer. He reports worsening, throbbing pain at his surgical site that began yesterday. His temperature is 38.2°C (100.8°F), blood pressure is 128/78 mm Hg, heart rate is 90/min, and respiratory rate is 14/min. Physical examination shows a midline abdominal incision closed with surgical staples. The inferior one-third of the incision is erythematous, indurated, and exquisitely tender to palpation. Thick, yellowish fluid is spontaneously draining from between two of the staples in this area. The remainder of the abdominal examination is unremarkable, with normal bowel sounds and no rebound tenderness. Which of the following is the most appropriate next step in management?

Emergency medical services bring a 22-year-old male to the trauma bay following an ejection from a moving vehicle. The patient is semi-conscious, with visible facial trauma and a deformed right lower extremity with surrounding ecchymosis. Arrange the following initial management steps in the correct chronological sequence according to the Advanced Trauma Life Support (ATLS) primary survey protocol.

A surgical clerkship director is teaching medical students about the evaluation of postoperative fever. To help students prioritize their differential diagnoses, she asks them to recall the classic timeline for various complications. Arrange the following common etiologies of postoperative fever in typical chronological order, from earliest expected onset to latest expected onset.

A 64-year-old man is evaluated in the surgical intensive care unit on postoperative day 8 following a pancreaticoduodenectomy. His postoperative course was complicated by delayed gastric emptying, requiring bowel rest and total parenteral nutrition (TPN) via a right internal jugular central venous catheter. Today, he develops sudden chills. His temperature is 39.4°C (102.9°F), blood pressure is 92/58 mm Hg, heart rate is 124/min, and respiratory rate is 22/min. Physical examination reveals mild erythema at the central line insertion site. The surgical drains continue to output a small amount of non-purulent, clear fluid, and his abdomen is soft and non-tender. His leukocyte count has increased from 10,500/mm³ yesterday to 19,500/mm³ today.

Which of the following are the most appropriate initial steps in the evaluation and management of this patient's acute change in condition? (Select exactly two)

Accompanied by her daughter, a 61-year-old female is evaluated in the surgical assessment unit due to three days of worsening left lower abdominal pain, chills, and anorexia. Her past medical history is notable for hypertension and hyperlipidemia. Vital signs show a temperature of 38.8°C (101.8°F), heart rate of 102/min, blood pressure of 128/78 mm Hg, and respiratory rate of 16/min. Physical examination reveals focal tenderness and voluntary guarding in the left lower quadrant, but no generalized rigidity or diffuse rebound tenderness. Laboratory studies demonstrate a leukocyte count of 16,500/mm³ with a left shift. A contrast-enhanced computed tomography scan of the abdomen and pelvis reveals severe sigmoid diverticulitis accompanied by a 6.5-centimeter unilocular fluid collection adjacent to the inflamed bowel segment. Based on current surgical guidelines, arrange the following steps in the most appropriate sequential order for the comprehensive management of this patient.

An 81-year-old woman is transported to the trauma bay via ambulance after sustaining a ground-level fall, striking her left flank against a heavy wooden bench. She has a history of essential hypertension and hyperlipidemia. On initial evaluation, her temperature is 36.4°C (97.5°F), blood pressure is 82/46 mmHg, pulse is 126/min, and respiratory rate is 24/min. Her airway is patent and breath sounds are equal bilaterally. Her abdomen is distended and exhibits severe guarding over the left upper and lower quadrants. Pelvic compression does not elicit instability. She is given 1 L of warmed lactated Ringer fluid via two large-bore peripheral intravenous catheters. Reassessment shows a blood pressure of 80/44 mmHg and a pulse of 130/min. A bedside ultrasound examination demonstrates a large amount of free anechoic fluid in the hepatorenal and splenorenal spaces. Which of the following is the most appropriate next step in management?

A 72-year-old man is evaluated for a new-onset fever on postoperative day 4 following an open repair of a ventral hernia. He has been recovering well, tolerating a regular diet, and ambulating with assistance in the surgical ward hallways. An indwelling urethral catheter was placed prior to surgery and removed on postoperative day 2. Today, his temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$). Blood pressure is $128/76\text{ mm Hg}$, pulse is $96/\text{min}$, and respirations are $16/\text{min}$. Oxygen saturation is $96\%$ on room air. The patient reports feeling slightly fatigued but denies shortness of breath, cough, nausea, or calf pain. He notes that he has been urinating more frequently than usual since the catheter was removed, which he attributes to his postoperative intravenous fluids. Examination shows a soft abdomen with mild tenderness near the surgical incision. The incision is clean and intact with no erythema, induration, or purulent discharge. The lungs are clear to auscultation bilaterally. Which of the following is the most appropriate next step in management?

A 32-year-old male utility worker is brought to the emergency department after sustaining a high-voltage electrical injury while repairing a power line. The incident occurred exactly 2 hours prior to his arrival. On presentation, he is awake, alert, and complains of severe pain in his extremities. His temperature is $36.8^\circ \text{C}$ ($98.2^\circ \text{F}$), heart rate is $112/\text{min}$, and blood pressure is $110/70 \text{ mm Hg}$. Physical examination reveals deep, full-thickness burns involving his entire anterior trunk and his entire right lower extremity. There are also deep, charred entry and exit wounds on his right hand and left foot, though these cover a negligible surface area. His body weight is estimated at $75 \text{ kg}$. A Foley catheter is inserted to monitor urine output, and large-bore intravenous access is obtained. According to the Advanced Trauma Life Support (ATLS) guidelines for high-voltage electrical injuries, what is the appropriate initial intravenous fluid infusion rate (in $\text{mL/hour}$) for this patient?

A 52-year-old man is brought to the emergency department complaining of sudden-onset, excruciating epigastric pain that started 2 hours ago. He has a history of chronic knee osteoarthritis for which he takes high-dose ibuprofen daily. His temperature is 38.2°C (100.8°F), pulse is 118/min, and blood pressure is 92/58 mmHg. The patient is lying completely still on the stretcher. Physical examination reveals a rigid, board-like abdomen with severe diffuse rebound tenderness. An upright chest radiograph demonstrates a crescent of radiolucency under the right hemidiaphragm. Which of the following is the most appropriate next step in management?