Surgery

A $72$-year-old man is evaluated on postoperative day $4$ following an urgent open repair of a perforated anterior duodenal ulcer. He reports rapidly increasing shortness of breath and a cough productive of clear, frothy sputum. His medical history is significant for ischemic cardiomyopathy with a left ventricular ejection fraction of $35\%$ and severe chronic obstructive pulmonary disease. His temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $158/88\text{ mmHg}$, pulse is $112/\text{min}$, and respirations are $28/\text{min}$. Pulse oximetry shows $88\%$ on $4\text{ L/min}$ of oxygen via nasal cannula. Physical examination reveals an elevated jugular venous pressure of $11\text{ cm H}_2\text{O}$. Lung auscultation demonstrates scattered expiratory wheezes and prominent bibasilar crackles. Cardiovascular examination reveals a regular tachycardia with an S3 gallop. The abdomen is soft, mildly distended, and tender only at the midline incision, with no rebound or guarding. Complete blood count shows a leukocyte count of $10,500/\text{mm}^3$. A portable chest radiograph reveals an enlarged cardiac silhouette, bilateral perihilar haziness, and cephalization of the pulmonary vessels, without subdiaphragmatic free air. Which of the following are the most appropriate next steps in the management of this patient? (Select 2)

A 45-year-old woman is evaluated on postoperative day 1 following an uncomplicated open cholecystectomy. She reports mild pain at the incision site but otherwise feels well. Her temperature is 38.2°C (100.8°F), blood pressure is 122/78 mmHg, pulse is 88/min, and respirations are 16/min. Physical examination reveals decreased breath sounds at both lung bases. The surgical incision is clean, dry, and intact with no erythema, induration, or purulent drainage. The patient's calves are non-tender. Which of the following is the most appropriate next step in management?

A 42-year-old woman is evaluated in the post-anesthesia care unit 90 minutes following a total thyroidectomy for a large multinodular goiter. The nurse urgently requests an evaluation as the patient has become increasingly agitated and is clutching her neck. Vital signs show a blood pressure of 155/90 mm Hg, a heart rate of 115/min, and a respiratory rate of 28/min. Pulse oximetry demonstrates an oxygen saturation of 88% on room air. Physical examination reveals audible inspiratory stridor and a tense, expanding ecchymotic mass over the anterior neck. Arrange the following interventions in the most appropriate chronological sequence for the management of this patient.

Match each classic clinical presentation of an acute surgical abdomen to the most likely diagnosis.

A 62-year-old male patient is evaluated in the emergency department for three days of progressively worsening left lower quadrant abdominal pain accompanied by chills. His vital signs show a temperature of 38.6°C (101.5°F), blood pressure of 128/78 mmHg, and heart rate of 92/min. On physical examination, there is focal tenderness and voluntary guarding in the left lower quadrant, but the abdomen is not rigid and there is no diffuse rebound tenderness. Laboratory evaluation reveals a leukocyte count of 16,500/mm³. A contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis confirms severe sigmoid diverticulitis complicated by a 5.5-cm, well-defined peri-colonic fluid collection.

Arrange the following management steps in the most appropriate chronological sequence for this patient, from immediate acute care to definitive long-term management.

An emergency medical services team transports a 71-year-old man to the acute care bay after he suddenly collapsed at a grocery store. Prior to collapsing, he complained of severe, tearing pain in his lower back and abdomen. His past medical history includes hypertension, hyperlipidemia, and a 45-pack-year smoking history. Upon arrival, he is lethargic but arousable. His temperature is 36.5°C (97.7°F), blood pressure is 74/42 mm Hg, pulse is 128/min, and respirations are 24/min. The patient's skin is pale, cold, and clammy. Physical examination of the abdomen reveals a prominent, expansile, pulsatile mass measuring approximately 7 cm in width. The abdomen is otherwise soft without peritoneal signs. Which of the following is the most appropriate next step in management?

Match each trauma patient presentation with the most appropriate definitive next step in management. Assume airway and breathing have been secured in all patients.

A 35-year-old man is brought to the emergency department after a motor vehicle collision. On initial evaluation, he opens his eyes only when the physician loudly calls his name. When asked what happened, he responds with single, random words that do not form coherent sentences. When pressure is applied to his right fingernail bed, he briskly flexes his elbow to pull his right arm away from the stimulus, but does not reach toward the examiner's hand. What is this patient's Glasgow Coma Scale (GCS) score?

Match each classic thoracic trauma clinical presentation with its most appropriate definitive diagnostic modality or immediate intervention.

An 82-year-old man is brought to the emergency department from a long-term care facility due to progressive abdominal swelling and a lack of bowel movements for the past three days. He has a history of Parkinson disease, hypertension, and chronic constipation. His medications include carbidopa-levodopa, amlodipine, and a daily multivitamin. On arrival, his temperature is 37.1°C (98.8°F), blood pressure is 138/82 mm Hg, pulse is 86/min, and respiratory rate is 16/min. Physical examination reveals a markedly distended, tympanitic abdomen. There is mild diffuse tenderness to palpation, but no guarding, rigidity, or rebound tenderness. Digital rectal examination demonstrates an empty rectal vault. Laboratory studies reveal a leukocyte count of 8,200/mm³ and normal serum electrolytes. A plain abdominal radiograph demonstrates a massively dilated large bowel loop resembling an inverted U-shape extending from the pelvis toward the right upper quadrant, with a loss of haustral markings. Which of the following is the most appropriate next step in management?

A 62-year-old man presents to the emergency department with a 2-day history of constant, worsening left lower quadrant abdominal pain. He also reports fever, mild nausea, and no bowel movements for the past 48 hours. His medical history is significant for hypertension and chronic constipation. His temperature is 38.6°C (101.5°F), blood pressure is 135/85 mm Hg, pulse is 92/min, and respirations are 16/min. Physical examination reveals focal tenderness to palpation in the left lower quadrant with voluntary guarding, but no rebound tenderness or diffuse rigidity. Laboratory studies show a leukocyte count of 14,000/mm³. Which of the following is the most appropriate next step in evaluation?

An 81-year-old woman is brought to the emergency department from a long-term care facility due to severe, unrelenting abdominal pain and recurrent bilious vomiting for the past 24 hours. She has not had a bowel movement or passed flatus for 2 days. Her medical history includes atrial fibrillation, hypertension, and osteoarthritis. She has no history of previous abdominal surgeries. Her temperature is 38.6°C (101.5°F), pulse is 122/min, and blood pressure is 94/56 mm Hg. Physical examination reveals a markedly distended and tympanic abdomen with diffuse guarding and rebound tenderness. Bowel sounds are absent. A firm, exquisitely tender, 4-cm mass is palpable in the right groin, located inferior to the inguinal ligament and medial to the femoral artery pulsation. The skin overlying the mass is erythematous and dusky. Laboratory studies show a leukocyte count of 19,500/mm³ and a serum lactate of 4.2 mmol/L. Which of the following is the most appropriate next step in management?

A 62-year-old man is evaluated in the surgical intensive care unit for a new-onset fever. He was admitted 12 days ago after sustaining severe blunt abdominal trauma in a motor vehicle collision. He underwent an emergency exploratory laparotomy with splenectomy and repair of multiple small bowel lacerations. His postoperative course has been complicated by acute respiratory distress syndrome requiring prolonged mechanical ventilation, and he has been receiving total parenteral nutrition via a right internal jugular central venous catheter for the past 10 days.

Today, his temperature has spiked to 39.4°C (102.9°F). Blood pressure is 100/65 mm Hg, pulse is 118/min, and respirations are 22/min on the ventilator. He is sedated but grimaces when the right upper quadrant of his abdomen is palpated. The laparotomy incision is clean and intact. The central venous catheter site shows no erythema, induration, or purulent exudate.

Blood and urine cultures are drawn, and empiric broad-spectrum intravenous antibiotics are initiated.

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

A 42-year-old male is transported to the emergency department via helicopter after a high-speed motorcycle collision. Upon arrival, his airway is patent, and breath sounds are vesicular and equal bilaterally. His blood pressure is 75/40 mmHg, and his heart rate is 132/min. The abdomen is soft, non-distended, and without rebound tenderness. Examination of the lower half of the body reveals a shortened and externally rotated right lower extremity, as well as significant ecchymosis over the scrotum and perineum. Gentle palpation of the iliac crests reveals abnormal mobility. A focused assessment with sonography for trauma (FAST) examination demonstrates no free intraperitoneal or pericardial fluid. Intravenous access is established, and administration of uncrossmatched blood is initiated. Which of the following is the most appropriate next step in management?

A 22-year-old male is brought to the emergency department via ambulance after being struck by a motor vehicle while riding his bicycle. He was reportedly thrown over the handlebars. On arrival, he is confused and diaphoretic. His temperature is $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), blood pressure is $78/40\text{ mmHg}$, pulse is $135\text{/min}$, and respirations are $24\text{/min}$. Oxygen saturation is $97\%$ on room air. The airway is clear, and breath sounds are equal bilaterally. Primary survey reveals marked abdominal distension with diffuse guarding and rebound tenderness. A focused assessment with sonography for trauma (FAST) demonstrates a large amount of free fluid in the hepatorenal recess (Morison's pouch). Intravenous fluid resuscitation is initiated with $1\text{ L}$ of warmed crystalloid, but his repeat blood pressure is $80/42\text{ mmHg}$. Which of the following is the most appropriate next step in management?

Match each anatomic description or clinical presentation with the correct type of abdominal or pelvic hernia.

Lower extremity injuries frequently involve concurrent vascular, neurologic, or systemic complications that require distinct, time-sensitive interventions. Match each specific lower extremity trauma presentation with its most appropriate next step in management or definitive intervention.

Match the following clinical presentations of abdominal pathology with their most appropriate definitive surgical or procedural management.

An otherwise healthy 42-year-old male undergoes an uncomplicated open appendectomy for acute appendicitis. Approximately 24 hours after the procedure, the nursing staff notes a new-onset temperature of 38.4°C (101.1°F). The patient reports mild incisional pain but denies dyspnea, cough, dysuria, or calf pain. Blood pressure is 128/76 mm Hg, pulse is 88/min, and respirations are 16/min. The surgical dressing is dry and intact, with no surrounding erythema. Auscultation of the chest reveals diminished breath sounds over both lung bases. Which of the following is the most likely etiology of this patient's elevated temperature?

A 59-year-old man is evaluated in the recovery unit four hours after undergoing a percutaneous coronary intervention via a right common femoral artery approach. He now complains of sudden, intense pain in his right foot and numbness in his toes. His vital signs are within normal limits. On physical examination, the right foot is mottled, pale, and cold to the touch compared to the left. The right femoral pulse is bounding. The right popliteal, dorsalis pedis, and posterior tibial pulses are not palpable and are absent on handheld Doppler ultrasound. He exhibits weakened plantar flexion of the right foot and decreased sensation over the dorsal and plantar surfaces. Which of the following is the most appropriate next step in the management of this patient?