Surgery

A 22-year-old man is brought to the trauma bay after being struck by a car while crossing the street. He is moaning in pain and has visible bruising on his chest and abdomen. According to the Advanced Trauma Life Support (ATLS) protocol, arrange the following initial assessment and management steps in the correct chronological order.

A 72-year-old man visits his primary care provider to discuss a 3-month history of a persistent, dry cough and worsening shortness of breath. He reports hearing a "whistling" sound when breathing, which he initially attributed to a respiratory infection. He has a 40-pack-year smoking history. A recent trial of nebulized bronchodilators prescribed at an urgent care clinic provided no relief. Over the past month, his voice has become progressively hoarse. Blood pressure is 162/94 mm Hg in the right arm and 160/92 mm Hg in the left. Pulse is 84/min, and respirations are 20/min. Physical examination reveals a harsh, high-pitched inspiratory sound heard most prominently over the anterior neck and upper sternum. Lung fields are clear to auscultation bilaterally. Cardiac examination reveals a regular rate and rhythm with no murmurs. There is no peripheral edema. A chest radiograph demonstrates a widened mediastinum with deviation of the trachea to the right, but no focal consolidation or pleural effusion. Based on the clinical presentation and imaging findings, which of the following is the most likely underlying mechanism for this patient's respiratory and vocal symptoms?

A 45-year-old man is admitted to the intensive care unit with severe acute gallstone pancreatitis. After initial improvement with aggressive fluid resuscitation and supportive care, he develops a new-onset fever of 39.4°C (102.9°F), leukocytosis of 18,000/mm³, and increasing abdominal pain on hospital day 14. He remains hemodynamically stable. Assuming each intervention is indicated by the findings or clinical failure of the preceding step, arrange the following management steps in the most appropriate 'step-up' sequence for this patient's suspected complication.

A 74-year-old man is brought to the emergency department after passing a large volume of bright red blood per rectum at home. Upon arrival, he is confused and diaphoretic. His blood pressure is 82/50 mm Hg, and his heart rate is 125/min. His abdomen is soft, non-tender, and non-distended. Digital rectal examination reveals copious gross bright red blood. He has a history of hypertension, hyperlipidemia, and osteoarthritis. Arrange the following interventions in the most appropriate sequence for the management of this patient's acute life-threatening hemorrhage.

A 28-year-old military contractor is brought to the trauma bay immediately after an improvised explosive device (IED) blast. On arrival, bright red blood is vigorously spurting from a right mid-thigh amputation. The patient has agonal respirations, severe maxillofacial crush injuries, and a hoarse, gurgling voice. Physical examination reveals absent breath sounds on the left hemithorax with distended neck veins. His blood pressure is undetectable, and his heart rate is 145/min. Arrange the following critical management steps in the correct chronological order according to the Advanced Trauma Life Support (ATLS) primary survey protocol.

Match each classic clinical presentation to its most likely acute surgical diagnosis.

A $62$-year-old male is urgently assessed on the general surgery floor on postoperative day $5$ following an elective open sigmoid colectomy for recurrent diverticulitis. Over the preceding $12$ hours, the patient has become increasingly lethargic and reports new-onset, agonizing abdominal pain. Temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $78/46 \text{ mmHg}$, pulse is $132/\text{min}$, and respirations are $28/\text{min}$. Pulse oximetry shows $94\%$ on room air. The patient appears diaphoretic and is poorly responsive to questioning. Physical examination reveals a markedly distended and rigid abdomen with diffuse guarding and severe rebound tenderness across all quadrants. The surgical incision is intact without erythema or drainage. Bowel sounds are absent. Laboratory analysis demonstrates a leukocyte count of $22,000/\text{mm}^3$ with $15\%$ bandemia and a serum lactate of $6.4 \text{ mmol/L}$. Peripheral intravenous access is secured, a $2\text{-L}$ bolus of isotonic crystalloid is rapidly infused, and broad-spectrum antimicrobial therapy is initiated. A repeat blood pressure measurement is $82/50 \text{ mmHg}$.

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

A 45-year-old woman is evaluated on postoperative day 5 following an elective open cholecystectomy for symptomatic cholelithiasis. Her postoperative course was initially uncomplicated, but today she reports new-onset pain at the surgical incision site. Her temperature is 38.5°C (101.3°F), blood pressure is 122/78 mm Hg, pulse is 88/min, and respirations are 14/min. Physical examination of the abdomen reveals normal bowel sounds and no generalized tenderness. The surgical incision has a 3-cm area of erythema and fluctuance at its inferior aspect. Gentle palpation yields purulent discharge from between the skin staples. There is no surrounding induration or crepitus. Which of the following is the most appropriate next step in management?

A 68-year-old man is evaluated on postoperative day 2 after undergoing an elective right total hip arthroplasty for severe osteoarthritis. His medical history includes hypertension and diet-controlled type 2 diabetes mellitus. His temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $135/85\text{ mmHg}$, pulse is $88\text{/min}$, and respiratory rate is $16\text{/min}$. Oxygen saturation is $94\%$ on room air. The patient reports mild incisional pain that is well-controlled with oral analgesics, but denies chest pain, shortness of breath, dysuria, or leg pain. Physical examination reveals decreased breath sounds and fine crackles at the bilateral lung bases. The surgical incision is clean, dry, and intact with no surrounding erythema or discharge. The bilateral calves are non-tender and without swelling. Based on the most likely diagnosis, which of the following are the most appropriate next steps in management? (Select all that apply)

Paramedics rush a 41-year-old female to the emergency department after she was thrown from a horse. The patient is confused and diaphoretic. Vital signs show a heart rate of 135/min, respiratory rate of 24/min, and blood pressure of 78/50 mm Hg. Large-bore intravenous access is established, and a 1-liter bolus of crystalloid is rapidly infused, but her blood pressure only improves to 82/55 mm Hg. Physical examination reveals extensive ecchymosis and guarding over the left upper quadrant of the abdomen. A bedside focused assessment with sonography for trauma (FAST) demonstrates a large anechoic stripe in the splenorenal recess. Which of the following is the most appropriate next step in management?

A 42-year-old woman is evaluated in the surgical ward on postoperative day 2 following an open total abdominal hysterectomy for large, symptomatic uterine fibroids. Her preoperative hemoglobin was $8.2 \text{ g/dL}$. Due to symptomatic anemia (fatigue, tachycardia) and a current hemoglobin of $6.8 \text{ g/dL}$, a transfusion of packed red blood cells is initiated. Twenty minutes into the transfusion, the patient reports sudden-onset severe back pain, chills, and shortness of breath. Her urine in the Foley catheter tubing suddenly appears dark red.

Arrange the following steps in the most appropriate chronological order for the immediate management of this patient's condition.

A 52-year-old man presents to the emergency department with a 2-day history of progressive pain, swelling, and redness over his left knee. He works as a carpet layer and spends several hours a day kneeling. His temperature is 38.2°C (100.8°F), pulse is 92/min, and blood pressure is 128/82 mmHg. Physical examination reveals a fluctuant, erythematous, and exquisitely tender mass localized directly over the anterior aspect of the left patella. The overlying skin is warm to the touch. There is no bulging of the parapatellar recesses, and the patellar ballottement test is negative. The patient is able to achieve 130 degrees of passive knee flexion with minimal discomfort. Which of the following is the most appropriate immediate next step in management?

A 34-year-old man is brought to the emergency department after sustaining a single stab wound to the left lateral chest during an altercation. On arrival, he is in severe respiratory distress. His blood pressure is 82/50 mmHg, heart rate is 128/min, and oxygen saturation is 88% on room air. Physical examination reveals a 3-cm linear laceration in the left 5th intercostal space at the mid-axillary line. Breath sounds are markedly diminished on the left side, and the trachea is deviated to the right. A needle thoracostomy is immediately performed, followed by placement of a left-sided tube thoracostomy. The chest tube yields a rush of air and 400 mL of dark blood. Following the procedure, the patient's oxygen saturation improves to 96% on supplemental oxygen, but his blood pressure remains 84/52 mmHg and heart rate is 125/min. A focused assessment with sonography for trauma (FAST) exam reveals no pericardial effusion but demonstrates a large amount of anechoic fluid in the splenorenal recess. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation and physical examination findings with the most likely injured shoulder structure and its corresponding functional deficit.

A 38-year-old female presents to the emergency department reporting a 6-hour history of acute, unrelenting, and severe mid-abdominal pain that radiates to her back. She has had three episodes of bilious emesis. Her surgical history is notable for a laparoscopic Roux-en-Y gastric bypass performed three years ago, after which she successfully lost 50 kg (110 lbs). On physical examination, she appears in acute distress. Her temperature is 38.1°C (100.6°F), heart rate is 122/min, blood pressure is 105/65 mm Hg, and respiratory rate is 22/min. The abdomen is moderately distended and demonstrates severe focal tenderness in the periumbilical region, with marked involuntary guarding and rebound tenderness. Laboratory studies reveal a white blood cell count of 17,200/mm³ and an arterial lactate of 4.1 mmol/L. An upright abdominal radiograph is largely non-specific, demonstrating a few minimally dilated loops of small intestine without free air. After initiating intravenous fluid resuscitation and broad-spectrum antibiotics, which of the following is the most appropriate next step in management?

A 38-year-old woman is brought to the emergency department by emergency medical services due to the abrupt onset of excruciating abdominal pain. The pain began 4 hours ago and has progressively worsened, accompanied by multiple episodes of bilious emesis. Her medical history is notable for severe obesity, for which she underwent a laparoscopic Roux-en-Y gastric bypass two years ago, resulting in a 45-kg (99-lb) weight loss. Vital signs show a temperature of 38.5°C (101.3°F), a pulse of 126/min, a respiratory rate of 22/min, and a blood pressure of 84/52 mm Hg. On physical examination, she appears toxic and lies completely still on the stretcher. The abdomen is distinctly distended and tympanitic; palpation elicits diffuse rigidity, marked rebound tenderness, and involuntary guarding. Bowel sounds are absent. A peripheral intravenous line is placed, and isotonic crystalloid resuscitation is rapidly initiated. Which of the following is the most appropriate next step in the care of this patient?

Emergency medical responders transport a 42-year-old bicyclist to the trauma center following a high-speed collision with a delivery van. Upon arrival, the patient is agitated, diaphoretic, and confused. Vital signs show a temperature of 36.4°C (97.5°F), blood pressure of 76/40 mm Hg, heart rate of 138/min, and respiratory rate of 28/min. Physical examination reveals extensive ecchymoses over the left lower thorax and a rigid, distended abdomen with diffuse rebound tenderness. The pelvis is stable to anteroposterior compression. A Focused Assessment with Sonography for Trauma (FAST) reveals a large anechoic stripe in the splenorenal and hepatorenal recesses. The patient's personal belongings include a legally executed advance directive designating his sister as his healthcare proxy. His father arrives at the trauma bay simultaneously and demands to make all treatment decisions. What is the most appropriate next step in management?

A 58-year-old woman is evaluated in the surgical ward for a new-onset fever and worsening abdominal pain. She is currently on postoperative day 6 following an elective open abdominal hysterectomy for symptomatic uterine fibroids. Her temperature is 38.8°C (101.8°F), blood pressure is 122/78 mmHg, pulse is 98/min, and respirations are 16/min. Physical examination of the abdomen reveals a 10-cm midline surgical incision. The lower half of the incision is markedly erythematous, indurated, and warm to the touch. Gentle palpation of the surrounding skin yields a moderate amount of opaque, purulent fluid from the wound edges. The remainder of her physical examination is unremarkable. Which of the following is the most appropriate next step in management?

A 65-year-old man with a history of severe chronic obstructive pulmonary disease, heart failure with reduced ejection fraction, and stage III chronic kidney disease is evaluated on postoperative day 3 following an open abdominal aortic aneurysm repair. Over the past 12 hours, his urine output has decreased to 15 mL/hr. He is increasingly lethargic and mildly confused.

Vital signs are temperature 38.4°C (101.1°F), heart rate 112/min, blood pressure 90/55 mm Hg, and respiratory rate 24/min. Pulse oximetry is 92% on a 3 L/min nasal cannula. Central venous pressure is 16 mm Hg (normal: 2-8 mm Hg).

Physical examination reveals jugular venous distension. Lung auscultation demonstrates bibasilar crackles and scattered expiratory wheezes. The abdomen is moderately distended, tense, and diffusely tender with decreased bowel sounds.

Laboratory studies show:
Blood urea nitrogen: 52 mg/dL
Serum creatinine: 2.6 mg/dL (baseline 1.5 mg/dL)
Serum lactate: 3.8 mmol/L
Fractional excretion of sodium (FENa): 2.5%

A bedside bladder pressure measurement is 26 mm Hg.

Based on these findings, which of the following are the most appropriate immediate steps in management? (Select all that apply)

A 24-year-old man is brought to the emergency department after a high-speed motorcycle collision. He complains of severe pain in his left leg. Physical examination reveals a deformed left knee with an obvious posterior dislocation. The dislocation is promptly reduced in the emergency department. Afterward, palpation of the left pedal pulses reveals they are diminished compared to the right side. The patient remains hemodynamically stable. To evaluate for potential popliteal artery injury, the physician measures systolic blood pressures using a continuous-wave Doppler ultrasound and a sphygmomanometer. The following systolic pressures are recorded:

What is the Ankle-Brachial Index (ABI) of the injured extremity?