Surgery

A 70-year-old man is evaluated in the surgical ward on postoperative day 2 following an elective partial gastrectomy. Over the past 4 hours, his recorded urine output has been 15 mL/hr. He has an indwelling Foley catheter in place. His blood pressure is 105/65 mmHg, heart rate is 98/min, and respiratory rate is 16/min. His mucous membranes appear dry, and his capillary refill time is 3 seconds. Arrange the following steps in the most appropriate chronological sequence for the evaluation and management of this patient's postoperative oliguria.

A 44-year-old woman presents to the emergency department with severe, constant right upper quadrant abdominal pain that began 6 hours ago after eating a fast-food meal. She reports nausea and two episodes of bilious vomiting. Her temperature is 38.2°C (100.8°F), heart rate is 102/min, and blood pressure is 118/76 mmHg. Physical examination reveals marked tenderness in the right upper quadrant with sudden inspiratory arrest during deep palpation. Arrange the following management steps in the most appropriate chronological order for this patient.

A 45-year-old industrial worker is brought to the emergency department after a chemical vat exploded. He sustained deep partial-thickness burns. Physical examination reveals burns covering his entire anterior trunk (chest and abdomen), his entire right upper extremity (both anterior and posterior surfaces), and his entire right lower extremity (both anterior and posterior surfaces). No other areas of the body are affected.

Based on the Rule of Nines, what is the estimated total body surface area (TBSA) percentage affected by burns in this patient?

Match each gastrointestinal surgical procedure to its classic primary clinical indication.

A 75-year-old man who recently underwent a total hip arthroplasty develops progressive abdominal distension over the past 3 days. He has not passed flatus or stool since the surgery. His current medications include intravenous morphine for pain control. Vital signs are within normal limits. Physical examination shows a massively distended, tympanic abdomen without focal tenderness, guarding, or rigidity. Laboratory studies reveal a serum potassium level of 3.1 mEq/L. Computed tomography of the abdomen and pelvis demonstrates diffuse dilation of the colon with a cecal diameter of 10.5 cm, and no evidence of mechanical obstruction or transition point.

Arrange the following management strategies for this condition in the correct sequential order, from the initial best step to the interventions reserved for refractory or complicated cases.

A medical student is reviewing peripheral vascular cases on the surgical ward. For each specific clinical presentation and physical examination finding described below, identify the most accurate corresponding diagnosis or pathological syndrome.

Match each distinct clinical presentation of acute or subacute abdominal pain to its most accurate surgical diagnosis or underlying etiology.

Match each pancreatic cystic lesion with its classic diagnostic finding, histologic characteristic, or indicated management strategy.

A 64-year-old woman is evaluated on postoperative day 6 following an elective right total knee arthroplasty. Her past medical history is significant for moderate chronic obstructive pulmonary disease and diet-controlled type 2 diabetes mellitus. Since the surgery, she has been receiving continuous intravenous piperacillin-tazobactam for surgical site prophylaxis due to a suspected intraoperative contamination event that was later deemed low-risk. Over the last 24 hours, she has developed a new temperature of 38.6°C (101.5°F) and reports five episodes of profuse, watery diarrhea associated with mild lower abdominal cramping. Vital signs include a blood pressure of 118/76 mmHg, a heart rate of 98/min, and a respiratory rate of 16/min. Oxygen saturation is 95% on room air. Physical examination reveals mild diffuse abdominal tenderness without rebound or guarding. Chest auscultation reveals distant breath sounds but no crackles or wheezes. The surgical incision is clean, dry, and intact, and both calves are soft and non-tender. Which of the following is the most appropriate next step in management?

A 28-year-old male construction worker is brought to the emergency department after a heavy concrete block fell on his right leg. His airway is patent, breathing is unlabored, and he is hemodynamically stable. The primary trauma survey reveals no other life-threatening injuries. Examination of the right lower extremity shows a 5-centimeter laceration over the anterior tibia with exposed, fragmented bone and moderate oozing of blood. The right foot is warm, with palpable dorsalis pedis and posterior tibial pulses. Motor and sensory exams of the foot are intact. Arrange the following management steps in the most appropriate chronological order.

Match each clinical trauma presentation with the most appropriate next step in definitive management or diagnosis.

A 61-year-old man is evaluated in the emergency department for sudden, severe, and generalized abdominal pain that started 3 hours ago. He has a past medical history of chronic knee osteoarthritis, for which he takes naproxen regularly. His temperature is 38.4°C (101.1°F), blood pressure is 92/58 mm Hg, and heart rate is 118/min. On physical examination, the patient is visibly uncomfortable and lying rigidly still on the stretcher. The abdomen is distended, diffusely rigid, and exhibits profound rebound tenderness in all quadrants. An upright chest radiograph reveals a crescent of radiolucency beneath the right hemidiaphragm. Intravenous fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

Arriving at the trauma center via helicopter emergency medical services is a 28-year-old male who was involved in a high-speed motorcycle collision. On initial assessment, the patient is lethargic and pale. Vital signs show a temperature of 36.5°C (97.7°F), heart rate of 142/min, blood pressure of 76/40 mm Hg, and respiratory rate of 28/min. The airway is patent, and breath sounds are equal bilaterally. The abdomen is soft and non-distended. Pelvic examination reveals mechanical instability to gentle anteroposterior compression. Blood is noted at the urethral meatus. A focused assessment with sonography for trauma (FAST) demonstrates no free fluid in the peritoneal, pericardial, or pleural spaces. Which of the following is the most appropriate next step in the management of this patient?

Helicopter emergency medical services arrive at a regional burn center with a 50-year-old male who was extricated from a residential fire. The injury occurred exactly 3 hours prior to arrival. Upon presentation, he is intubated and mechanically ventilated. His estimated body weight is 80 kg. Vital signs show a blood pressure of 115/75 mm Hg and a heart rate of 112/min. Physical examination of the skin reveals blistering, weeping, and exquisitely tender lesions over the entire anterior trunk. The entire right lower extremity is covered in white, leathery, and insensate eschar. The entire left upper extremity exhibits diffuse erythema with intact epidermis, blanching on pressure, and no blistering. A large-bore peripheral intravenous catheter is successfully placed. Based on the most current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns, what should the initial intravenous crystalloid infusion rate be set to in mL/hr?

Following a collision with a tree while skiing, a 21-year-old man is transported to the trauma center by medical helicopter. Upon arrival, his blood pressure is 82/45 mm Hg and his heart rate is 128/min. His respiratory rate is 22/min, and oxygen saturation is 98% on high-flow oxygen. He appears pale and is confused, but localizes to painful stimuli. The airway is patent, and breath sounds are equal bilaterally. Examination reveals significant ecchymosis over the left lower chest wall and left upper quadrant of the abdomen. The abdomen is tender to palpation with involuntary guarding. The pelvis is mechanically stable to lateral and anteroposterior compression. Which of the following is the most appropriate next step in the management of this patient?

A 52-year-old man is evaluated on the surgical ward for a new-onset fever. He is currently on postoperative day 9 following an elective sigmoid colectomy for recurrent diverticulitis. His early postoperative course was complicated by a catheter-associated urinary tract infection diagnosed on postoperative day 2, for which his indwelling catheter was removed and he was started on intravenous piperacillin-tazobactam.

Currently, the patient reports feeling well and has been ambulating independently in the hallways. He has no abdominal pain, nausea, vomiting, dysuria, or shortness of breath. He is tolerating a regular diet.

Vital signs are as follows:

Physical examination reveals a soft, non-tender abdomen with a clean, well-approximated surgical incision. There is no calf tenderness or edema. Lungs are clear to auscultation bilaterally.

Laboratory results:

Urinalysis is clear with no leukocyte esterase or nitrites.

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

A 29-year-old male is brought to the emergency department after being crushed between a concrete loading dock and a reversing forklift. On arrival, his airway is patent, and breath sounds are equal bilaterally. Vital signs show a blood pressure of 76/40 mm Hg and a heart rate of 142/min. Physical examination reveals a mechanically unstable pelvis in response to anteroposterior compression. Genitourinary examination demonstrates a scrotal hematoma and a prominent drop of blood at the urethral meatus. A commercial pelvic binder is immediately applied, and a massive transfusion protocol is initiated. Ten minutes later, after the rapid infusion of uncrossmatched packed red blood cells and fresh frozen plasma, his blood pressure remains 78/42 mm Hg. A Focused Assessment with Sonography for Trauma (FAST) examination demonstrates a large stripe of anechoic fluid in the hepatorenal and splenorenal recesses. Which of the following is the most appropriate next step in management?

Paramedics rush a 58-year-old male to the resuscitation bay after he experienced sudden, unbearable epigastric pain followed by a syncopal episode. His past medical history is notable for severe osteoarthritis managed with daily high-dose naproxen. On assessment, the patient is lethargic, diaphoretic, and lies completely motionless on the stretcher. Vital signs are significant for a heart rate of 122/min, blood pressure of 82/50 mmHg, and respiratory rate of 24/min. Abdominal examination reveals diffuse rigidity and exquisite rebound tenderness in all four quadrants. Following administration of 2 Liters of warmed isotonic crystalloid, his blood pressure remains 86/54 mmHg. An upright chest radiograph demonstrates a crescent-shaped radiolucency between the liver shadow and the right hemidiaphragm. Intravenous broad-spectrum antibiotics are initiated. What is the most appropriate next step in the care of this patient?

Paramedics rush a 68-year-old male to the trauma bay following an episode of massive hematemesis at his residence. His wife, who arrived separately, reports to the staff that he experienced a smaller episode of bloody vomiting yesterday but refused medical evaluation at that time. The electronic health record shows a history of hypertension, tobacco use disorder, and an open surgical repair of an infrarenal abdominal aortic aneurysm thirty-six months ago. Currently, the patient is lethargic, diaphoretic, and extremely pale. Vital signs include a temperature of $36.8^\circ \text{C}$ ($98.2^\circ \text{F}$), blood pressure of $70/40 \text{ mm Hg}$, heart rate of $142\text{/min}$, and respiratory rate of $28\text{/min}$. Physical examination reveals a well-healed midline abdominal scar. The abdomen is soft and non-distended without guarding or rebound tenderness. Bilateral femoral pulses are palpable but weak. Arterial blood gas analysis reveals a pH of $7.15$, $\text{pCO}_2$ of $30 \text{ mm Hg}$, and $\text{HCO}_3^-$ of $10 \text{ mEq/L}$. Despite the rapid administration of two units of uncrossmatched O-negative packed red blood cells through two large-bore intravenous lines, his blood pressure remains critically low at $74/42 \text{ mm Hg}$. Which of the following is the most appropriate next step in the management of this patient?

Following a kick to the left flank by a horse, a 45-year-old man arrives at the trauma center. He complains of severe left-sided abdominal pain that radiates to his left shoulder. Upon arrival, he appears in significant distress. Vital signs are temperature 36.8°C (98.2°F), blood pressure 105/65 mm Hg, pulse 112/min, and respirations 18/min. Oxygen saturation is 98% on room air. Two large-bore intravenous lines are established, and he is rapidly infused with 1 L of lactated Ringer solution. Following the fluid resuscitation, his blood pressure improves to 128/76 mm Hg and his pulse decreases to 88/min. Physical examination reveals ecchymosis over the left lower ribs and significant tenderness in the left upper quadrant with voluntary guarding. Breath sounds are clear and equal bilaterally. A bedside focused assessment with sonography for trauma (FAST) reveals a moderate amount of anechoic fluid in the splenorenal recess. Which of the following is the most appropriate next step in management?