Surgery

A 31-year-old man is brought to the emergency department by ambulance after sustaining a stab wound to the abdomen during a physical altercation. On arrival, he is lethargic and pale. Vital signs are temperature $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure $78/42\text{ mmHg}$, pulse $142/\text{min}$, and respirations $24/\text{min}$. Pulse oximetry is $97\%$ on high-flow oxygen. Primary survey reveals a patent airway and equal bilateral breath sounds. There is a single $4\text{ cm}$ laceration in the left upper quadrant, just below the costal margin. The patient's abdomen is markedly distended, rigid, and exhibits diffuse rebound tenderness. Peripheral pulses are thready. Two large-bore intravenous lines are established, and isotonic fluid resuscitation is initiated. Which of the following is the most appropriate next step in the management of this patient?

A 61-year-old man is evaluated on postoperative day 2 following an open repair of a large ventral hernia. He reports mild shortness of breath and states that it is extremely painful to take a deep breath or cough. His temperature is $38.3^\circ\text{C}$ ($101.0^\circ\text{F}$), blood pressure is $135/85\text{ mmHg}$, pulse is $92/\text{min}$, and respiratory rate is $20/\text{min}$. Pulse oximetry shows an oxygen saturation of $93\%$ on room air. On physical examination, the abdominal dressing is clean, dry, and intact with no surrounding erythema. Pulmonary auscultation reveals decreased breath sounds at the lung bases bilaterally, but no crackles, rhonchi, or wheezing are heard. Cardiac examination shows a regular rate and rhythm without murmurs. The calves are soft and non-tender. Laboratory studies show a leukocyte count of $12,200/\text{mm}^3$. Which of the following are the most appropriate management steps for this patient's current condition? (Select 2)

An 82-year-old woman is brought to the emergency department from a skilled nursing facility due to a 3-day history of progressive abdominal distension, colicky abdominal pain, and intractable vomiting. The nursing facility staff reports that her vomit has a dark green, bilious appearance and she has not had a bowel movement or passed flatus for the last 4 days. Her medical history is significant for moderate dementia, hypertension, and recurrent episodes of postprandial right upper quadrant pain for which she previously declined surgical intervention.

Vital signs are:
Temperature: 37.4°C (99.3°F)
Heart rate: 105/min
Blood pressure: 110/70 mm Hg
Respiratory rate: 18/min

Physical examination reveals a markedly distended abdomen with high-pitched, hyperactive bowel sounds. There is mild, diffuse tenderness to palpation, but no guarding, rigidity, or rebound tenderness. Laboratory studies show a leukocyte count of 11,000/mm³ and mild hypokalemia.

A computed tomography (CT) scan of the abdomen and pelvis reveals dilated loops of small bowel with a distinct transition point in the right lower quadrant, air within the biliary tree, and a 3-cm radio-opaque, calcified mass impacted in the terminal ileum.

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

A 38-year-old man is brought to the trauma bay following a high-speed motorcycle collision. He is confused and agitated. His blood pressure is 75/40 mm Hg, and his heart rate is 142/min. His airway is patent, and breath sounds are clear and equal bilaterally. The pelvis is clinically stable on examination, and there are no obvious sources of external hemorrhage. Arrange the following steps in the most appropriate chronological sequence for the evaluation and management of this patient's condition.

A 68-year-old man is evaluated on postoperative day 1 following an open partial gastrectomy for a perforated gastric ulcer. His past medical history is significant for hypertension and type 2 diabetes mellitus. The nursing staff reports that his urine output over the last 2 hours has been a total of $25$ mL. His temperature is $37.2^{\circ}\text{C}$ ($99.0^{\circ}\text{F}$), blood pressure is $105/65$ mmHg, pulse is $108/\text{min}$, and respiratory rate is $16/\text{min}$. The patient is currently receiving intravenous normal saline at $100$ mL/hr and has an indwelling Foley catheter in place. The abdomen is tender near the surgical incision with no rebound or guarding. Arrange the following steps in the most appropriate chronological order for the evaluation and management of this patient's postoperative oliguria.

Following three days of progressive obstipation and bilious vomiting, a 48-year-old man arrives at the emergency department. He states that his abdominal pain, which was initially intermittent and crampy, has abruptly become constant and excruciating within the last few hours. His surgical history includes a midline laparotomy for a ruptured appendix a decade ago. Vital signs show a temperature of 38.6°C (101.5°F), a pulse of 118/min, and a blood pressure of 96/60 mm Hg. The abdominal examination demonstrates widespread rigidity, diffuse rebound tenderness, and absent bowel sounds. Blood tests indicate a leukocyte count of 18,500/mm³ and an elevated serum lactate. Upright abdominal radiographs reveal prominent dilated loops of small bowel with multiple air-fluid levels and no free air. Which of the following is the most appropriate next step in the management of this patient?

Match each patient's clinical presentation with the most likely surgical diagnosis.

A 42-year-old woman is brought to the emergency department by ambulance following an all-terrain vehicle (ATV) rollover. She was thrown from the vehicle and struck her abdomen against a large rock. She reports severe diffuse abdominal pain. On presentation, her temperature is 36.6°C (97.9°F), blood pressure is 82/50 mmHg, pulse is 132/min, and respirations are 24/min. Intravenous fluid resuscitation with lactated Ringer's is initiated. Primary survey demonstrates an intact airway and clear, equal breath sounds bilaterally. The abdomen is visibly distended with diffuse involuntary guarding and rebound tenderness. Compression of the iliac crests reveals a stable pelvis. A bedside focused assessment with sonography for trauma (FAST) is performed and demonstrates an anechoic fluid collection in the hepatorenal recess (Morison pouch). Which of the following is the most appropriate next step in management?

Emergency medical services bring a 24-year-old male to the trauma center following a high-velocity motorcycle collision. He was found approximately 30 meters from his vehicle without a helmet. Due to a severely depressed level of consciousness (Glasgow Coma Scale score of 5), he was intubated at the scene. Upon arrival, he is receiving mechanical ventilation. Vital signs show a blood pressure of $76/40 \text{ mmHg}$ and a heart rate of $142 \text{ /min}$. Physical examination reveals a right pupil that is $7 \text{ mm}$ and unresponsive to light, while the left pupil is $3 \text{ mm}$ and reactive. Breath sounds are clear and symmetric bilaterally. A portable chest radiograph shows clear lung fields without pneumothorax. A portable pelvic radiograph demonstrates intact pelvic ring structures. Bedside ultrasonography of the abdomen demonstrates a significant anechoic fluid collection between the liver and the right kidney. Two large-bore intravenous lines are present, and the massive transfusion protocol is actively running. What is the most appropriate next step in the management of this patient?

A 19-year-old male collegiate rugby player collapses on the field after being tackled forcefully around the midsection by an opposing player. He is rushed to the emergency department. En route, emergency medical services administer 2 L of intravenous crystalloid solution. On arrival, he is restless and complaining of severe abdominal pain. His temperature is 36.1°C (97.0°F), pulse is 142/min, blood pressure is 76/40 mm Hg, and respiratory rate is 26/min. Oxygen saturation is 98% on high-flow oxygen. Physical examination reveals an exquisitely tender, board-like abdomen with severe rebound tenderness across all four quadrants. There is early ecchymosis developing over the periumbilical area. The pelvis is mechanically stable to anteroposterior and lateral compression. Cardiopulmonary auscultation reveals clear breath sounds bilaterally. Which of the following interventions should be prioritized next for this patient?

A 74-year-old man is brought to the emergency department from a long-term care facility due to progressive abdominal distension, severe pain, and recurrent vomiting for the past 48 hours. He has not had a bowel movement or passed flatus for 3 days. His medical history is significant for an open ventral hernia repair 8 years ago. On arrival, his temperature is 39.4°C (102.9°F), blood pressure is 85/50 mm Hg, pulse is 128/min, and respirations are 24/min. Physical examination reveals a markedly distended abdomen with diffuse rigidity, severe rebound tenderness, and absent bowel sounds. Laboratory studies show a leukocyte count of 24,000/mm³ and a serum lactate level of 6.8 mmol/L. An upright abdominal radiograph demonstrates multiple dilated loops of small bowel with prominent air-fluid levels and a paucity of colonic gas. Which of the following is the most appropriate next step in the management of this patient?

An individual in his late sixties is evaluated in the surgical assessment unit due to persistent crampy abdominal pain and multiple episodes of bilious vomiting over the past 48 hours. He reports no passage of stool or flatus since the symptoms began. The patient has a surgical history significant for an open partial colectomy performed a decade ago. Vital signs demonstrate a temperature of 38.5°C (101.3°F), pulse of 118/min, and blood pressure of 96/60 mmHg. Physical examination reveals a markedly distended abdomen with absent bowel sounds. Palpation elicits diffuse guarding and pronounced rebound tenderness, particularly in the periumbilical area. Laboratory investigations show a leukocyte count of 18,200/mm³ with 85% neutrophils and a serum lactate concentration of 4.1 mmol/L. Upright radiograph displays dilated small intestinal loops with prominent air-fluid levels and a complete lack of colonic gas. 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 3 hours after a total thyroidectomy for a large multinodular goiter. The nurse urgently calls for evaluation because the patient is agitated and reports increasing difficulty breathing. Her blood pressure is 162/94 mm Hg, pulse is 118/min, and respirations are 28/min. Pulse oximetry shows an oxygen saturation of 88% on room air. Physical examination reveals audible inspiratory stridor. The anterior neck appears significantly swollen, tense, and ecchymotic beneath the surgical dressing. Arrange the following steps in the most appropriate chronological order for the immediate management of this patient's condition.

A 28-year-old man is brought to the emergency department via ambulance after being rescued from a house fire. The incident occurred exactly 2 hours prior to arrival. He weighs $80$ kg. Primary survey reveals a patent airway, clear breath sounds bilaterally, and a heart rate of $115$/min. Physical examination shows deep partial-thickness and full-thickness burns covering his entire anterior torso, entire right arm, and the anterior surface of his right leg. Peripheral intravenous access is established. Based on current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burn resuscitation (using $2 \text{ mL/kg/\%TBSA}$), what should be the initial intravenous crystalloid fluid infusion rate programmed for the remainder of the first 8 hours post-injury?

A 35-year-old male construction worker is brought to the emergency department after falling 20 feet (6 meters) from a scaffold. He is secured to a backboard with a rigid cervical collar in place. He is obtunded, opens his eyes only to painful stimuli, and makes incomprehensible sounds. Vital signs are temperature 36.5°C (97.7°F), blood pressure 75/45 mm Hg, pulse 135/min, and respirations 28/min. Pulse oximetry shows 88% on high-flow oxygen. Physical examination reveals copious blood in the oropharynx with audible gurgling. There are absent breath sounds and dullness to percussion over the right hemithorax. The abdomen is grossly distended and rigid. Arrange the following management steps in the most appropriate sequential order according to the Advanced Trauma Life Support (ATLS) protocol.

A 45-year-old male construction worker arrives at the emergency department triage desk complaining of an abrupt onset of excruciating epigastric pain that began 2 hours ago. The pain has now spread throughout his entire abdomen. He appears acutely ill, diaphoretic, and lies completely still on the gurney. Vital signs show a temperature of 38.2°C (100.8°F), blood pressure of 100/60 mm Hg, heart rate of 115/min, and respiratory rate of 22/min. Physical examination demonstrates a rigid, board-like abdomen with severe, diffuse rebound tenderness and involuntary guarding. Arrange the following steps in the most appropriate chronological sequence for the initial evaluation and management of this patient.

On postoperative day 8 following an exploratory laparotomy and right salpingo-oophorectomy for a ruptured ectopic pregnancy, a 42-year-old woman requires urgent evaluation for sudden, severe abdominal pain. She had previously been recovering appropriately, with a return of bowel function and tolerance of a soft diet by day 4. However, over the past 12 hours, she has developed colicky pain and recurrent bilious vomiting, and she has not passed flatus or stool. Her temperature is 38.7°C (101.7°F), blood pressure is 100/65 mmHg, pulse is 122/min, and respirations are 22/min. On examination, the patient is in obvious distress. Her abdomen is markedly distended. Palpation elicits diffuse tenderness, involuntary guarding, and severe rebound tenderness. Bowel sounds are absent. Laboratory results indicate a leukocyte count of 16,800/mm³ with 12% bands and a serum lactate level of 3.8 mmol/L. An upright abdominal radiograph demonstrates multiple air-fluid levels within dilated loops of small intestine and a paucity of colonic gas. Which of the following is the most appropriate next step in management?

Match each clinical presentation of peptic ulcer disease complications with its most appropriate definitive surgical management.

Emergency medical services via helicopter transport a 22-year-old male to the trauma center following a high-speed motorcycle crash. Upon arrival, he has a traumatic partial amputation of the left lower leg. Bright red blood is spurting profusely through the prehospital bandages despite direct pressure. The patient is unresponsive, with a Glasgow Coma Scale score of 6, and is making gurgling respiratory sounds. His abdomen is markedly distended and rigid to palpation. Vital signs are temperature $35.2^\circ\text{C}$ ($95.4^\circ\text{F}$), heart rate $148/\text{min}$, blood pressure $70/40 \text{ mm Hg}$, and respiratory rate $8/\text{min}$. Large-bore intravenous access is currently being established. Arrange the following management steps in the most appropriate chronological order according to current Advanced Trauma Life Support (ATLS) and damage control surgery principles.

A 62-year-old man is brought to the emergency department complaining of severe abdominal pain. He reports a two-day history of crampy abdominal discomfort, accompanied by multiple episodes of bilious emesis and an inability to pass flatus. His surgical history is significant for an open appendectomy at age 25. Earlier today, the pain acutely transitioned from intermittent cramps to a constant, sharp pain. His temperature is 38.8°C (101.8°F), blood pressure is 92/60 mmHg, and heart rate is 122/min. On physical examination, the abdomen is distended, rigid, and exhibits diffuse rebound tenderness and involuntary guarding. Which of the following is the most appropriate next step in the management of this patient?