Surgery

A 42-year-old man weighing 90 kg is brought to the emergency department via ambulance after being involved in an industrial boiler explosion and fire. The incident occurred exactly 3 hours prior to arrival. He has a patent airway and his respirations are unlabored. Physical examination reveals erythema, blistering, and severe pain over the entire anterior torso and the entire posterior torso. The entire right lower extremity demonstrates leathery, charred, and insensate skin. Both upper extremities exhibit painful, blanching erythema with no blistering. During transport, emergency medical services established peripheral intravenous access and administered exactly 1260 mL of lactated Ringer solution.

Based on current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns, what should the infusion rate (in mL/hour) of lactated Ringer solution be set to for the remainder of the first 8 hours post-injury?

Match each clinical presentation to the most appropriate biliary tract diagnosis.

Match each clinical presentation of anorectal disease with the most appropriate definitive surgical or procedural management.

A 58-year-old man presents to the emergency department with 3 days of progressive left lower quadrant abdominal pain and a subjective fever. His temperature is 38.1°C (100.6°F), blood pressure is 130/80 mm Hg, and heart rate is 88/min. Abdominal examination reveals localized tenderness in the left lower quadrant but no rigidity, rebound, or guarding. Laboratory studies show a leukocyte count of 13,000/mm³. Arrange the following management steps in the most appropriate chronological order for this patient.

Match each of the following clinical presentations of trauma patients with the most appropriate definitive next step in diagnosis or management.

Match the following classic mechanisms of knee injury with their most characteristic diagnostic physical examination finding.

A 55-year-old woman is evaluated in the emergency department due to a 2-day history of diffuse, crampy abdominal pain, accompanied by multiple episodes of green-tinged vomiting and an inability to pass flatus or stool. Her surgical history includes a total abdominal hysterectomy performed 10 years ago. Her temperature is 37.1°C (98.8°F), pulse is 90/min, blood pressure is 128/82 mm Hg, and respirations are 14/min. Physical examination shows a protuberant, tympanitic abdomen with high-pitched, tinkling bowel sounds. There is mild diffuse tenderness to palpation, but no guarding, rigidity, or rebound tenderness. Laboratory studies show a leukocyte count of 8,400/mm³, serum sodium of 137 mEq/L, potassium of 3.4 mEq/L, and normal serum lactate. An upright abdominal plain radiograph reveals multiple dilated loops of small intestine with prominent air-fluid levels and a lack of gas in the colon. What is the most appropriate initial management for this patient?

A $65$-year-old man is evaluated on postoperative day $4$ following a right total knee arthroplasty. He has a history of mild chronic obstructive pulmonary disease (COPD) managed with an as-needed albuterol inhaler. The patient reports sudden-onset shortness of breath and right-sided pleuritic chest pain. Vital signs show a temperature of $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure of $128/82\text{ mmHg}$, heart rate of $115/\text{min}$, and respiratory rate of $24/\text{min}$. Pulse oximetry reveals an oxygen saturation of $88\%$ on room air. Physical examination shows a well-healing surgical incision without erythema or purulence, and the right calf appears swollen compared to the left. Auscultation of the lungs reveals clear breath sounds bilaterally without wheezing or crackles. The physician suspects an acute pulmonary embolism.

Arrange the following steps in the most appropriate chronological order for the diagnostic and therapeutic management of this patient.

A 38-year-old male is brought to the emergency department via ambulance after his compact car was struck on the driver's side by a commercial truck. On arrival, he is pale and lethargic but follows simple commands. Vitals show a temperature of $36.5^{\circ}$ C ($97.7^{\circ}$ F), blood pressure of $82/46$ mm Hg, pulse of $130$/min, and respiratory rate of $28$/min.

Primary survey reveals a patent airway. Breathing assessment demonstrates markedly diminished breath sounds over the left lower hemithorax, and the trachea appears slightly deviated to the right. The abdomen is diffusely tender with involuntary guarding. A focused assessment with sonography for trauma (FAST) reveals an anechoic collection in the splenorenal recess.

An orogastric tube is placed to decompress the stomach. A portable anteroposterior chest radiograph is immediately obtained in the resuscitation bay, which demonstrates the radiopaque tip of the orogastric tube coiled within the left lower thorax and a shift of the mediastinal structures toward the right.

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

A 67-year-old woman is brought to the emergency department due to worsening abdominal pain. For the past two days, she experienced crampy periumbilical pain accompanied by multiple episodes of green vomitus and an inability to pass flatus. Four hours ago, the pain suddenly became constant and diffuse. Her medical history is notable for a total abdominal hysterectomy ten years ago. Her temperature is 38.9°C (102.0°F), pulse is 122/min, blood pressure is 85/55 mm Hg, and respirations are 22/min. Physical examination reveals a distended and silent abdomen with board-like rigidity, diffuse guarding, and severe rebound tenderness. Laboratory studies show a leukocyte count of 19,500/mm³ and a serum lactate level of 4.2 mmol/L. Which of the following is the most appropriate next step in management?

On her second day of recovery following an elective sigmoidectomy for recurrent diverticulitis, a 59-year-old woman is noted to have a temperature of 38.4°C (101.1°F). She complains of mild incisional pain but denies chills, chest pain, shortness of breath, or dysuria. Her other vital signs include a blood pressure of 130/80 mmHg, a pulse of 92/min, and a respiratory rate of 16/min. Oxygen saturation is 96% on room air. The patient has spent most of her time in bed due to pain. Lung auscultation reveals diminished breath sounds over the lower lung fields bilaterally without wheezes or crackles. The surgical abdomen is soft and mildly tender near the incision, with no redness or purulent discharge. The indwelling urinary catheter was removed yesterday. Which of the following is the most appropriate next step in management?

A 62-year-old man is brought to the emergency department after a motor vehicle collision in which he was an unrestrained driver. Paramedics report significant front-end vehicle damage. The patient's wife arrives and states he has a history of alcoholic cirrhosis and was hospitalized two months ago for abdominal distension requiring paracentesis. On presentation, his temperature is 36.8°C (98.2°F), blood pressure is 80/50 mm Hg, heart rate is 132/min, and respiratory rate is 24/min. He is confused but localizes to pain. His airway is patent and breath sounds are equal bilaterally. Physical examination reveals scleral icterus, spider angiomas on the chest, and a markedly distended abdomen with shifting dullness and a positive fluid wave. There is no overt abdominal guarding or rebound tenderness. The pelvis is stable to anterior-posterior and lateral compression. A bedside focused assessment with sonography for trauma (FAST) demonstrates a large volume of anechoic fluid in the hepatorenal recess (Morison pouch) and the splenorenal recess. Which of the following is the most appropriate next step in the management of this patient?

During a home renovation project, a 55-year-old contractor falls approximately 4 meters (13 feet) from a scaffold, landing forcefully on his left side. He is rapidly transported to the local trauma center. On primary survey, his airway is patent and breath sounds are clear and equal bilaterally. Cervical spine precautions are maintained. Vital signs show a heart rate of 132/min, blood pressure of 78/48 mmHg, and respiratory rate of 22/min. Peripheral pulses are weak and thready. Physical examination reveals significant ecchymosis over the left lower rib cage. The abdomen is distended, diffusely tender to palpation, and exhibits involuntary guarding. The pelvis is clinically stable to anterior-posterior and lateral compression. Bedside ultrasonography of the left upper quadrant demonstrates a distinct anechoic fluid collection between the spleen and the left kidney. Which of the following is the most appropriate next step in management?

A 74-year-old woman is brought to the emergency department due to sudden-onset, severe abdominal pain that began 3 hours ago. She reports nausea and one episode of non-bloody emesis. Her past medical history is significant for heart failure with preserved ejection fraction and paroxysmal atrial fibrillation, for which she recently stopped taking her prescribed direct oral anticoagulant due to financial constraints. Temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $142/85$ mmHg, pulse is $118$/min and irregular, and respirations are $20$/min. Physical examination reveals a soft, non-distended abdomen with diffuse mild tenderness to deep palpation, but no rebound tenderness, guarding, or rigidity. Bowel sounds are hypoactive. Rectal examination shows trace heme-occult positive stool. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$, serum bicarbonate of $16$ mEq/L, and serum lactate of $4.8$ mmol/L. Based on standard surgical guidelines, arrange the following management steps in the most appropriate chronological order for this patient.

Paramedics rush a 68-year-old retired teacher into the resuscitation bay after he collapsed at home. His wife reports that he suddenly grabbed his chest and screamed about an agonizing pain tearing through his back before losing consciousness. His medical records indicate a history of chronic tobacco use, severe hypertension, and a previously documented descending thoracic aortic aneurysm measuring 6.1 cm in diameter. Current vital signs exhibit profound hemodynamic collapse: blood pressure is 68/38 mm Hg and heart rate is 128/min with a weak, thready pulse. Point-of-care ultrasound of the chest reveals a massive collection of fluid in the left pleural space. The patient remains unresponsive. Which of the following is the most appropriate next step in management?

A $68$-year-old man comes to the clinic reporting a $6$-month history of bilateral leg pain, tingling, and cramping. The symptoms consistently begin after walking for about $10$ minutes and radiate from his lower back down the posterior aspect of both thighs to the calves. He notes that the discomfort is significantly relieved when he sits down or leans forward on a shopping cart at the grocery store, but it does not improve when he simply stops walking and stands upright. He has a medical history of hypertension and hyperlipidemia. Vital signs are within normal limits. Physical examination reveals normal muscle strength ($5/5$) and intact deep tendon reflexes in both lower extremities. Dorsalis pedis and posterior tibial pulses are $2+$ bilaterally. The skin on the lower legs is warm with normal hair distribution. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient's condition?

A 71-year-old man is evaluated on the surgical floor for acute-onset dyspnea, orthopnea, and palpitations. He underwent an elective open left radical nephrectomy for localized renal cell carcinoma 48 hours ago. The patient has a history of chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy. His current medications include inhaled umeclidinium, low-dose aspirin, and atorvastatin. Temperature is 37.8°C (100.0°F), blood pressure is 105/65 mm Hg, pulse is 115/min and irregularly irregular, and respirations are 28/min. Pulse oximetry shows 89% on room air. The patient is sitting on the edge of the bed and using accessory muscles of respiration. Neck examination demonstrates distended jugular veins while upright. Pulmonary auscultation reveals bilateral dependent crackles, but no expiratory wheezing is present. Cardiac examination confirms an irregular rhythm with a prominent S3 gallop. The surgical incision is well-approximated with no purulent drainage. Which of the following are the most appropriate immediate steps in the management of this patient? (Select all that apply)

A 34-year-old man comes to the emergency department reporting a 3-day history of left shoulder pain, intractable hiccups, and persistent fevers. Fourteen days ago, he underwent an exploratory laparotomy, splenectomy, and distal pancreatectomy following severe blunt abdominal trauma sustained in a motorcycle collision. He was discharged on postoperative day 8. His current temperature is $39.0^\circ\text{C}$ ($102.2^\circ\text{F}$), blood pressure is 122/76 mmHg, pulse is 112/min, and respirations are 22/min. Oxygen saturation is 96% on room air. Physical examination reveals decreased breath sounds at the left lung base. The abdomen is soft with mild tenderness in the left upper quadrant, but no rebound guarding is present. The surgical incision is well-healed without erythema or discharge. Laboratory studies show a leukocyte count of $18,200/\text{mm}^3$. A chest radiograph demonstrates a left-sided pleural effusion and atelectatic changes at the left lung base. Which of the following is the most appropriate next step in management?

A 62-year-old man is evaluated on postoperative day 2 following a robotic-assisted radical prostatectomy. He reports mild chest discomfort that worsens with deep breathing. His temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure is $128/78\text{ mmHg}$, pulse is $92/\text{min}$, and respirations are $20/\text{min}$. Oxygen saturation is $94\%$ on room air. Auscultation reveals decreased breath sounds at the bilateral lung bases without crackles or wheezes. The abdominal incisions are clean, dry, and intact. His indwelling urinary catheter was removed on postoperative day 1, and he is currently voiding without difficulty. Which of the following are the most appropriate next steps in management? (Select exactly 2 correct answers)

A 24-year-old woman arrives at the trauma center via helicopter after losing control while down-hill skiing and forcefully striking a stationary snow-making machine. She complains of severe left flank and abdominal pain. Her temperature is 36.2 °C (97.2 °F), pulse is 135/min, blood pressure is 78/48 mmHg, and respirations are 24/min. On physical examination, her airway is patent, and breath sounds are clear and equal bilaterally. The abdomen exhibits marked tenderness in the left upper quadrant with localized guarding. The pelvis is stable to anteroposterior and lateral compression. A bedside focused assessment with sonography for trauma (FAST) exam reveals an anechoic stripe between the spleen and the left kidney. She is rapidly administered 1 L of warmed lactated Ringer solution and 1 unit of uncrossmatched O-negative packed red blood cells. Reassessment vital signs show a pulse of 128/min and a blood pressure of 82/50 mmHg. Which of the following is the most appropriate next step in the management of this patient?