Surgery

A 54-year-old woman is assessed in the intensive care unit due to declining urine output. She underwent an exploratory laparotomy with small bowel resection for a strangulated internal hernia 24 hours ago. During the complex procedure, she received massive fluid resuscitation. Over the past four hours, her urine output via an indwelling Foley catheter has sequentially measured 15 mL, 12 mL, 10 mL, and 5 mL per hour. She is intubated, sedated, and receiving mechanical ventilation.

Her current vital signs include a temperature of 37.3°C (99.1°F), blood pressure of 105/65 mm Hg, and a heart rate of 118/min. Central venous pressure (CVP) is elevated at 15 mm Hg. Physical examination reveals a markedly firm and tensely distended abdomen. Review of the mechanical ventilator flow sheet demonstrates that peak inspiratory pressures have risen from 22 cm H2O to 42 cm H2O since the morning. Her serum creatinine has increased to 1.9 mg/dL from a preoperative baseline of 0.7 mg/dL.

Which of the following is the most appropriate next step in evaluating or managing this patient's condition?

On the fourth day following an elective left total hip arthroplasty, a 68-year-old female develops a new fever. Her maximum temperature over the past shift was 38.6°C (101.5°F). She has a past medical history of hypertension and chronic obstructive pulmonary disease. The patient complains of increased urinary frequency, burning with urination, and vague suprapubic discomfort. An indwelling urethral catheter was utilized intraoperatively and discontinued 24 hours prior to this current evaluation. Her chronic mild cough remains at baseline with clear sputum. Physical examination demonstrates distant breath sounds bilaterally without focal crackles or wheezing. The surgical wound is well-approximated without erythema, fluctuance, or purulent drainage. Examination of the lower extremities reveals bilateral trace pitting edema without calf tenderness or asymmetric swelling. Vital signs include a blood pressure of 134/82 mmHg, pulse of 94/min, and respiratory rate of 16/min. Oxygen saturation is 95% on ambient air. Which of the following is the most appropriate next step in management?

A 48-year-old woman is evaluated in the post-anesthesia care unit 90 minutes after undergoing a total thyroidectomy for a multinodular goiter. She reports sudden, progressive difficulty breathing and a sensation of severe pressure in her neck. Her voice has become hoarse and muffled. Vital signs are temperature 37.1°C (98.8°F), blood pressure 155/95 mm Hg, pulse 115/min, and respirations 28/min. Oxygen saturation is 89% on 4 L/min via nasal cannula. Physical examination reveals a tense, rapidly expanding swelling beneath the cervical incision and prominent inspiratory stridor. Oxygen by nonrebreather mask is initiated.

Arrange the following management steps in the most appropriate chronological order for this patient.

A 65-year-old man is evaluated on the surgical ward. He is on postoperative day 6 following an emergent exploratory laparotomy for a perforated duodenal ulcer. His medical history is significant for type 2 diabetes mellitus, obesity, and a 40-pack-year smoking history. Over the past 24 hours, he has had several paroxysms of severe coughing. A few minutes ago, while attempting to transition from his bed to a chair, he felt a sudden "tearing" sensation in his abdomen followed by a gush of salmon-colored fluid from his surgical site. On examination, the surgical dressing is saturated. Removal of the dressing reveals complete separation of the fascial edges with loops of small bowel protruding through the abdominal wound. His temperature is 37.2°C (99.0°F), blood pressure is 135/85 mm Hg, pulse is 98/min, and respirations are 20/min.

Arrange the following management steps in the most appropriate chronological order for this patient's acute complication.

A physician is called to the surgical ward to evaluate a 59-year-old female patient for a new-onset fever. The patient underwent a laparotomy and small bowel resection for a strangulated ventral hernia six days ago. Over the past 12 hours, she has developed a fever of $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), chills, and worsening abdominal pain. Vital signs show a blood pressure of $105/65\text{ mmHg}$, pulse of $118/\text{min}$, and respirations of $18/\text{min}$. Physical examination reveals a moderately distended abdomen with marked tenderness in the periumbilical region and hypoactive bowel sounds. The surgical incision is completely closed with surgical staples intact; there is no surrounding erythema, warmth, or purulent drainage. An indwelling urinary catheter was removed on postoperative day two, and the patient has been voiding without difficulty. Cardiopulmonary examination is unremarkable, and there is no lower extremity edema or calf tenderness. A complete blood count reveals a leukocyte count of $17,000/\text{mm}^3$. Which of the following is the most appropriate next step in management?

A 19-year-old male collegiate rugby player is evaluated in the emergency department immediately after a severe on-field collision. During the match, he was struck forcefully in the left flank by an opponent's shoulder. En route to the hospital, he received 1 L of intravenous lactated Ringer solution. Upon arrival, he appears pale, diaphoretic, and lethargic. His temperature is 36.5°C (97.7°F), blood pressure is 78/40 mm Hg, and pulse is 138/min. Oxygen saturation is 99% on room air. The trachea is midline, and breath sounds are clear and symmetric bilaterally. Heart sounds are rapid but normal in intensity, with no jugular venous distention. The abdomen is distended, rigid, and diffusely tender, with significant guarding in the left upper quadrant. The patient also reports worsening pain in his left shoulder while lying supine. A focused assessment with sonography for trauma (FAST) examination reveals an anechoic stripe in the splenorenal recess. What is the most appropriate next step in the management of this patient?

A 72-year-old man is evaluated on postoperative day 2 following an elective open sigmoid colectomy for recurrent diverticulitis. He reports mild incisional pain but denies dyspnea, cough, or dysuria. His temperature is 38.6°C (101.5°F), blood pressure is 132/84 mmHg, pulse is 98/min, and respirations are 18/min. Pulse oximetry shows 95% on room air. Physical examination reveals decreased breath sounds at the lung bases bilaterally without wheezes or crackles. The surgical incision is clean, dry, and intact with no erythema, induration, or purulent drainage. The abdomen is mildly distended with hypoactive bowel sounds. His indwelling urinary catheter was removed on postoperative day 1, and he is voiding without difficulty. Which of the following are appropriate next steps in the management of this patient's current condition? (Select 2 answers)

On the fourth day after undergoing an uncomplicated sigmoid colectomy for recurrent diverticulitis, a 68-year-old man is assessed for new-onset breathing difficulties. Over the past 12 hours, he has developed progressive shortness of breath accompanied by a cough producing thick, yellow sputum. His medical history includes chronic obstructive pulmonary disease (COPD) and heart failure with preserved ejection fraction.

Vital signs are:
Temperature: $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$)
Blood pressure: $135/85\text{ mmHg}$
Heart rate: $108/\text{min}$
Respiratory rate: $24/\text{min}$
Oxygen saturation: $88\%$ on room air

Physical examination reveals a patient in mild respiratory distress using accessory muscles of respiration. Auscultation of the lungs demonstrates a prolonged expiratory phase with diffuse, bilateral wheezing. Jugular venous pressure is normal, and there are no crackles or lower extremity edema. The abdomen is soft, non-distended, and mildly tender around the surgical incision, but lacks guarding or rebound tenderness. The incision is intact with no erythema or purulent drainage.

Laboratory and imaging results:
Leukocyte count: $11,500/\text{mm}^3$
Brain natriuretic peptide (BNP): $85\text{ pg/mL}$ (Normal: $<100\text{ pg/mL}$)
Procalcitonin: $0.05\text{ ng/mL}$ (Normal: $<0.15\text{ ng/mL}$)
Chest radiograph: Hyperinflated lungs and flattened hemidiaphragms; no focal consolidations, pleural effusions, or vascular congestion

Which of the following are the most appropriate next steps in the management of this patient? (Select 2)

Match the following clinical presentations of acute trauma to the most appropriate initial diagnostic or therapeutic intervention according to standard trauma protocols.

A 28-year-old female is brought to the emergency department by emergency medical services after a high-speed motorcycle collision. She was found approximately 30 feet from her vehicle. On arrival, her temperature is 36.5°C (97.7°F), blood pressure is 76/40 mm Hg, pulse is 138/min, and respirations are 28/min. The patient is lethargic and pale. The airway is intact, and breath sounds are present and equal bilaterally. A rigid cervical collar is in place. Abdominal examination reveals diffuse tenderness and guarding. The patient receives 1 L of warmed intravenous crystalloid solution and 1 unit of uncrossmatched packed red blood cells, but her blood pressure only improves to 82/45 mm Hg. A portable chest radiograph shows a widened mediastinum but no evidence of pneumothorax or hemothorax. A focused assessment with sonography for trauma (FAST) examination reveals a large anechoic fluid collection in the hepatorenal recess (Morison's pouch). An anteroposterior pelvic radiograph shows no fractures. Which of the following is the most appropriate next step in management?

Following the primary survey and initial resuscitation in the trauma bay, the next steps in management diverge significantly based on the patient's hemodynamic status, mechanism of injury, and bedside diagnostic findings. Match each clinical presentation below with the most appropriate immediate diagnostic or therapeutic next step.

A 28-year-old carpenter is brought to the emergency department after accidentally severing his right index finger with a table saw. The amputated digit was recovered at the scene and brought to the hospital by coworkers in a dry tissue paper. The patient is hemodynamically stable, and a trauma primary survey reveals no other injuries. The emergency department team is preparing the amputated digit for transport with the patient to a specialized microsurgery center. Arrange the following steps for the proper preservation and transport of the amputated digit in the correct chronological sequence.

Paramedics bring a $54$-year-old woman to the emergency department due to acute, unremitting abdominal pain and persistent bilious vomiting that began $8$ hours ago. Her medical history is notable for a total abdominal hysterectomy for uterine fibroids performed $4$ weeks ago. She reports that the pain initially started as intermittent cramps but rapidly progressed to become constant and excruciating over the last $2$ hours. Her temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $86/52\text{ mm Hg}$, pulse is $128/\text{min}$, and respirations are $24/\text{min}$. The patient appears diaphoretic, toxic, and lies completely still on the gurney. Physical examination reveals a markedly distended abdomen with involuntary guarding, board-like rigidity, and severe rebound tenderness in all four quadrants. Auscultation yields absent bowel sounds. Laboratory analysis demonstrates a leukocyte count of $21,500/\text{mm}^3$ and a serum lactate level of $5.2\text{ mmol/L}$. An upright abdominal radiograph displays multiple dilated loops of small intestine with prominent air-fluid levels and an absence of colonic gas. Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old woman is evaluated in the surgical ward for sudden-onset left-sided shoulder pain, nausea, and severe anxiety. She is currently on her third postoperative day following a laparoscopic Roux-en-Y gastric bypass for morbid obesity. She has a history of obstructive sleep apnea, hypertension, and osteoarthritis. Current medications include subcutaneous enoxaparin, intravenous fluids, and a patient-controlled analgesia pump with morphine.

Vital signs reveal a temperature of $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure of $112/68\text{ mmHg}$, pulse of $132/\text{min}$, and respiratory rate of $22/\text{min}$. Pulse oximetry shows $95\%$ on room air.

Physical examination demonstrates a restless, anxious patient. The lungs are clear to auscultation bilaterally. Cardiac auscultation reveals a rapid, regular rhythm with no murmurs. The abdomen is obese, soft, and mildly tender diffusely, with no rebound tenderness or guarding. The laparoscopic port sites show no erythema or discharge. An electrocardiogram shows sinus tachycardia.

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

A 34-year-old man is brought to the emergency department 30 minutes after being involved in a high-speed motor vehicle collision. He was the unrestrained driver of a vehicle that struck a concrete barrier. On arrival, he is groaning and withdrawing from painful stimuli.

Vital signs are temperature 36.5°C (97.7°F), blood pressure 78/45 mmHg, pulse 135/min, and respirations 22/min.

Primary survey reveals a patent airway and a midline trachea. Breath sounds are clear and equal bilaterally. Jugular venous distention is absent.

The abdomen is distended, with significant guarding and rebound tenderness. The pelvis is stable to anterior-posterior and lateral compression.

Two large-bore intravenous lines are placed, and warmed isotonic crystalloid fluid resuscitation is initiated. A bedside ultrasound examination demonstrates an anechoic stripe between the liver and right kidney.

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

An emergency medical services team transports a 42-year-old male construction worker to the trauma center after he fell approximately $6\text{ meters}$ ($20\text{ feet}$) from a scaffold. On arrival, the patient is confused and complains of severe left-sided abdominal pain and chest wall tenderness. His airway is patent. Initial vital signs demonstrate a temperature of $36.2^\circ\text{C}$ ($97.2^\circ\text{F}$), heart rate of $135/\text{min}$, respiratory rate of $26/\text{min}$, and blood pressure of $78/50\text{ mmHg}$. Symmetrical breath sounds are auscultated bilaterally. He receives a rapid intravenous infusion of $1\text{ L}$ of warmed crystalloid solution and $1\text{ unit}$ of uncrossmatched type O-negative packed red blood cells. Fifteen minutes later, his blood pressure improves to $112/68\text{ mmHg}$ and heart rate decreases to $98/\text{min}$. However, during the secondary survey, he becomes progressively more lethargic. Repeat vital signs show a heart rate of $138/\text{min}$ and a blood pressure of $82/45\text{ mmHg}$. An extended focused assessment with sonography for trauma (E-FAST) reveals a large anechoic collection in the splenorenal recess and no evidence of pneumothorax. Pelvic radiography shows no fractures. Arterial blood gas analysis on room air reveals a pH of $7.21$, $p\text{CO}_2$ of $34\text{ mmHg}$, and calculated bicarbonate of $14\text{ mEq/L}$. Which of the following is the most appropriate next step in the management of this patient?

During a routine follow-up appointment, a 74-year-old male patient reports three months of progressively worsening shortness of breath and a persistent, dry cough. He also notes a recent, unexplained change in his voice, describing it as increasingly hoarse. His past medical history includes a 45-pack-year smoking habit and chronic obstructive pulmonary disease (COPD). Two weeks prior, an urgent care provider treated him with oral corticosteroids and macrolide antibiotics for a presumed COPD exacerbation; however, his symptoms have steadily deteriorated.

Currently, his blood pressure is 158/92 mm Hg, heart rate is 88/min, and respiratory rate is 22/min. Oxygen saturation is 94% on room air. Physical examination reveals a palpable downward pull of the trachea synchronous with cardiac systole. Auscultation of the anterior neck and upper chest demonstrates a prominent, high-pitched inspiratory sound. The lung bases are clear, and there is no peripheral edema. A plain chest radiograph reveals a significantly enlarged aortic silhouette and widening of the mediastinum.

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

A 64-year-old man is evaluated on the surgical ward due to an inability to urinate. He underwent an elective open right inguinal hernia repair under spinal anesthesia 8 hours ago. He reports increasing lower abdominal fullness and a persistent urge to void, but he has been unable to pass urine despite multiple attempts. His temperature is 37.0°C (98.6°F), blood pressure is 130/85 mmHg, and pulse is 82/min. The abdomen is soft and non-distended, with a clean and dry surgical dressing in the right groin. Physical examination reveals mild suprapubic fullness and dullness to percussion. Arrange the following interventions in the most appropriate chronological sequence for managing this patient's condition.

Pair each patient presentation with the most accurate acute surgical diagnosis.

A 45-year-old industrial worker is rapidly brought to the emergency department after being trapped in a structural fire. On arrival, he has obvious soot in his oropharynx, marked hoarseness, and inspiratory stridor. Physical examination reveals deep, leathery, charred skin completely encircling his anterior and posterior thorax. His respiratory rate is 34/min, and he is demonstrating poor breathing efforts with minimal chest wall expansion. Oxygen saturation is 86% on a high-flow oxygen mask. Blood pressure is 98/60 mm Hg, and pulse is 128/min. Arrange the following interventions in the most appropriate chronological sequence based on prioritized trauma and burn life support principles.