Surgery

A 24-year-old university student presents to the outpatient clinic reporting persistent right wrist pain. Approximately 24 hours ago, he fell forward while skateboarding and braced his impact with an outstretched right hand. He describes a constant, dull ache located near the base of his thumb. On physical examination, there is minimal visible swelling and no obvious deformity. Palpation reveals distinct tenderness in the triangular depression on the radial aspect of the wrist when the thumb is fully extended. Capillary refill is less than 2 seconds, and sensation is intact in all digits. Initial anteroposterior, lateral, and scaphoid-view radiographs of the right wrist show no evidence of acute fracture, cortical disruption, or dislocation. Based on these findings, which of the following is the most appropriate next step in patient management?

A 78-year-old woman is brought to the emergency department after slipping and falling in her kitchen. She complains of severe left groin pain and is unable to bear weight on her left leg. She has a medical history of hypertension, type 2 diabetes mellitus, and osteoporosis. Vital signs are temperature 37.1°C (98.8°F), heart rate 82/min, blood pressure 138/86 mm Hg, and respiratory rate 16/min. Physical examination reveals normal alignment of the left lower extremity with no shortening or external rotation. However, severe pain is elicited with active straight leg raise and gentle internal rotation of the left hip. The dorsalis pedis and posterior tibial pulses are 2+ and symmetric. Sensation is intact to light touch in all distal dermatomes. Anteroposterior and cross-table lateral radiographs of the left hip and pelvis show severe osteopenia and degenerative joint disease but no cortical step-off or radiolucent fracture lines. Which of the following is the most appropriate next step in management?

Emergency medical services bring a $74$-year-old woman to the acute care center due to a sudden deterioration in her clinical status. She resides in an assisted living facility and has a surgical history significant for multiple open pelvic operations. Caregivers report that she began experiencing intermittent, crampy abdominal discomfort two days ago, which abruptly transitioned into unrelenting, severe diffuse pain over the last three hours. Upon arrival, she is lethargic. Vital signs reveal a temperature of $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), a heart rate of $128/\text{min}$, and a blood pressure of $82/48\text{ mm Hg}$. Physical assessment reveals a significantly distended abdomen with marked involuntary guarding and rebound tenderness in all four quadrants. Auscultation reveals absent bowel sounds. A point-of-care abdominal radiograph demonstrates markedly dilated small bowel loops and an absence of distal colonic gas. Which of the following is the most appropriate next step in management?

A 59-year-old man is evaluated in the intensive care unit on postoperative day 5 following a partial gastrectomy with Billroth II reconstruction for a perforated peptic ulcer. Over the past 3 hours, he has become increasingly confused and agitated. His temperature is $39.5^\circ\text{C}$ ($103.1^\circ\text{F}$), blood pressure is $76/42\text{ mmHg}$, pulse is $134/\text{min}$, and respirations are $26/\text{min}$. Pulse oximetry shows $94\%$ on room air. Central venous pressure is $3\text{ cm H}_2\text{O}$. Physical examination reveals a rigid, diffusely tender abdomen with involuntary guarding and generalized rebound tenderness. The surgical dressing is saturated with bilious fluid. Laboratory studies show a leukocyte count of $24,000/\text{mm}^3$ with $18\%$ bands. Arterial blood gas analysis on room air reveals a pH of $7.22$, $\text{pCO}_2$ of $32\text{ mmHg}$, and $\text{pO}_2$ of $78\text{ mmHg}$. Which of the following are the most appropriate immediate steps in the management of this patient? (Select 2 answers)

A 62-year-old woman is evaluated on postoperative day 1 following an open total abdominal hysterectomy for symptomatic uterine fibroids. Over the last $6$ hours, her recorded urine output has been a total of $70\text{ mL}$. Her temperature is $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), blood pressure is $100/65\text{ mmHg}$, pulse is $98\text{/min}$, and respiratory rate is $16\text{/min}$. Her oxygen saturation is $98\%$ on room air. She has been receiving maintenance intravenous normal saline at $75\text{ mL/hr}$. Physical examination reveals dry oral mucosa and a soft abdomen with mild incisional tenderness. Breath sounds are clear bilaterally. A Foley catheter is in place. Which of the following are appropriate initial actions in the management of this patient? (Select all that apply)

A 10-year-old boy is brought to the emergency department via ambulance after falling forcefully onto the handlebars of his bicycle. He is pale and intermittently responsive. Heart rate is $155\text{ /min}$, and blood pressure is $72/40\text{ mm Hg}$. Capillary refill time is $4\text{ seconds}$. Intravenous access is rapidly obtained, and an initial bolus of $20\text{ mL/kg}$ of warm isotonic crystalloid is administered, but his vital signs do not improve. Primary survey reveals equal breath sounds bilaterally and no external bleeding. His abdomen is tightly distended with diffuse tenderness. Bedside focused assessment with sonography for trauma (FAST) demonstrates significant free fluid in the splenorenal and hepatorenal recesses.

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

A 52-year-old woman is evaluated in the emergency department after a severe motor vehicle collision. She was the restrained driver of a vehicle that struck a concrete retaining wall at highway speeds. Upon arrival, she is lethargic but her airway is patent. She appears pale and diaphoretic. Vital signs are a temperature of 36.6°C (97.9°F), a pulse of 135/min, a blood pressure of 78/48 mmHg, and a respiratory rate of 28/min. Oxygen saturation is 96% on supplemental oxygen.

Breath sounds are clear and equal bilaterally, and the trachea is midline. Heart sounds are normal. The abdomen is soft, nondistended, and mildly tender to deep palpation in the lower quadrants. There is marked ecchymosis over the suprapubic region. Anteroposterior pelvic radiography performed in the trauma bay demonstrates a symphyseal diastasis of $4 \text{ cm}$ and a displaced fracture of the left sacroiliac joint. A pelvic binder is immediately applied, and she receives rapid intravenous transfusion of uncrossmatched blood products and crystalloid.

Following initial resuscitation, her blood pressure is 82/50 mmHg and pulse is 128/min. A bedside focused assessment with sonography for trauma (FAST) exam demonstrates no pericardial effusion and no intraperitoneal free fluid.

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

A 65-year-old man with a history of an open appendectomy presents to the emergency department with severe crampy abdominal pain, bilious vomiting, and obstipation for the past 24 hours. His vital signs show a heart rate of 110/min and blood pressure of 115/75 mm Hg. Physical examination reveals a distended, tympanic abdomen with high-pitched "tinkling" bowel sounds, but no rebound tenderness or guarding. Arrange the following management steps in the most appropriate sequential order.

During surgical ward rounds, a physician evaluates a patient who is currently on day 5 of recovery following an urgent laparotomy for a perforated duodenal ulcer. The primary nurse reports a new onset of fever. The patient's temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), heart rate is $98/\text{min}$, and blood pressure is $128/82\text{ mmHg}$. The patient complains of severe, throbbing pain at the abdominal incision that has worsened significantly over the past 24 hours. Physical examination reveals an abdominal midline incision closed with surgical staples. There is a $4\text{-cm}$ area of expanding erythema, induration, and marked tenderness around the lower half of the incision, accompanied by spontaneous drainage of thick, purulent fluid. Which of the following is the most appropriate next step in management?

A 72-year-old man is evaluated for decreased urine production on the evening of his first postoperative day. Earlier that morning, he underwent an elective open repair of an infrarenal abdominal aortic aneurysm. His medical history is notable for coronary artery disease, ischemic cardiomyopathy with a left ventricular ejection fraction of 35%, and diet-controlled type 2 diabetes mellitus. Over the past 3 hours, urine output via his indwelling urethral catheter has been 12 mL/hr. The catheter was just flushed with sterile saline and is patent. Vital signs include a temperature of 38.1°C (100.6°F), blood pressure of 94/58 mm Hg, heart rate of 114/min, and respiratory rate of 18/min. Pulse oximetry shows 96% on room air. The patient appears lethargic but is easily arousable. Jugular venous pressure is estimated at 3 cm H2O. Lungs are clear to auscultation bilaterally. Cardiac examination reveals a regular, rapid rhythm with no murmurs or S3 gallop. The abdominal dressing is dry and intact; the abdomen is diffusely tender to palpation but lacks rigidity or rebound.

Laboratory studies:
Hemoglobin: 11.2 g/dL
Leukocyte count: 11,500/mm³
Serum sodium: 136 mEq/L
Serum potassium: 4.6 mEq/L
Blood urea nitrogen: 42 mg/dL
Serum creatinine: 1.9 mg/dL (Baseline: 1.1 mg/dL)
Urine sodium: 8 mEq/L
Fractional excretion of sodium (FENa): 0.6%

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

A 52-year-old man is evaluated in the hospital for a sudden change in his clinical status. He was admitted 12 hours ago with a diagnosis of an acute small bowel obstruction. His medical history includes an open appendectomy complicated by peritonitis 15 years ago. On admission, his vital signs were normal, his abdomen was distended but soft, and he had no signs of peritonitis. He was managed conservatively with intravenous fluids, bowel rest, and nasogastric tube decompression. Over the past hour, his abdominal pain has transitioned from intermittent and crampy to severe, constant, and unremitting. His temperature is 38.9°C (102.0°F), pulse is 124/min, blood pressure is 100/60 mm Hg, and respirations are 24/min. The patient is diaphoretic and lying perfectly still in bed. Physical examination reveals a markedly distended abdomen with diffuse rigidity, involuntary guarding, and severe rebound tenderness. Bowel sounds are absent. Laboratory studies demonstrate a leukocyte count of 19,000/mm³ with a left shift and a serum lactate level of 4.8 mmol/L (Normal: 0.5–2.2 mmol/L). Which of the following is the most appropriate next step in management?

A $45$-year-old man is brought to the emergency department following a high-speed motor vehicle collision. The patient was an unrestrained driver and was ejected from the vehicle. His body mass index is $42 \text{ kg/m}^2$. Upon arrival, he is confused and diaphoretic. His temperature is $36.5^\circ\text{C}$, blood pressure is $76/40 \text{ mmHg}$, pulse is $138\text{ /min}$, and respiratory rate is $24\text{ /min}$. Pulse oximetry shows $97\%$ on high-flow oxygen. Primary survey reveals an intact airway. The trachea is midline, and breath sounds are clear and equal bilaterally. Neck veins are flat. The abdomen is obese with a visible seatbelt sign, but deep palpation is limited; there is mild diffuse tenderness without obvious rigidity. Anteroposterior compression of the pelvis does not elicit instability. Chest and pelvic radiographs show no abnormalities. A bedside focused assessment with sonography for trauma (FAST) is attempted but is technically inadequate and indeterminate due to severe obesity and obscuring bowel gas. Intravenous fluid resuscitation with isotonic crystalloids is initiated. Which of the following is the most appropriate next step in management?

A 45-year-old woman is evaluated in the post-anesthesia care unit (PACU) 2 hours after undergoing an uncomplicated total thyroidectomy for a multinodular goiter. The nurse urgently calls the physician because the patient has developed sudden-onset respiratory distress. The patient is agitated, diaphoretic, and pointing to her throat. She has a high-pitched inspiratory stridor and is using accessory muscles of respiration. Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 145/90 mmHg, heart rate of 118/min, and respiratory rate of 28/min. Oxygen saturation is 88% on room air. Physical examination reveals a tense, rapidly expanding swelling beneath the anterior neck surgical dressing.

Arrange the following management steps in the most appropriate chronological order.

A 22-year-old man is transported to the emergency department after falling approximately 20 feet from a roof. Upon arrival, he is moaning in pain and clutching his left torso. His airway is unobstructed, and breath sounds are clear and symmetric bilaterally. His heart rate is 142/min and his blood pressure is 78/40 mmHg. Supplemental oxygen is applied, and two large-bore intravenous catheters are placed. Following a 1-liter infusion of warmed crystalloid, his blood pressure remains 80/42 mmHg. A bedside ultrasonographic evaluation of the abdomen reveals a significant anechoic fluid collection in the splenorenal recess. Radiographic evaluation of the chest and pelvis demonstrates no acute fractures or abnormalities. Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old man presents to the emergency department with a 5-day history of worsening right lower quadrant abdominal pain, chills, and anorexia. His temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $112/74\text{ mmHg}$, and heart rate is $108/\text{min}$. On physical examination, the abdomen is non-distended. There is a palpable, tender mass in the right lower quadrant with localized guarding, but no diffuse rebound tenderness. Laboratory studies show a leukocyte count of $18,000/\text{mm}^3$ with $85\%$ neutrophils. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 30-year-old man is brought to the trauma bay after a high-speed motorcycle collision. On arrival, he has active, pulsatile bleeding from a partially amputated right lower extremity. He is moaning, his eyes remain closed, and he exhibits abnormal flexion posturing to painful stimuli. His respiratory rate is 32/min, and oxygen saturation is 84% on room air. Auscultation of the chest reveals absent breath sounds on the right side. Arrange the following initial management steps in the most appropriate chronological order according to current trauma resuscitation protocols.

Nursing staff pages the surgical provider on call at 10:00 PM regarding a patient who recently recorded a temperature of $38.4^{\circ}\text{C}$ ($101.1^{\circ}\text{F}$). The patient is a $55$-year-old female recovering from an uncomplicated right hemicolectomy performed for a large, benign tubulovillous adenoma. The operation was completed approximately $28$ hours ago. Her pain is currently managed with a morphine patient-controlled analgesia (PCA) device. She has remained in bed since the surgery due to generalized fatigue and mild incisional pain. She denies nausea, vomiting, cough, dysuria, or shortness of breath. Vital signs show a heart rate of $88\text{ /min}$, blood pressure of $128/82\text{ mm Hg}$, respiratory rate of $16\text{ /min}$, and oxygen saturation of $97\%$ on ambient air. Physical examination demonstrates clear breath sounds bilaterally. The abdomen is non-distended and moderately tender near the midline incision, without guarding or rebound tenderness. The surgical dressing is clean, dry, and intact. Her indwelling urinary catheter, placed in the operating room, is draining clear yellow urine. Which of the following is the most appropriate next step in the management of this patient's elevated temperature?

Match each classic clinical presentation of an acute abdomen with its most appropriate initial management step or definitive treatment.

During morning rounds, a physician is urgently called to evaluate a hospitalized patient whose condition has suddenly deteriorated. The patient is a seventy-two-year-old retired teacher who was admitted twenty-four hours ago for an adhesive small bowel obstruction. Her initial management included nothing by mouth, intravenous crystalloid fluids, and nasogastric decompression. Currently, the patient is lethargic and moaning in pain. Vital signs indicate a temperature of $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), a pulse of $128/\text{min}$, and a blood pressure of $86/48 \text{ mm Hg}$. Compared to her admission examination, her abdomen is now exquisitely tender to light palpation, demonstrating rigid abdominal wall musculature and absent bowel sounds. Recent laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ and a serum lactate level of $6.1 \text{ mmol/L}$. Which of the following is the most appropriate next step in the management of this patient?

A $74$-year-old man is evaluated on the surgical ward for progressively worsening shortness of breath. He underwent an open right hemicolectomy for colon adenocarcinoma $48$ hours ago. The patient has a medical history of diet-controlled type 2 diabetes mellitus, chronic obstructive pulmonary disease, and ischemic cardiomyopathy with a most recent left ventricular ejection fraction of $35\%$. During the operation, he received $3.5$ liters of crystalloid solution. His temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $152/88$ mmHg, pulse is $112$/min, and respiratory rate is $24$/min. Pulse oximetry shows an oxygen saturation of $89\%$ on room air. Physical examination reveals an estimated jugular venous pressure of $10$ cm $\text{H}_2\text{O}$. Chest auscultation reveals bilateral basilar crackles and diffuse expiratory wheezes. The surgical incision is clean, dry, and intact. A portable chest radiograph demonstrates an enlarged cardiac silhouette, prominent central pulmonary vessels, and bilateral patchy alveolar opacities at the bases. Which of the following is the most appropriate next step in management of this patient's respiratory distress?