Surgery

Emergency medical personnel deliver a 19-year-old male to the emergency department following a gunshot wound to the abdomen. The patient is confused and visibly pale. Initial vital signs include a blood pressure of 72/42 mm Hg, a heart rate of 145/min, and respirations of 26/min. Examination shows a single bullet entry hole in the periumbilical region with no corresponding exit wound. The abdominal wall is rigid, and generalized guarding is present. Bilateral breath sounds are clear. Large-bore intravenous access is obtained, and a massive transfusion protocol is initiated. Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old woman is brought to the emergency department via ambulance after being rescued from a house fire. Paramedics report the injury occurred exactly 2 hours prior to her arrival. On physical examination, she is in significant pain but has a patent airway with no signs of inhalation injury. She has deep partial-thickness and full-thickness burns involving her entire anterior torso, her entire left arm, and the anterior surface of her left leg. The remainder of her skin is uninjured. Her weight is $75\text{ kg}$. Large-bore intravenous access is established. Based on the most current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns, what should be the initial rate of intravenous lactated Ringer solution administration for this patient in $\text{mL/hr}$?

Match each clinical presentation of a patient recovering from abdominal surgery with the most likely postoperative complication.

An internal medicine consultation is requested for a 62-year-old male on his second day of recovery following an open partial colectomy for diverticulitis. The patient has a 40-pack-year smoking history and mild chronic obstructive pulmonary disease. He currently reports sharp abdominal pain, especially when taking a deep breath. His temperature is $38.6^{\circ}\text{C}$ ($101.5^{\circ}\text{F}$), blood pressure is $138/82\text{ mmHg}$, pulse is $102/\text{min}$, and respirations are $22/\text{min}$. Pulse oximetry shows $91\%$ on room air. Physical examination reveals decreased breath sounds at the lung bases bilaterally, with no wheezing or crackles. The abdomen is tender near the incision but without rebound or guarding. The surgical incision is clean, dry, and intact. Which of the following are the most appropriate initial steps in the management of this patient's current condition? (Select 2 options)

Emergency medical services bring a 26-year-old male construction worker to the trauma center after he was crushed under a collapsed retaining wall. The patient's primary survey reveals a patent airway, clear breath sounds bilaterally, and stable hemodynamics with a blood pressure of 118/76 mm Hg and a heart rate of 92/min. Secondary survey is notable for severe pelvic instability, marked perineal ecchymosis, and fresh blood visible at the urethral meatus. Digital rectal examination demonstrates a high-riding prostate. Assuming sequential workup eventually reveals a complete posterior urethral transection accompanied by an intraperitoneal bladder rupture, arrange the following management steps in the correct chronological sequence.

A 50-year-old male seeks medical attention at the emergency department after two days of progressively worsening, crampy periumbilical pain, progressive abdominal distension, and an inability to pass flatus or stool. He reports multiple episodes of bilious emesis. His surgical history is notable for an exploratory laparotomy following blunt abdominal trauma a decade ago. Vital signs show a heart rate of 98/min, blood pressure of 135/85 mm Hg, and respiratory rate of 16/min. The patient is afebrile. Abdominal examination demonstrates marked distension, hyperactive high-pitched bowel sounds, and generalized tympany without rigidity or rebound tenderness. Arrange the following management steps in the most appropriate chronological sequence for this patient.

During morning rounds, the surgical team evaluates a 68-year-old male who is currently on his fourth postoperative day following an elective open ventral hernia repair with mesh placement. He has a known medical history of moderate chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy with a left ventricular ejection fraction of 45%. Overnight, the patient developed worsening shortness of breath and an increased production of thick, yellow sputum.

Current vital signs are as follows:

Physical examination demonstrates a prolonged expiratory phase with diffuse bilateral wheezing. The jugular venous pressure is estimated at 6 cm $H_2O$. There is no peripheral edema. The abdominal incision is clean, dry, and fully intact without erythema, warmth, or induration. A sputum culture that was obtained two days ago due to a mild, non-productive cough has just finalized; it demonstrates moderate growth of *Haemophilus influenzae*. Susceptibility testing confirms the organism is sensitive to amoxicillin, azithromycin, and levofloxacin.

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

A 56-year-old man undergoes an emergent partial colectomy with primary anastomosis for ischemic colitis. Over the first four days following the procedure, his recovery is unremarkable and he transitions to a clear liquid diet. On the morning of his fifth hospital day, he reports new-onset lower abdominal discomfort, tenesmus, and frequent, small-volume loose stools. His temperature is 38.9°C (102°F), blood pressure is 128/82 mmHg, heart rate is 108/min, and respiratory rate is 16/min. Physical examination demonstrates a clean, well-approximated midline surgical incision without fluctuance, drainage, or erythema. There is localized tenderness in the suprapubic region. Digital rectal examination reveals a boggy, highly tender fullness anteriorly. Laboratory studies show a leukocyte count of 18,500/mm³. Which of the following is the most appropriate next step in the management of this patient?

An $82$-year-old female resident of an assisted living facility is evaluated in the hospital following a mechanical fall. The patient reports that she tripped over an electrical cord in her room earlier today. She now experiences severe pain in her right groin and is completely unable to bear weight. Prior to this incident, she was ambulatory and walked independently with a cane. Her past medical history is notable for osteoporosis, type $2$ diabetes mellitus, and essential hypertension. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $135/85\text{ mm Hg}$, pulse is $88/\text{min}$, and respirations are $14/\text{min}$. On physical examination, the right lower extremity is noticeably shorter than the left and lies in an externally rotated position. Distal pulses are strong and symmetric, and sensory function is intact in both legs. Plain radiographs of the pelvis and right hip demonstrate a complete, displaced fracture line extending across the transcervical region of the right femur. The greater and lesser trochanters are intact. What is the most appropriate definitive surgical management for this patient's injury?

A physician assesses a 77-year-old female patient on the third day following surgical repair of a right femoral neck fracture. The patient reports a sudden onset of severe difficulty breathing and the inability to lie flat in bed, which began approximately one hour ago. Her past medical history includes essential hypertension, diet-controlled type 2 diabetes, and severe tobacco use disorder with associated chronic obstructive pulmonary disease. Since her operation, she has received continuous isotonic saline infusions due to transient intraoperative hypotension. Current vital signs demonstrate a temperature of 38.1°C (100.6°F), blood pressure of 168/92 mmHg, pulse of 115/min, and respirations of 28/min. Pulse oximetry shows an oxygen saturation of 86% on room air. Physical examination reveals prominent jugular venous distention. Lung auscultation demonstrates bilateral dependent fine inspiratory crackles without any expiratory wheezing. Cardiac evaluation reveals a regular tachycardia with a distinct early diastolic extra heart sound. The surgical incision is clean, dry, and intact. Which of the following is the most appropriate initial medical intervention for this patient?

Following an industrial accident where he was struck in the torso by a swinging steel pipe, a 48-year-old construction worker is transported to the trauma bay. Upon arrival, his blood pressure is 82/48 mm Hg, heart rate is 126/min, and respiratory rate is 22/min. Oxygen saturation is 97% on room air. The patient is lethargic but appropriately protects his airway. The trachea is midline, and breath sounds are clear and equal bilaterally. Heart sounds are normal. The abdomen is distended and exhibits diffuse tenderness to palpation, with involuntary guarding. Anteroposterior and lateral compression of the pelvis does not elicit pain or instability. Peripheral pulses are weak and 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 management?

Match each of the following eponymous forearm and wrist fractures with its correct anatomical injury description.

Paramedics transport a 55-year-old male pedestrian to the trauma center after he was struck by a moving delivery van. He complains of excruciating pain in his lower abdomen and hips. On primary assessment, his airway is patent, and breath sounds are equal bilaterally. His blood pressure is 78/42 mm Hg, and his pulse is 135/min. Physical examination demonstrates marked bruising over the suprapubic region. Gentle lateral compression of the iliac crests reveals a mechanically unstable pelvic ring. A pelvic binder is immediately applied, and 1 liter of intravenous Lactated Ringer's solution is infused rapidly. A bedside ultrasound (FAST) examination reveals an anechoic stripe in the hepatorenal recess. Repeat vital signs show a blood pressure of 82/46 mm Hg and a pulse of 128/min. Which of the following is the most appropriate next step in management?

A 42-year-old woman is evaluated in the surgical telemetry unit on postoperative day 6 following a laparoscopic Roux-en-Y gastric bypass. Over the past 4 hours, she has reported rapidly worsening left shoulder pain and severe diffuse abdominal pain. She has no history of trauma to her shoulder. Her temperature is 39.1°C (102.4°F), blood pressure is 82/50 mm Hg, pulse is 134/min, and respirations are 26/min. Pulse oximetry is 94% on room air. She is diaphoretic, mottled, and appears in significant distress. Abdominal examination reveals a rigid, board-like abdomen with diffuse guarding and severe rebound tenderness. The laparoscopic port sites are clean, dry, and intact. A peripheral intravenous line is established, and rapid infusion of isotonic crystalloid is initiated, but her blood pressure remains 84/52 mm Hg. Which of the following is the most appropriate next step in management?

A 55-year-old man presents to the emergency department reporting the sudden onset of agonizing epigastric pain that rapidly generalized to his entire abdomen. The pain began approximately 2 hours ago. His past medical history is significant for osteoarthritis, for which he takes diclofenac regularly. On arrival, his temperature is 38.3°C (100.9°F), blood pressure is 108/68 mm Hg, and pulse is 112/min. Physical examination demonstrates a patient lying completely still on the stretcher. His abdomen is markedly rigid and board-like, with diffuse involuntary guarding and rebound tenderness. Arrange the following management steps in the most appropriate chronological order for this patient.

While recovering on the surgical ward six days after an emergency laparotomy for a perforated duodenal ulcer, a patient experiences a sudden 'popping' sensation in his abdomen during an intense coughing spell. The evaluating nurse notes that the surgical staples have separated, and segments of the small intestine are visibly protruding through the fascial defect onto the skin surface. The patient is tachycardic but maintaining his airway. Arrange the following medical interventions in the correct chronological order to appropriately manage this acute complication.

Match each trauma patient presentation with the most appropriate immediate diagnostic test or therapeutic intervention.

A $45$-year-old male construction worker is brought to the emergency department after a high-voltage electrical injury. He accidentally touched a live power line and was thrown to the ground. The incident occurred exactly $3\text{ hours}$ prior to his arrival at the trauma center. No intravenous fluids were administered during transport. The patient weighs $90\text{ kg}$. On physical examination, there are deep, full-thickness burns covering his entire anterior torso and his entire right upper extremity. The remainder of his skin is unaffected. A Foley catheter is placed, yielding dark red urine. According to the Advanced Trauma Life Support (ATLS) guidelines, at what rate (in $\text{mL/hr}$) should intravenous lactated Ringer solution be administered over the remainder of the first 8-hour post-injury window?

A 30-year-old man is brought to the emergency department after a fall from a height of 6 meters (20 feet). He is confused and agitated. His temperature is 36.8°C (98.2°F), blood pressure is 75/40 mm Hg, and pulse is 135/min. Primary survey reveals a patent airway and clear, equal breath sounds bilaterally. A focused assessment with sonography for trauma (FAST) examination is negative for intraperitoneal or pericardial fluid. Pelvic examination shows stability to anteroposterior and lateral compression, and a portable anteroposterior pelvic radiograph is normal. Examination of the left lower extremity reveals a visibly deformed, shortened thigh with tense swelling. There are no open wounds. Distal pulses are palpable but diminished in the left foot compared to the right. Which of the following is the most appropriate next step in management?

A 71-year-old woman is evaluated in the emergency department due to the acute onset of severe, unremitting groin pain accompanied by nausea and green-colored emesis over the past 8 hours. She also reports a failure to pass gas or stool since yesterday. Her temperature is 38.5°C (101.3°F), pulse is 118/min, and blood pressure is 95/60 mm Hg. Physical examination reveals a moderately distended abdomen. High-pitched, tinkling bowel sounds are auscultated. Below the right inguinal ligament and medial to the femoral artery pulsation, there is a 3-cm, tense, exquisitely tender mass. The skin overlying the mass appears erythematous and slightly violaceous. The mass cannot be pushed back into the abdominal cavity. Laboratory analysis is notable for a leukocyte count of 17,000/mm³ and a serum lactate concentration of 4.2 mmol/L. Which of the following is the most appropriate next step in the management of this patient?