Surgery

A $59$-year-old man is evaluated in the post-anesthesia care unit $8$ hours after an elective bilateral laparoscopic inguinal hernia repair. He reports significant lower abdominal pressure and a distressing inability to urinate since the procedure. During the surgery, he received intravenous fluid resuscitation and general anesthesia. His postoperative pain is currently being managed with intravenous hydromorphone. Vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $135/85$ mm Hg, pulse $88$/min, and respirations $14$/min. Physical examination reveals a palpable, tender mass in the suprapubic region. Arrange the following steps in the most appropriate chronological sequence for the management of this patient's condition, starting with the immediate next step.

A $28$-year-old man is brought to the emergency department by ambulance after being struck by a motor vehicle while crossing the street. On arrival, he is moaning in pain. His temperature is $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), pulse is $132/\text{min}$, respirations are $22/\text{min}$, and blood pressure is $78/40\text{ mm Hg}$. Pulse oximetry shows $97\%$ on room air. The patient's airway is patent, and breath sounds are equal bilaterally. A rigid cervical collar is in place. Physical examination reveals ecchymosis over the lower abdomen and perineum, as well as blood at the urethral meatus. Gentle anteroposterior compression of the iliac crests reveals mechanical instability of the pelvis. Intravenous access is established, and a massive transfusion protocol is initiated. A pelvic binder is applied in the emergency department, but the patient's blood pressure remains $80/42\text{ mm Hg}$. A focused assessment with sonography for trauma (FAST) examination shows no free fluid in the pericardial, perihepatic, perisplenic, or pelvic spaces. Which of the following is the most appropriate next step in management?

A 40-year-old man is brought to the emergency department after being rescued from a house fire. He has full-thickness burns involving his entire anterior chest, abdomen, and both upper extremities (approximately 36% total body surface area). He is awake but agitated. On primary survey, he has singed nasal hairs, a hoarse voice, and carbonaceous sputum. Vital signs are temperature 37.0°C (98.6°F), blood pressure 110/70 mmHg, heart rate 115/min, and respiratory rate 24/min. Arrange the following management steps in the optimal chronological order according to standard Advanced Trauma Life Support (ATLS) and burn protocols.

A 45-year-old man is brought to the emergency department after being ejected from a vehicle during a high-speed rollover collision. On arrival, he is unresponsive. His blood pressure is 65/40 mm Hg, heart rate is 142/min, and respiratory rate is 8/min. Examination reveals active, pulsatile arterial bleeding from a severe crush injury to the right thigh. The patient has snoring respirations and significant maxillofacial trauma. Breath sounds are markedly decreased over the left hemithorax, and the trachea is deviated to the right. The pelvis is mechanically unstable on physical examination. Arrange the following steps in the most appropriate chronological sequence of management according to current Advanced Trauma Life Support (ATLS) principles.

A 68-year-old woman is evaluated on the surgical ward on postoperative day 4 following an elective right total knee arthroplasty. She reports new-onset shortness of breath and a mild, nonproductive cough that began this morning. Her medical history is significant for hypertension, heart failure with preserved ejection fraction, and osteoarthritis. Vital signs include a temperature of 37.9°C (100.2°F), blood pressure of 158/92 mmHg, heart rate of 104/min, respiratory rate of 22/min, and oxygen saturation of 91% on room air. Physical examination reveals prominent jugular venous distention when seated at a 45-degree angle. Pulmonary auscultation demonstrates bilateral crackles at the lung bases. Cardiac examination shows a regular tachycardia with a present S4 gallop, but no murmurs. The right knee surgical dressing is clean, and the incision shows mild erythema without purulent drainage, consistent with normal wound healing. Bilateral lower extremities exhibit 1+ pitting edema. A portable chest radiograph is obtained and demonstrates bilateral perihilar alveolar opacities, prominent pulmonary vasculature, and trace pleural effusions without focal consolidation.

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

Determine the most appropriate definitive surgical or procedural management for each of the following gastrointestinal and colorectal pathologies.

Emergency medical services bring a 31-year-old female equestrian to the trauma center after her horse tripped and rolled over her torso during a jumping event. The patient is pale, diaphoretic, and lethargic. Vital signs are temperature 36.8°C (98.2°F), blood pressure 82/45 mm Hg, pulse 128/min, and respirations 22/min. Pulse oximetry shows 96% on high-flow oxygen. Primary survey reveals a patent airway and equal bilateral breath sounds. The abdomen is markedly distended with diffuse guarding and rebound tenderness. Bedside ultrasound evaluation of the abdomen demonstrates a significant amount of anechoic fluid in Morison pouch. Which of the following is the most appropriate next step in the management of this patient?

During morning rounds, the surgical team examines a 41-year-old male patient who underwent an emergency appendectomy for a perforated appendix six days ago. Over the last 24 hours, he has developed lower abdominal discomfort, tenesmus, and the passage of several small-volume, loose stools. His temperature is $38.9^\circ\text{C}$ ($102^\circ\text{F}$), blood pressure is 118/76 mmHg, pulse is 105/min, and respirations are 18/min. Cardiopulmonary examination is unremarkable. The midline abdominal incision is clean, dry, and intact with no surrounding erythema, fluctuance, or induration. Deep palpation of the lower abdomen elicits moderate tenderness, but no rebound or guarding is appreciated. Digital rectal examination reveals a markedly tender, boggy mass positioned anteriorly. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$. Which of the following is the most appropriate next step in the management of this patient?

A 62-year-old male with a history of chronic obstructive pulmonary disease and ischemic heart disease is brought to the trauma center after being struck by a forklift. He is lethargic and complains of severe abdominal pain. Vital signs show a temperature of $36.5^\circ$ C ($97.7^\circ$ F), a blood pressure of $76/40$ mm Hg, a pulse of $128$/min, and a respiratory rate of $26$/min. Examination reveals large ecchymoses over the left lower ribs and severe diffuse abdominal tenderness with involuntary guarding. A focused assessment with sonography for trauma (FAST) demonstrates a substantial anechoic fluid collection in the splenorenal recess. A portable chest radiograph shows fractures of the left eighth, ninth, and tenth ribs with no pneumothorax. Which of the following is the most appropriate next step in the management of this patient?

Helicopter transport arrives at a regional burn center carrying a 30-year-old female who was trapped in a residential fire. She currently weighs $70\text{ kg}$. The injury occurred exactly $2\text{ hours}$ prior to her arrival. Physical examination reveals full-thickness burns involving her entire anterior trunk, her entire right lower extremity, and her entire left upper extremity. The trauma team confirms this accounts for exactly $45\%$ of her total body surface area (TBSA). Large-bore intravenous access is established. Utilizing the classic Parkland formula ($4\text{ mL/kg/\%TBSA}$), what is the targeted fluid administration rate in $\text{mL/hr}$ for the remainder of the first 8-hour post-burn period?

An otherwise healthy 48-year-old male presents to the triage desk reporting a two-day history of worsening, crampy periumbilical pain. He notes several episodes of vomiting green, foul-smelling fluid since this morning and has not had a bowel movement or passed gas for the last 36 hours. Ten years prior, he underwent an open appendectomy for a perforated appendix.

Currently, his temperature is 37.9°C (100.2°F), heart rate is 115/min, respirations are 18/min, and blood pressure is 105/65 mm Hg.

Physical examination shows significant abdominal distension with tympany to percussion. Auscultation reveals a lack of bowel sounds. The abdomen is tender to deep palpation diffusely, but there is no involuntary guarding or rigidity.

Laboratory results are significant for a leukocyte count of 16,000/mm³ and a serum lactate level of 3.8 mmol/L.

A contrast-enhanced CT scan of the abdomen and pelvis displays dilated loops of small intestine with a distinct transition zone in the right lower quadrant. Additionally, there is thickening of the bowel wall, decreased enhancement of the mucosa at the transition point, and adjacent mesenteric fluid.

Based on these findings, what is the most appropriate next step in the patient's care?

A 28-year-old woman, G2P1, at 20 weeks gestation presents to the emergency department with a 12-hour history of worsening right lower quadrant abdominal pain, nausea, and anorexia. Her temperature is 38.1°C (100.6°F), heart rate is 108/min, and blood pressure is 112/72 mm Hg. Physical examination reveals tenderness superior and lateral to McBurney's point with localized guarding. Fetal heart tones are 145/min. Laboratory studies show a leukocyte count of 16,500/mm³ with 85% neutrophils. Assuming each diagnostic study is sequentially indicated due to inconclusive prior results, arrange the following steps in the most appropriate chronological order for evaluating and managing this patient.

A 27-year-old man is brought to the emergency department by ambulance 20 minutes after sustaining a stab wound to the abdomen during an altercation. On arrival, he is lethargic and confused. His temperature is $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), blood pressure is $80/45\text{ mmHg}$, pulse is $135/\text{min}$, and respiratory rate is $22/\text{min}$. Pulse oximetry is $97\%$ on room air. Two large-bore intravenous lines are established, and a bolus of warmed isotonic crystalloid is initiated. The airway is patent, and breath sounds are clear and equal bilaterally. Physical examination reveals a 4-cm transverse laceration in the left lower quadrant of the abdomen. The abdomen is distended, and there is generalized guarding and rebound tenderness across all four quadrants. Which of the following is the most appropriate next step in management?

Approximately $36$ hours after undergoing an elective abdominal hysterectomy for symptomatic uterine fibroids, a $55$-year-old patient develops an elevated temperature of $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$). She reports mild pain at the surgical site but denies shortness of breath, cough, dysuria, or calf pain. Her current medications include scheduled acetaminophen and as-needed intravenous morphine. Her pulse is $88/\text{min}$, blood pressure is $128/82\text{ mm Hg}$, and respiratory rate is $14/\text{min}$. Oxygen saturation is $95\%$ on room air. Physical examination reveals decreased breath sounds at the bilateral lung bases without crackles or wheezes. The abdominal incision is well-approximated with no erythema, induration, or discharge. The urinary catheter placed during surgery was removed on postoperative day zero. Which of the following is the most appropriate next step in management?

A $76$-year-old woman is brought to the emergency department from her assisted living facility due to a $4$-day history of worsening, colicky abdominal pain, nausea, and frequent bilious vomiting. She has not passed flatus or stool for the past $2$ days. Her medical history includes type 2 diabetes mellitus, hypertension, and episodic right upper quadrant abdominal pain for which she declined surgery several years ago.

Her temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), pulse is $102/\text{min}$, respirations are $18/\text{min}$, and blood pressure is $110/70\text{ mm Hg}$. On physical examination, the abdomen is distended and tympanitic with high-pitched, hyperactive bowel sounds. There is mild, diffuse tenderness without guarding or rebound.

An abdominal computed tomography scan with intravenous contrast reveals dilated loops of small bowel with a transition point in the right lower quadrant. Air is visible within the biliary tree, and a $3.5\text{-cm}$ calcified intraluminal mass is identified near the ileocecal valve.

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

During a routine afternoon check, nursing staff requests an evaluation for a patient experiencing new-onset right arm discomfort. The patient is a $48$-year-old female recovering on the surgical ward on postoperative day $3$ following an uncomplicated laparoscopic myomectomy for symptomatic uterine fibroids. Her temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $122/76\text{ mm Hg}$, pulse is $88\text{/min}$, and respirations are $14\text{/min}$. The abdomen is soft, non-tender, and the laparoscopic port sites are clean and dry. Lung fields are clear to auscultation bilaterally. Examination of the right forearm reveals a $4\text{-cm}$ area of localized erythema, mild induration, and tenderness tracking proximally from an intact peripheral intravenous catheter. A palpable, tender cord is present along the course of the vein. There is no fluctuance, purulent drainage, or surrounding generalized limb edema. Which of the following are the most appropriate next steps in management? (Select two)

A 38-year-old male is brought to the emergency department after a high-speed head-on motor vehicle collision. He was an unrestrained driver and was ejected from the vehicle. Upon arrival, his blood pressure is 76/40 mmHg and his heart rate is 135/min. He is unresponsive with a Glasgow Coma Scale score of 3. The airway is secured with an endotracheal tube, and breath sounds are clear and equal bilaterally. The trachea is midline, and jugular veins are flat. Examination of the abdomen reveals mild distension and a transverse band of ecchymosis across the lower abdomen. The pelvis is mechanically stable to anteroposterior and lateral compression. Intravenous access is rapidly established, and a massive transfusion protocol is initiated. Which of the following is the most appropriate next step in management?

Following a severe pedestrian-vehicle collision, a young adult female is delivered to the trauma bay by paramedics. She was struck directly by a commercial truck that lost control on an icy road. On arrival, the patient is agitated, pale, and sweating profusely. The airway is clear, and bilateral breath sounds are symmetric and unlabored. Vital signs show a heart rate of 135/min and a blood pressure of 78/42 mm Hg, which remain unchanged after the rapid intravenous infusion of one liter of crystalloid solution. The abdomen is diffusely tender and mildly distended with a large ecchymosis across the periumbilical region. The pelvis is mechanically stable to anteroposterior and lateral compression. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation with the most appropriate definitive or initial procedural management.

A 66-year-old man is evaluated on postoperative day 2 following an elective open ventral hernia repair with mesh placement. The nursing staff notes that he has developed new-onset tachypnea and a low-grade fever. His medical history is significant for ischemic cardiomyopathy, chronic obstructive pulmonary disease, and tobacco use disorder. Vital signs include a temperature of 38.2°C (100.8°F), blood pressure of 132/84 mmHg, heart rate of 94/min, and respiratory rate of 22/min. Oxygen saturation is 93% on room air. Physical examination reveals decreased breath sounds at the bilateral lung bases. There are no pulmonary crackles, expiratory wheezing, or jugular venous distention. The abdominal dressing is clean, dry, and intact. Which of the following are the most appropriate next steps in management? (Select two)