Surgery

A 51-year-old woman is brought to the emergency department complaining of sudden-onset, severe, and unremitting abdominal pain for the past 6 hours. She has vomited bilious material twice since the pain began. Her surgical history is notable for a total abdominal hysterectomy performed five years ago for uterine fibroids. On presentation, her temperature is 38.3°C (100.9°F), heart rate is 118/min, and blood pressure is 105/65 mm Hg. Physical examination shows a significantly distended abdomen with focal rigidity and pronounced rebound tenderness in the left lower quadrant. Bowel sounds are absent. Laboratory results reveal a leukocyte count of 16,500/mm³ and a serum lactate level of 3.2 mmol/L. A CT scan of the abdomen and pelvis with intravenous contrast demonstrates a transition point in the distal jejunum, poor enhancement of the bowel wall distal to the transition point, a mesenteric "whirl" sign, and moderate free pelvic fluid. Which of the following is the most appropriate next step in management?

A 41-year-old man is brought to the emergency department after a motorcycle collision. He is unresponsive but opens his eyes to painful stimuli. Vital signs are temperature $36.2^\circ\text{C}$, blood pressure $78/48 \text{ mm Hg}$, heart rate $132/\text{min}$, and respiratory rate $24/\text{min}$. The airway is patent, and breath sounds are equal bilaterally. A properly positioned pelvic binder was placed by emergency medical services. Extended focused assessment with sonography for trauma (eFAST) demonstrates no intraperitoneal fluid and no pericardial effusion. There is normal lung sliding bilaterally. An anteroposterior pelvic radiograph reveals a severe diastasis of the pubic symphysis and a right sacroiliac joint disruption. After receiving $1\text{ L}$ of warmed intravenous crystalloids and $2\text{ units}$ of uncrossmatched type O-negative blood, the patient's blood pressure is $82/50 \text{ mm Hg}$ and heart rate is $128/\text{min}$. Which of the following is the most appropriate next step in management?

A 77-year-old man is brought to the emergency department from a psychiatric group home with a 2-day history of worsening abdominal distension and an inability to pass flatus or stool. He has a medical history significant for schizophrenia and chronic severe constipation. His current medications include haloperidol, benztropine, and daily docusate. Vital signs reveal a blood pressure of 132/84 mmHg, a heart rate of 102/min, a respiratory rate of 16/min, and a temperature of 37.0°C (98.6°F). Physical examination demonstrates a massively distended, tympanic abdomen. There is generalized mild discomfort upon deep palpation, but no guarding, rigidity, or rebound tenderness is elicited. Digital rectal examination reveals an empty rectal vault without masses or gross blood.

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

A 68-year-old man with a history of stable coronary artery disease, type 2 diabetes mellitus, and hypertension presents to the clinic for preoperative evaluation prior to an elective open repair of an abdominal aortic aneurysm. The surgical team is systematically assessing his perioperative risk for major adverse cardiac events (MACE). According to the American College of Cardiology/American Heart Association (ACC/AHA) guidelines, arrange the following steps of the preoperative cardiovascular evaluation algorithm in the correct chronological sequence.

A 29-year-old male arrives at the trauma center after a severe crush injury caused by a tractor rolling over his lower body. He is awake and in significant pain. Vital signs reveal a blood pressure of $115/75$ mm Hg, heart rate of $98$/min, and respiratory rate of $18$/min. Primary survey is intact, and a FAST examination is negative for intraperitoneal fluid. Pelvic radiography confirms a displaced butterfly fracture of the pubic rami. On genitourinary examination, there is severe perineal ecchymosis and frank blood visible at the urethral meatus. The patient reports a strong urge to urinate but is unable to void. A digital rectal examination demonstrates a high-riding, nonpalpable prostate. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for managing this patient's genitourinary injuries.

During morning rounds, the rapid response team is called for a patient who suddenly developed severe dyspnea and pleuritic chest discomfort. The patient, a 73-year-old retired teacher, is currently recovering in the orthopedic ward four days after an elective right total hip replacement. She has a history of essential hypertension, mild chronic obstructive pulmonary disease, and diet-controlled type 2 diabetes. Upon arrival, her vital signs are temperature 37.7°C (99.9°F), blood pressure 110/68 mmHg, pulse 122/min, and respirations 28/min. Oxygen saturation is 89% on room air. Physical examination reveals clear breath sounds bilaterally without wheezing or crackles. Jugular venous distension is present. The right calf is visibly swollen, erythematous, and tender to palpation. An electrocardiogram demonstrates sinus tachycardia. Which of the following are the most appropriate immediate steps in managing this patient's condition? (Select all that apply)

A 28-year-old warehouse worker is rushed to the emergency department after being pinned against a loading dock by a reversing forklift. He is in severe respiratory distress and profusely diaphoretic. His temperature is 37.0°C (98.6°F), blood pressure is 70/30 mm Hg, pulse is 142/min, and respirations are 36/min. Oxygen saturation is 82% on high-flow oxygen via a non-rebreather mask. Physical examination reveals marked jugular venous distention. The trachea is visibly deviated to the right. The left chest wall has a large, developing contusion. Auscultation reveals completely absent breath sounds on the left side, and percussion of the left hemithorax is hyperresonant. Heart sounds are rapid but distinct. Which of the following is the most appropriate initial step in the management of this patient?

Six days following an open reduction and internal fixation of a right proximal femur fracture, a 69-year-old female patient reports new-onset right leg discomfort. She has been participating in daily physical therapy but states her right leg feels unusually heavy and painful today. Her temperature is 38.3°C (100.9°F), blood pressure is 128/82 mmHg, pulse is 94/min, and respiratory rate is 16/min. Pulse oximetry shows 98% on room air. Examination reveals that the surgical incision over the lateral hip is well-approximated, dry, and without erythema or drainage. However, the right calf and lower thigh are visibly edematous, warm, and tender to deep palpation. Cardiopulmonary examination is unremarkable, and she denies dysuria, cough, or shortness of breath. Which of the following is the most appropriate next step in the management of this patient?

A 65-year-old woman presents to the emergency department complaining of sudden, excruciating abdominal pain that began 90 minutes ago. She has a history of rheumatic heart disease, mitral stenosis, and paroxysmal atrial fibrillation for which she takes a beta-blocker. She admits to frequently missing her oral anticoagulant doses. On physical examination, her temperature is 37.2°C (99.0°F), blood pressure is 142/85 mmHg, pulse is 118/min and irregularly irregular, and respirations are 18/min. Her abdomen is soft, non-distended, and non-rigid. Palpation elicits mild, diffuse tenderness without guarding or rebound. Bowel sounds are decreased. Laboratory studies show a leukocyte count of 14,500/mm³ and serum lactate of 4.2 mmol/L. Which of the following is the most appropriate next step in management?

A 30-year-old woman, gravida 2, para 1, at 32 weeks gestation is brought to the emergency department after falling approximately 8 feet (2.4 meters) from a ladder. She complains of severe, generalized abdominal pain. On presentation, she is pale, diaphoretic, and lethargic. Her temperature is 36.6°C (97.9°F), blood pressure is 78/45 mm Hg, and pulse is 132/min. Her respiratory rate is 24/min and oxygen saturation is 97% on face mask oxygen. Cardiopulmonary auscultation is unremarkable. Abdominal examination reveals a gravid, distended abdomen that is diffusely tender with involuntary guarding. A focused assessment with sonography for trauma (FAST) scan shows a significant volume of anechoic fluid in the hepatorenal recess (Morison's pouch). Fetal heart tones are present at 145/min. Which of the following is the most appropriate next step in management?

A 72-year-old woman is evaluated on postoperative day 5 following an elective sigmoid colectomy for recurrent diverticulitis. She has a history of chronic obstructive pulmonary disease (COPD) and heart failure with preserved ejection fraction. She reports increasing incisional pain, a productive cough, and mild shortness of breath. Temperature is 38.7°C (101.7°F), blood pressure is 135/85 mmHg, pulse is 102/min, and respirations are 18/min. Pulse oximetry shows 94% on room air. Lung auscultation reveals a prolonged expiratory phase and scattered expiratory wheezes bilaterally. Jugular venous pressure is 6 cm H2O, and there are no crackles or lower extremity edema. The surgical incision has a 4-cm area of fluctuance, erythema, and purulent discharge. The wound is swabbed for culture, and Gram stain of the purulent fluid shows only Gram-positive cocci in clusters. The local hospital antibiogram demonstrates a less than 1% prevalence of methicillin-resistant Staphylococcus aureus (MRSA). Which of the following are the most appropriate next steps in the management of this patient? (Select 2 answers)

Carefully review the following clinical vignettes of patients presenting after major thoracic or thoracoabdominal trauma. Match each patient presentation with the most appropriate next step in their diagnosis or management.

A 52-year-old man is brought to the emergency department by ambulance after a high-speed motor vehicle collision. He was the unrestrained driver and was ejected from the vehicle. On arrival, the patient is lethargic and confused. His blood pressure is 78/48 mm Hg, and his pulse is 132/min and thready. His respiratory rate is 24/min, and oxygen saturation is 96% on a non-rebreather face mask. Physical examination reveals equal breath sounds bilaterally and normal heart sounds with no murmurs. The abdomen is distended, tympanitic, and diffusely tender with involuntary guarding. The pelvis is stable to anterior-posterior and lateral compression. Extremities show multiple abrasions but no obvious deformities. An arterial blood gas analysis shows a pH of 7.22, pCO2 of 32 mm Hg, and HCO3- of 12 mEq/L. Which of the following is the most appropriate next step in the management of this patient?

Emergency medical personnel bring a 35-year-old female to the trauma center after she was struck by a fast-moving delivery van while riding her bicycle. She is in severe distress and gasping for air.

Vital signs on arrival are:
Temperature: 36.4°C (97.5°F)
Blood pressure: 78/42 mmHg
Pulse: 142/min
Respirations: 34/min
Oxygen saturation: 86% on room air

Initial evaluation reveals an intact and patent airway. Examination of the chest shows asymmetrical expansion, with absent breath sounds and hyperresonance to percussion over the right hemithorax. The trachea appears deviated toward the left side, and the jugular veins are significantly distended. The abdomen is diffusely tender and distended. A focused assessment with sonography for trauma (FAST) demonstrates a substantial accumulation of free fluid in the hepatorenal recess.

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

Match each clinical presentation of a trauma patient to the most appropriate next step in management based on standard trauma evaluation principles.

A $28$-year-old man is brought to the emergency department $30$ minutes after crashing his all-terrain vehicle (ATV) into a tree. The paramedics report that he was thrown approximately $20$ feet and landed in a muddy ditch. On arrival, he is lethargic and confused. His medical history is significant for an appendectomy at age $10$. His estranged wife is present in the emergency department demanding to make all medical decisions, although his electronic medical record clearly lists his brother as his legally appointed healthcare proxy. The brother is currently $45$ minutes away. Vital signs are temperature $36.1^\circ\text{C}$ ($97.0^\circ\text{F}$), blood pressure $78/40\text{ mm Hg}$, pulse $138\text{/min}$, and respirations $24\text{/min}$. Physical examination reveals diffuse abdominal distension, rigidity, and rebound tenderness. There is a large area of ecchymosis over the left upper quadrant. A focused assessment with sonography for trauma (FAST) exam demonstrates a significant amount of anechoic fluid in the splenorenal and hepatorenal recesses. Which of the following is the most appropriate next step in the management of this patient?

Paramedics transport a $32$-year-old male to the trauma center following ejection from a tumbling vehicle on the interstate. On arrival, the patient is unresponsive, cyanotic, and producing audible gurgling respiratory sounds. Vital signs are blood pressure $75/40$ mmHg, heart rate $142$/min, and respiratory rate $32$/min. Physical examination demonstrates a lack of breath sounds over the right hemithorax, markedly distended neck veins, and tracheal deviation to the left. His abdomen is rigid and diffusely tender to palpation. Arrange the following interventions in the most appropriate chronological order according to standard trauma resuscitation principles.

A 48-year-old male ski instructor is airlifted to the trauma bay after colliding with a tree at high speed. During transport, he received $1$ L of lactated Ringer solution. Upon arrival, the patient appears pale, diaphoretic, and confused. His temperature is $36.1^\circ\text{C}$ ($97.0^\circ\text{F}$), pulse is $135$/min, respirations are $24$/min, and blood pressure is $78/42$ mm Hg. Pulse oximetry shows $95\%$ on room air. The trachea is midline, and breath sounds are present and equal bilaterally. Heart sounds are rapid but normal in intensity, with no jugular venous distention. The abdomen is tense with significant left upper quadrant tenderness and involuntary guarding. The pelvis is mechanically stable to gentle compression. Bedside focused assessment with sonography for trauma (FAST) demonstrates a well-defined anechoic stripe in the splenorenal recess. Which of the following is the most appropriate next step in the management of this patient?

A 35-year-old man is brought to the emergency department after being rescued from a burning building. The fire department successfully extracted him from the fire 2 hours ago. On examination, the patient is hemodynamically stable and weighs 90 kg ($198.4$ lbs). He has severe deep partial-thickness and full-thickness burns involving his entire anterior trunk, his entire right arm, and the anterior aspect of his left leg. The remainder of his skin, including his face, neck, and posterior surfaces, is unaffected. Large-bore intravenous access is obtained. Using the traditional Parkland formula ($4$ mL/kg/% total body surface area), at what rate (in mL/hr) should intravenous lactated Ringer solution be administered to this patient initially?

Match each of the following clinical trauma presentations with the single most appropriate next step in management.