General Surgery MCQs (Prometric) — Set 2026-07-23 13-47-16 — Mock Exam 8

A 69-year-old man is recovering after uncomplicated right hemicolectomy. On postoperative day 2, hemoglobin is 68 g/L, down from 102 g/L, but repeated examinations and drain output show no ongoing bleeding. He has exertional dizziness and tachycardia when mobilizing, while resting blood pressure is normal. He has stable coronary artery disease without acute ischemic symptoms, pulmonary edema, or volume overload. What is the most appropriate transfusion strategy?

A 41-year-old restrained driver presents after a high-speed collision with a prominent seat-belt mark, initially mild abdominal tenderness, and normal blood pressure. CT shows small-volume free fluid and subtle mesenteric stranding but no solid-organ injury or free air. Four hours later, pain intensifies, heart rate rises from 88 to 116/min, lactate increases to 3.6 mmol/L, and localized guarding develops despite resuscitation. What is the most appropriate next management?

A 73-year-old man with chronic obstructive pulmonary disease is scheduled for open upper-abdominal surgery. He stopped smoking six weeks ago, uses inhaled bronchodilators correctly, and has no current exacerbation or respiratory infection. Oxygen saturation is 94% at baseline, exercise tolerance is limited, and postoperative coughing is expected to be painful. Which perioperative strategy best reduces pulmonary complications?

A 48-year-old woman undergoes breast-conserving surgery for a 1.7-cm grade 2 invasive ductal carcinoma with an associated intraductal component. Sentinel nodes are negative, estrogen receptors are positive, and HER2 is negative. Final pathology shows no invasive carcinoma at any margin, but ductal carcinoma in situ is present directly on ink at the medial radial margin. The remaining margins exceed 3 mm, and postoperative radiotherapy is planned. What is the most appropriate next surgical step?

A 77-year-old man with no previous abdominal surgery presents with six hours of sudden severe central abdominal pain, vomiting, and progressive distension. Heart rate is 116/min, lactate is 4.3 mmol/L, and examination reveals diffuse tenderness with involuntary guarding. The displayed contrast-enhanced CT shows the key mesenteric configuration, associated bowel-wall thickening, edema, and free fluid. There is no free intraperitoneal air. What is the most appropriate next management?

A 70-year-old man is postoperative day 7 after low anterior resection for rectal cancer with a diverting loop ileostomy. He develops fever, pelvic discomfort, and purulent rectal discharge. Blood pressure is 118/70 mmHg after fluids, lactate is 1.7 mmol/L, and CT shows a localized presacral collection without diffuse peritonitis. The displayed endoscopic image supplies the decisive anastomotic finding. The conduit appears viable, and interventional drainage is feasible. What is the most appropriate management?

A 71-year-old man presents 36 hours after onset of right upper-quadrant pain, fever, and vomiting. Ultrasound shows gallstones, gallbladder-wall thickening, pericholecystic fluid, and a positive sonographic Murphy sign; the common bile duct is 5 mm. Bilirubin is normal, leukocyte count is 15.2 × 10⁹/L, and blood pressure remains stable after fluids. He has compensated heart failure, but anesthesia assessment finds no absolute contraindication to surgery. What is the most appropriate definitive management?

A 44-year-old man is in intensive care after damage-control laparotomy for major abdominal trauma and massive transfusion. His abdomen was closed under tension. Twelve hours later, peak airway pressure rises, urine output falls to 5 mL/hour, lactate increases, and vasopressor requirements escalate. Bladder pressure is repeatedly 28 mmHg despite sedation, neuromuscular blockade, nasogastric decompression, and evacuation of intraluminal contents. What is the most appropriate next intervention?

A 73-year-old man presents to a hospital without vascular surgery with sudden abdominal and back pain, syncope, and a pulsatile abdominal mass. Blood pressure is 82/54 mmHg, heart rate is 118/min, and bedside ultrasound shows an 8.4-cm abdominal aortic aneurysm with free intraperitoneal fluid. He remains conscious and maintains a radial pulse after limited blood-product resuscitation. A vascular center is 25 minutes away and has accepted the patient. What is the most appropriate management?

A 58-year-old woman has continuous nasogastric drainage after surgery for gastric-outlet obstruction. On postoperative day 3, she develops weakness and frequent ventricular ectopy. Potassium is 2.3 mmol/L, magnesium is 0.48 mmol/L, creatinine is normal, and urine output is adequate. The displayed ECG provides the decisive electrical abnormality. She remains hemodynamically stable and can be continuously monitored. What is the most appropriate immediate treatment?

A 57-year-old woman develops increasing pain and purulent drainage from a midline incision seven days after small-bowel surgery. Temperature is 38.3°C, heart rate 104/min, and examination shows erythema extending 3 cm around several separated skin staples. The fascia is intact on gentle assessment, CT shows no deep collection, and blood pressure is normal. What is the most appropriate management?

A 66-year-old man develops worsening abdominal pain, fever, and confusion four days after sigmoid colectomy. Blood pressure is 86/50 mmHg despite fluids, lactate is 5.2 mmol/L, and examination reveals generalized rigidity. The displayed CT supplies the decisive postoperative finding. Broad-spectrum antibiotics and vasopressors have begun, but there is no safe percutaneous route capable of controlling the diffuse contamination. What is the most appropriate next action?

A 44-year-old woman develops oliguria and increasing graft-site discomfort six weeks after kidney transplantation. Creatinine rises from 96 to 214 µmol/L, tacrolimus concentration is therapeutic, and urine culture is negative. The displayed ultrasound supplies the decisive structural finding, while Doppler confirms preserved arterial and venous perfusion. A pelvic fluid collection is compressing the transplant ureter, and there is no generalized sepsis. What is the most appropriate management?

A 52-year-old woman presents with six weeks of rapidly progressive breast enlargement, diffuse edema, erythema involving more than one-third of the breast, and palpable fixed axillary nodes. Core biopsy confirms grade 3 invasive carcinoma that is HER2-positive. Skin punch biopsy demonstrates dermal lymphatic tumor emboli, and CT staging shows no distant metastases. She is medically fit and has not received previous cancer treatment. What is the most appropriate initial treatment strategy?

A 39-year-old woman has 18 months of progressive dysphagia to both liquids and solids, nocturnal regurgitation, and a 7-kg weight loss. Endoscopy shows retained saliva but no obstructing lesion; biopsies from the gastroesophageal junction are benign. High-resolution manometry demonstrates elevated integrated relaxation pressure with absent peristalsis and panesophageal pressurization. The displayed contrast study provides the decisive structural finding. She is fit for definitive treatment and prefers an operation that includes an antireflux procedure. What is the most appropriate management?

A 29-year-old woman with familial adenomatous polyposis has hundreds of colorectal adenomas, including dense rectal involvement that cannot be controlled endoscopically. Several lesions contain high-grade dysplasia, but staging shows no invasive cancer. Anal sphincter function is normal, she has no significant obesity, and she accepts the possibility of temporary diversion. What is the most appropriate risk-reducing operation?

A 59-year-old man with hepatitis-related cirrhosis undergoes surveillance imaging. He has no ascites or encephalopathy, but platelets are 68 × 10⁹/L, endoscopy shows large esophageal varices, and bilirubin is mildly elevated. The displayed multiphase CT demonstrates the decisive characteristics of a solitary 2.7-cm segment VI lesion. There is no macrovascular invasion, nodal disease, or distant metastasis. Performance status is excellent, and no contraindication to transplantation is identified. What is the most appropriate definitive strategy?

A 73-year-old man undergoes emergency laparotomy for acute superior mesenteric arterial occlusion. Revascularization restores mesenteric pulsation, and 80 cm of clearly necrotic jejunum is resected. A further 60-cm segment is mildly dusky but improves after warming, oxygenation, and restoration of blood pressure; Doppler signals are present but weak. Removing this segment would leave marginal intestinal length. The patient requires vasopressors and remains physiologically unstable. What is the most appropriate operative strategy?

A 20-month-old boy has episodic crying, drawing up of the legs, vomiting, and one stool mixed with blood and mucus. Between episodes he appears tired but remains responsive. Temperature is 37.4°C, perfusion is normal after intravenous fluids, and examination reveals a right upper-quadrant mass without guarding or abdominal rigidity. The displayed ultrasound supplies the decisive diagnosis. There is no free intraperitoneal air, and pediatric surgery is available if nonoperative reduction fails. What is the most appropriate initial treatment?

A 70-year-old man is admitted after five days of poor intake and fever caused by a postoperative wound infection. Sodium is 162 mmol/L, glucose is normal, urine osmolality is high, and examination shows dry mucosa without pulmonary edema. He is alert but lethargic, and family confirms that reduced water intake developed gradually over four days. After restoring circulation with isotonic crystalloid, what is the most appropriate subsequent correction strategy?

A 63-year-old man with diabetes presents with rapidly worsening thigh pain two days after a minor skin injury. Temperature is 39.2°C, blood pressure 88/52 mmHg, lactate 5.0 mmol/L, and pain is far greater than the limited superficial erythema suggests. The displayed CT provides the decisive deep-tissue finding. Broad-spectrum antibiotics and resuscitation have begun, and surgical support is immediately available. What is the most appropriate next action?

A 59-year-old woman has persistent abdominal distension and nausea on day 4 after open right hemicolectomy. She passes no flatus, but pain is mild and diffuse without guarding. Potassium is 2.8 mmol/L, she has received regular opioids, and inflammatory markers are decreasing. The displayed abdominal radiograph shows the decisive bowel pattern. There is no focal transition point, hernia, free air, or rising lactate. What is the most appropriate initial management?

A 52-year-old man develops progressive graft dysfunction nine months after kidney transplantation. Creatinine rises from 120 to 205 µmol/L, ultrasound excludes obstruction, and graft vessels are patent. Plasma BK viral load is markedly elevated, donor-specific antibodies are absent, and the displayed biopsy supplies the decisive diagnosis. He is afebrile, urine culture is negative, and tacrolimus exposure has been relatively high. What is the most appropriate initial management?

A 43-year-old man is evaluated for a firm 2.6-cm thyroid nodule and several enlarged central cervical nodes. Serum calcitonin is 1,840 pg/mL, CEA is elevated, and TSH is normal. Fine-needle aspiration is suspicious for malignancy, while the displayed histology provides the decisive tumor type. His mother underwent unspecified thyroid surgery at age 38. He has occasional headaches but no documented hypertension. What is the most important next step before definitive thyroid surgery?

A 64-year-old man undergoes CT for persistent early satiety and iron-deficiency anemia. Endoscopy identifies a smooth submucosal gastric fundal mass with intact mucosa; endoscopic ultrasound shows origin from the muscularis propria. Core biopsy demonstrates spindle cells positive for KIT and DOG1, with a low mitotic rate. The displayed CT shows the lesion’s relationship to adjacent structures, without metastases or nodal enlargement. What is the most appropriate surgical treatment?

A 76-year-old woman develops sudden left-sided abdominal pain and bloody diarrhea after an episode of postoperative hypotension. CT shows segmental thickening from the splenic flexure through the descending colon, without arterial occlusion, pneumatosis, or free air. Lactate is 1.9 mmol/L, abdominal tenderness is localized without guarding, and blood pressure has normalized. Flexible sigmoidoscopy confirms ischemic mucosal injury without gangrene. What is the most appropriate management?

A 63-year-old woman has progressive painless jaundice, pruritus, and weight loss. MRI shows a hilar cholangiocarcinoma involving the right hepatic duct and extending into the left duct proximal to the segment IV branch. There are no metastases, the portal vein is patent, and planned surgery would require extended right hepatectomy. Volumetry estimates the left lateral future liver remnant at 21% of total functional liver volume. Bilirubin is 248 µmol/L, and she has no cholangitis. What is the most appropriate preoperative strategy?

A 46-year-old woman presents with sudden severe central abdominal pain, retching, and minimal distension three years after laparoscopic Roux-en-Y gastric bypass. Heart rate is 112/min, lactate is 3.1 mmol/L, and tenderness is increasing despite analgesia. The displayed CT demonstrates the decisive mesenteric configuration with clustered small-bowel loops and venous congestion, but no free air. She remains stable after initial fluids, and an experienced laparoscopic surgeon is available. What is the most appropriate management?

A 9-day-old term infant develops sudden bilious vomiting, irritability, and abdominal tenderness. He is tachycardic, capillary refill is four seconds, and lactate is 4.6 mmol/L. Abdominal radiography shows a gas-filled stomach with little distal bowel gas but no free air. After intravenous fluids, nasogastric decompression, and antibiotics, urgent upper gastrointestinal contrast imaging shows the duodenojejunal junction failing to cross the midline with a corkscrew proximal jejunum. What is the most appropriate next management?

A 64-year-old man with a new high-output ileostomy produces 3.4 L daily after subtotal colectomy. He reports thirst, cramps, and dizziness. Blood pressure falls on standing, sodium is 131 mmol/L, magnesium is 0.42 mmol/L, and creatinine has doubled. He has been drinking several liters of plain water and tea daily, while bowel obstruction and intra-abdominal sepsis have been excluded. What is the most appropriate initial management?

A 60-year-old man develops fever and persistent leukocytosis ten days after emergency sigmoid resection for perforated diverticulitis. CT shows a well-defined 6-cm left-subphrenic collection with rim enhancement and a safe percutaneous access route. He is hemodynamically stable, lactate is normal, bowel function has returned, and there is no diffuse peritonitis, anastomotic disruption, or multiple inaccessible collections. What is the most appropriate source-control strategy?

A 54-year-old woman has persistent milky drain output after retroperitoneal lymph-node dissection. Output is 650 mL daily, increases after meals, and fluid triglyceride concentration is markedly elevated. She is afebrile, albumin is mildly reduced, CT shows no abscess or active bleeding, and the drain remains well positioned. There is no peritonitis or bowel injury. What is the most appropriate initial management?

A 42-year-old woman is 18 days after deceased-donor kidney transplantation. Her creatinine has risen from 105 to 224 µmol/L over four days despite correction of dehydration and therapeutic tacrolimus levels. Urinalysis shows mild proteinuria without infection, Doppler ultrasonography shows patent graft vessels without obstruction, and donor-specific antibodies are absent. The biopsy image demonstrates the decisive graft abnormality. She is afebrile and hemodynamically stable. What is the most appropriate initial treatment?

A 68-year-old woman has toxic multinodular goiter treated with carbimazole. She reports progressive dysphagia, positional dyspnea, and inability to lie flat. CT demonstrates substernal extension with marked tracheal narrowing, while laryngoscopy shows normal vocal-cord movement. Thyroid function has nearly normalized, and cardiopulmonary assessment indicates that she can tolerate surgery. Fine-needle aspiration of the dominant nodule is benign. What is the most appropriate definitive management?

A 72-year-old man taking naproxen presents four hours after sudden severe epigastric pain. He is tachycardic but responds to intravenous fluids; examination shows generalized guarding. CT demonstrates free intraperitoneal air and a small anterior duodenal perforation with limited fluid. He has no previous ulcer surgery, no gastric outlet obstruction, and no suspicion of malignancy. After antibiotics, proton-pump inhibitor therapy, and nasogastric decompression, what is the most appropriate definitive treatment?

A 42-year-old man with ileocolonic Crohn disease presents with recurrent perianal drainage but little pain. MRI shows a transsphincteric fistula with a small associated abscess and two external openings. Proctoscopy demonstrates mild rectal inflammation without stricture. He is afebrile, receives biologic therapy, and has preserved continence. What is the most appropriate initial surgical management?

A 67-year-old woman undergoes MRI after an incidental pancreatic cyst is found on renal imaging. She has no jaundice, pancreatitis, weight loss, or new diabetes. Serum CA 19-9 is normal. The displayed MRCP provides the decisive ductal configuration. Endoscopic ultrasonography confirms a 2.1-cm cyst without mural nodules, solid tissue, or suspicious cytology; the main pancreatic duct measures 3 mm. She is fit for surgery but wishes to avoid an unnecessary resection. What is the most appropriate management?

A 37-year-old man presents with 20 hours of sharply localized left lower-quadrant pain. He has mild nausea but no vomiting, altered bowel habit, or urinary symptoms. Temperature is 37.2°C, heart rate is 84/min, leukocyte count is 11.3 × 10⁹/L, and C-reactive protein is mildly elevated. Examination shows focal tenderness without guarding. The displayed contrast CT provides the decisive diagnosis and shows no abscess, obstruction, or free air. What is the most appropriate management?

A 34-year-old man sustains blunt chest trauma. An initial portable radiograph is obtained while he is responsive, but minutes later he develops severe respiratory distress, blood pressure of 78/46 mmHg, tachycardia, distended neck veins, and markedly reduced breath sounds on the left. The displayed radiograph provides the decisive thoracic finding. There is no external chest wound, and massive hemorrhage has not been identified. What is the most appropriate immediate intervention?

A 79-year-old woman with chronic heart failure receives 4.5 L of crystalloid during the first postoperative day after colectomy. She develops dyspnea, elevated jugular venous pressure, bilateral crackles, and oxygen saturation of 86%. Blood pressure is 148/82 mmHg, urine output is preserved, and the displayed chest radiograph provides the decisive pulmonary finding. There is no fever, purulent sputum, or unilateral leg swelling. What is the most appropriate fluid-management response?

A 71-year-old woman develops profuse watery diarrhea after receiving broad-spectrum antibiotics for postoperative pneumonia. Leukocyte count is 19 × 10⁹/L, creatinine has risen from 80 to 151 µmol/L, and abdominal examination shows mild diffuse tenderness without guarding, ileus, or distension. Stool testing is positive for toxigenic Clostridioides difficile, and the displayed endoscopic image supplies characteristic mucosal confirmation. She is hemodynamically stable and can take oral medication. What is the most appropriate treatment?

An 81-year-old man becomes agitated and disoriented on the second night after emergency hernia surgery. He was cognitively independent before admission. Oxygen saturation is 95%, glucose is normal, and examination shows no focal neurological deficit. He has pain, constipation, urinary retention, sleep disruption, and has received repeated benzodiazepine doses. Temperature is normal and laboratory testing shows no major metabolic abnormality. What is the most appropriate management?

A 61-year-old man is eight months after liver transplantation and receives tacrolimus, mycophenolate, and prednisolone. He develops fever, abdominal discomfort, and six watery stools daily after completing treatment for rejection. Blood cultures and stool bacterial studies are negative. Colonoscopy shows scattered ulcers, and the biopsy image provides the key diagnosis. His leukocyte count is 2.4 × 10⁹/L, creatinine is normal, and plasma viral PCR is strongly positive. What is the most appropriate management?

A 57-year-old man is two hours after total thyroidectomy for a large multinodular goiter. He suddenly develops neck pressure, difficulty breathing, agitation, and inspiratory stridor. Examination shows rapidly increasing tense swelling beneath the incision, oxygen saturation is 88% despite supplemental oxygen, and the operating theatre is currently occupied. Intravenous access remains functional, but the anesthetist has not yet arrived. What is the most appropriate immediate action?

A 28-year-old woman with ileocolonic Crohn disease has recurrent postprandial pain and vomiting despite optimized biologic therapy. MR enterography shows a single 7-cm fibrotic terminal-ileal stricture with marked proximal dilation, no abscess, and no active fistula. Colonoscopy cannot traverse the narrowing, and biopsies show no dysplasia. She previously underwent a 40-cm jejunal resection after trauma and wishes to preserve bowel length. What is the most appropriate operative strategy?

A 27-year-old man has recurrent painless maroon stools requiring three transfusions over six months. Upper endoscopy, colonoscopy with terminal ileal intubation, and capsule endoscopy have not identified the source. During another active episode, CT angiography is nondiagnostic, but catheter angiography produces the displayed finding arising from a distal ileal arterial branch. He is now hemodynamically stable after resuscitation and has no inflammatory bowel disease. What is the most appropriate definitive management?

A 62-year-old man is postoperative day 8 after pancreaticoduodenectomy. His drain produces 180 mL daily of cloudy fluid with amylase 9,600 U/L. He has fever, leukocytosis, delayed gastric emptying, and a 6-cm peripancreatic collection on CT. Blood pressure and renal function are stable, and CT shows no active arterial bleeding. The operative drain does not adequately communicate with the collection. What is the most appropriate next management?

A 76-year-old nursing-home resident presents with 36 hours of progressive distension, constipation, and cramping lower abdominal pain. He is hemodynamically stable, lactate is 1.6 mmol/L, and examination reveals marked tympany without guarding. The displayed abdominal radiograph provides the decisive diagnosis. CT confirms no free air, bowel-wall nonenhancement, or obstructing colorectal mass. An experienced endoscopist is immediately available. What is the most appropriate initial treatment?

A 66-year-old man has persistent fever and dyspnea three weeks after bacterial pneumonia. Pleural aspiration yields frank pus with pH 6.9, and cultures grow Streptococcus anginosus. A correctly positioned chest tube, antibiotics, and intrapleural fibrinolytic therapy have produced minimal drainage over five days. The displayed contrast CT demonstrates the decisive pleural organization. He remains febrile but is stable enough for general anesthesia and has reasonable baseline pulmonary function. What is the most appropriate next treatment?

A 52-year-old man has persistent pancreatic ascites and is unable to eat adequately after complicated pancreatitis. A central venous catheter has been used for parenteral nutrition for twelve days. He develops fever and rigors during infusion, and paired cultures grow the same organism from the catheter sample two hours before the peripheral sample. Blood pressure is stable, and no other infection source is identified. What is the most appropriate nutritional-access plan?

A 64-year-old man with poorly controlled diabetes presents with fever, rigors, right-upper-quadrant pain, and confusion. Blood pressure is 88/52 mmHg, lactate is 4.3 mmol/L, and alkaline phosphatase is elevated. The displayed CT and ultrasound provide the decisive hepatic finding. The lesion is 8 cm, contains gas, and has a safe percutaneous route. After fluids and norepinephrine, he remains stable enough for intervention, with no rupture or generalized peritonitis. What is the most appropriate source-control strategy?

A 63-year-old woman develops unilateral thigh swelling and discomfort six days after pancreatic surgery. She is hemodynamically stable, oxygen saturation is normal, hemoglobin is unchanged, and there is no active postoperative bleeding. The displayed compression ultrasound provides the decisive vascular finding. Renal function is normal, epidural analgesia was removed two days ago, and no further invasive procedure is planned. What is the most appropriate treatment?

A 58-year-old man with decompensated metabolic-associated steatohepatitis is assessed for liver transplantation. He has recurrent ascites, two admissions for encephalopathy, a MELD score of 24, and preserved functional independence. Staging CT identifies a solitary 2.1-cm hepatocellular carcinoma without vascular invasion or metastases. During assessment, blood cultures grow methicillin-sensitive Staphylococcus aureus from an infected dialysis catheter; he remains febrile despite 24 hours of antibiotics. Cardiac evaluation is acceptable. What is the best immediate transplant decision?

A 62-year-old woman has recurrent calcium-oxalate stones, a fragility wrist fracture, serum calcium of 2.92 mmol/L, and repeatedly elevated parathyroid hormone. Renal function is mildly reduced, and familial hypocalciuric hypercalcemia has been excluded by urinary calcium assessment. Cervical ultrasonography and sestamibi imaging fail to localize an abnormal gland. She is medically fit and wishes definitive treatment. What is the most appropriate operative plan?

An 80-year-old man with atrial fibrillation presents with abrupt severe abdominal pain that appears disproportionate to early examination findings. Four hours later, he develops guarding, lactate rises to 6.8 mmol/L, and metabolic acidosis worsens despite resuscitation. CT angiography identifies a proximal superior mesenteric artery embolus. The displayed CT additionally demonstrates the decisive bowel findings. He has no recent intracranial bleeding and was previously independent. What is the most appropriate next management?

A 69-year-old man with chronic kidney disease presents with recurrent painless hematemesis and melena. After crystalloid and two units of packed red cells, blood pressure is 112/68 mmHg and hemoglobin is 78 g/L. Previous endoscopy six months ago found no ulcer or varices. Urgent endoscopy now reveals the actively bleeding abnormality displayed, with otherwise normal surrounding gastric mucosa. What is the most appropriate endoscopic treatment?

A 65-year-old woman is postoperative day 12 after pancreaticoduodenectomy. She develops 80 mL of fresh blood from an abdominal drain, followed by transient hypotension that responds to transfusion. Hemoglobin falls from 96 to 74 g/L. CT angiography shows a 9-mm gastroduodenal-artery stump pseudoaneurysm adjacent to a known pancreatic fistula, without diffuse intraperitoneal bleeding. She is currently stable, and interventional radiology is immediately available. What is the most appropriate definitive treatment?

A 68-year-old woman with atrial fibrillation presents with sudden severe abdominal pain and vomiting. Initial examination shows only moderate tenderness, but three hours later she develops guarding. Lactate rises from 2.9 to 6.1 mmol/L despite fluids, and metabolic acidosis worsens. CT angiography identifies an embolus in the proximal superior mesenteric artery. The displayed CT provides the decisive assessment of bowel injury. What is the most appropriate next management?

A 57-year-old woman is six hours after lower-limb reconstruction using a free anterolateral-thigh flap. Hourly assessment now shows rapid flap swelling, brisk dark bleeding on pinprick, and loss of the previously audible venous Doppler signal, while the arterial signal remains strong. Loosening the dressing and correcting hypotension do not improve the findings. The operating microsurgical team can return within 20 minutes. What is the most appropriate management?

A 61-year-old man remains ventilated after emergency surgery for perforated diverticulitis. Vasopressor requirements are decreasing, lactate is falling, and the abdomen has been closed without bowel discontinuity. Gastric feeding repeatedly causes large residual volumes and regurgitation. The displayed radiograph shows the position of a newly inserted feeding tube. There is no distal obstruction, bowel ischemia, or uncontrolled shock. What is the most appropriate nutritional plan?

A 59-year-old woman develops septic shock six days after emergency repair of a perforated small bowel. CT shows an anastomotic leak with diffuse fluid, and urgent reoperation provides washout, diversion, and drainage. Intra-abdominal cultures later grow Candida glabrata and mixed enteric bacteria. She has received broad-spectrum antibiotics, remains vasopressor dependent, and has recent abdominal surgery and central venous access. What is the most appropriate antifungal management?

A 72-year-old man develops oliguria after colectomy. Creatinine rises from 90 to 168 µmol/L over 24 hours. He has dry mucosa, postural hypotension, and recent vomiting; bladder scan shows 40 mL, and renal ultrasound shows no hydronephrosis. He received an angiotensin-converting-enzyme inhibitor and nonsteroidal anti-inflammatory medication that morning. There is no pulmonary edema, hyperkalemia, or severe acidosis. What is the most appropriate initial management?

A 36-year-old woman received a kidney transplant three years ago and takes tacrolimus, azathioprine, and low-dose prednisolone. She presents with 18 hours of migrating right lower-quadrant pain, vomiting, localized guarding, and a temperature of 38.1°C. CT confirms uncomplicated acute appendicitis; the transplanted kidney and ureter are located in the right iliac fossa near the operative field. Creatinine is unchanged, and she has no septic shock. What is the most appropriate management?

A 55-year-old woman undergoes abdominal imaging after renal colic, revealing a homogeneous 2.8-cm right adrenal mass. She has no cushingoid features, episodic adrenergic symptoms, hypokalemia, or resistant hypertension. Overnight dexamethasone suppression, plasma metanephrines, and aldosterone-renin testing are normal. The lesion has remained unchanged for 18 months, and the displayed paired MRI sequences provide the decisive tissue characterization. What is the most appropriate management?

A 51-year-old man undergoes extensive small-bowel resection for mesenteric ischemia, leaving 70 cm of jejunum connected to an intact colon. Six weeks later, he requires parenteral nutrition and has high-volume diarrhea, dehydration, hypomagnesemia, and weight loss. There is no recurrent ischemia, obstruction, sepsis, or active inflammatory disease. The remaining bowel is viable, and liver tests are normal. Which management strategy best promotes intestinal adaptation and eventual nutritional autonomy?

A 73-year-old woman taking aspirin presents with melena and syncope. Endoscopy shows a 20-mm posterior duodenal ulcer with a visible vessel, which is treated using injection and thermal coagulation. Thirty hours later, she develops recurrent melena, tachycardia, and a hemoglobin fall from 91 to 68 g/L. Repeat endoscopy achieves temporary hemostasis, but major bleeding recurs six hours later. After resuscitation she remains stable enough for transfer, and interventional radiology is immediately available. What is the most appropriate next intervention?

An 81-year-old woman undergoes CT for investigation of microscopic hematuria. Liver tests are normal, she has no abdominal symptoms, and there is no history of malignancy or chronic liver disease. The displayed paired contrast phases provide the decisive characterization of a 5.2-cm hepatic lesion. MRI confirms identical benign vascular behavior without restricted diffusion, and prior imaging shows no meaningful growth over four years. What is the most appropriate management?

A 63-year-old man is postoperative day 5 after emergency small-bowel resection for perforation. He develops fever, confusion, abdominal tenderness, and increasing oxygen requirements. Blood pressure is 92/58 mmHg after initial fluids, lactate is 4.2 mmol/L, and CT shows a 9-cm interloop collection with gas, without generalized free perforation. The collection has a safe percutaneous access route, and the bowel anastomosis appears intact. What is the most appropriate source-control strategy?

A 16-year-old boy presents four hours after sudden severe left scrotal pain with nausea. The left testis is high-riding and very tender, the cremasteric reflex is absent, and urinalysis shows no pyuria. The displayed Doppler ultrasound was obtained immediately because the operating team was being assembled and did not delay treatment. The contralateral testis appears normal. What is the most appropriate management?

A 45-year-old woman has eaten almost nothing for twelve days because of an obstructing upper gastrointestinal tumor. BMI is 17 kg/m², phosphate is 0.62 mmol/L, potassium is 3.1 mmol/L, and magnesium is low. Definitive surgery is planned after nutritional optimization. She is hemodynamically stable and has functioning jejunal access distal to the obstruction. What is the safest way to begin nutritional support?

A 72-year-old man with an indwelling biliary stent for unresectable cholangiocarcinoma presents with fever, jaundice, confusion, and hypotension. Bilirubin is 186 µmol/L, lactate is 5.0 mmol/L, and ultrasound shows biliary dilatation above an obstructed stent. Blood cultures are obtained, broad-spectrum antibiotics and fluids are started, and norepinephrine is required. There is no perforation or surgically correctable abdominal catastrophe. What is the most appropriate next management?

A 60-year-old man notices separation of his groin incision nine days after open hernia repair. He is afebrile, pain is improving, and laboratory inflammatory markers are normal. The displayed photograph shows the decisive wound depth. Examination confirms that the deep fascial repair remains intact, with no exposed mesh, purulent drainage, cellulitis, or recurrent hernia. What is the most appropriate management?

A 49-year-old man undergoes deceased-donor liver transplantation for primary sclerosing cholangitis. Twelve hours later, he requires escalating vasopressors and remains acidotic despite adequate resuscitation. AST is 8,400 U/L, INR is 5.1, lactate is 10.2 mmol/L, and he develops progressive encephalopathy. Doppler ultrasonography and CT angiography show patent hepatic arterial, portal venous, and hepatic venous flow without surgical bleeding. What is the most appropriate definitive management?

A 63-year-old woman with obesity and chronic cough presents with 14 hours of focal left lower abdominal pain, vomiting, and a tender nonreducible swelling lateral to the rectus muscle. She has no previous abdominal operation. Temperature is 37.9°C, heart rate is 104/min, and lactate is 2.1 mmol/L. The displayed CT identifies the defect and shows bowel within the sac, without free air or established pneumatosis. After intravenous fluids and antibiotics, what is the most appropriate management?

A 60-year-old man is postoperative day 6 after transthoracic esophagectomy with an intrathoracic anastomosis. He develops fever, atrial fibrillation, increasing oxygen requirement, and foul output from the right chest drain. CT with oral contrast shows a contained anastomotic leak draining into the pleural space; the gastric conduit remains well perfused, and there is no diffuse mediastinal necrosis. He is hemodynamically stable after fluids. What is the most appropriate management?

A 66-year-old woman with systemic sclerosis has progressive fatigue and recurrent iron-deficiency anemia requiring monthly transfusions. She denies hematemesis or visible melena. Colonoscopy and capsule endoscopy are unrevealing, and anticoagulants are not used. Endoscopy demonstrates the abnormal antral pattern displayed, without gastric varices or peptic ulceration. Oral and intravenous iron have not maintained her hemoglobin. What is the most appropriate definitive endoscopic treatment?

A 52-year-old man with alcohol-related chronic pancreatitis has disabling daily pain despite abstinence, pancreatic enzymes, analgesic optimization, and three endoscopic attempts to clear duct stones. CT shows an inflammatory pancreatic-head mass, multiple head calcifications, and a 9-mm duct dilated throughout the body and tail. Biopsy and serial imaging show no evidence of malignancy, and the bile duct and duodenum are not obstructed. What is the most appropriate operation?

A 59-year-old woman with no previous abdominal operations presents with vomiting, distension, and constant central pain. CT shows a closed-loop small-bowel obstruction caused by an internal hernia, with mesenteric edema and reduced bowel-wall enhancement. Heart rate is 118/min, lactate is 3.8 mmol/L, and focal guarding persists after resuscitation. There is no free air, and she is stable enough for anesthesia. What is the most appropriate management?

A 50-year-old man has a proximal high-output enterocutaneous fistula after repeated laparotomies. Output remains 2.8 L/day despite antisecretory treatment, and enteral feeding substantially increases output and causes dehydration. CT shows no undrained abscess or distal obstruction. He is losing weight, nitrogen balance is negative, and definitive reconstruction is not planned for several months. What is the most appropriate nutritional strategy?

A 67-year-old man undergoes reoperation and drainage for a postoperative intra-abdominal abscess. Cultures grow an extended-spectrum beta-lactamase-producing Escherichia coli susceptible to meropenem and ertapenem but resistant to ceftriaxone and piperacillin-tazobactam. Blood cultures are negative, source control is complete, vasopressors have stopped, renal function is normal, and no Pseudomonas species is isolated. What is the most appropriate antimicrobial strategy?

A 68-year-old woman is being considered for discharge five days after colorectal surgery. She is afebrile, tolerates solid food, passes stool, walks independently, and controls pain using oral medication. The incision is clean, renal function is baseline, and no drain remains. However, her daughter reports new confusion overnight, and the patient cannot explain her medication schedule or identify whom to contact for worsening symptoms. What is the most appropriate disposition?

A 63-year-old woman undergoes assessment after screening mammography detects the abnormality shown. Examination reveals no palpable mass or axillary nodes. Stereotactic biopsies from the anterior and posterior extent both show high-grade ductal carcinoma in situ with necrosis and no invasion. The involved segment spans 7.4 cm in a small breast, and breast MRI shows no contralateral lesion. What is the most appropriate operation?

An 82-year-old woman presents five days after laparoscopic port-site surgery with increasing focal abdominal-wall pain, fever, and overlying erythema. She has passed stool and reports only mild nausea, so a complete bowel obstruction is not clinically evident. Leukocyte count is 17.2 × 10⁹/L, lactate is 3.4 mmol/L, and the displayed CT shows the decisive relationship between the bowel wall and fascial defect. What is the most appropriate operative management?

A 45-year-old man presents with four days of right lower-quadrant pain, fever, and anorexia. Examination reveals a tender localized mass without generalized peritonitis. Leukocyte count is 15.8 × 10⁹/L, and he is hemodynamically stable. The displayed CT provides the decisive anatomical finding and shows no free intraperitoneal air. Interventional radiology is available, and the collection is safely accessible. What is the most appropriate initial management?

A 78-year-old man develops sudden large-volume hematochezia while hospitalized for pneumonia. Blood pressure is 84/50 mmHg, heart rate is 122/min, and hemoglobin has fallen from 113 to 76 g/L. After activation of a major-hemorrhage protocol, temporary blood-pressure improvement is achieved, but brisk bleeding continues. Nasogastric aspirate is nonbloody, abdominal examination shows no peritonitis, and bowel preparation for colonoscopy cannot be completed. What is the most appropriate next investigation?

A 46-year-old man receiving chemotherapy for lymphoma presents with fever, left upper-quadrant pain, and positive blood cultures for Salmonella species. Leukocyte count is 17.8 × 10⁹/L, but blood pressure normalizes after fluids and antibiotics. The displayed contrast CT supplies the decisive splenic finding. There is one accessible 6.5-cm collection, no rupture, no diffuse peritonitis, and no other intra-abdominal source. Platelet count and coagulation studies are adequate. What is the most appropriate source-control strategy?

A 41-year-old woman has a BMI of 37 kg/m², hypertension, obstructive sleep apnea, and unsuccessful sustained weight loss despite structured nutritional, behavioral, and pharmacological therapy. She understands the need for lifelong follow-up and has no active substance misuse or uncontrolled psychiatric illness. However, she currently smokes ten cigarettes daily and has not yet completed nutritional laboratory screening. What is the most appropriate next step?

A 27-year-old woman becomes hypotensive and tachycardic after high-speed blunt trauma. Breath sounds are equal, the abdomen is soft, and pelvic radiography shows no major disruption. Neck veins are distended, heart sounds are difficult to hear, and pulse pressure is narrow. The displayed subcostal ultrasound provides the decisive cause of shock. She deteriorates despite cautious crystalloid, and a trauma surgeon is present. What is the most appropriate immediate action?

A 33-year-old restrained driver presents after a high-speed frontal collision. He has left chest pain, dyspnea, and reduced breath sounds. A chest tube placed for suspected hemothorax drains little, but respiratory distress persists. The displayed CT provides the decisive anatomical finding. Blood pressure is 118/70 mmHg, there is no major intracranial injury, and no hollow-viscus perforation is identified. What is the most appropriate management?

A 62-year-old man is scheduled for elective repair of a minimally symptomatic incisional hernia. Two months ago, he had an acute coronary syndrome treated with a drug-eluting coronary stent and now takes aspirin and ticagrelor. Cardiopulmonary symptoms are absent, ventricular function is preserved, and the hernia is reducible without obstruction. The surgeon expects extensive dissection with substantial bleeding risk and requests interruption of both antiplatelet agents. What is the most appropriate plan?

A 54-year-old woman undergoes lumpectomy and sentinel-node biopsy for a 2.3-cm estrogen-receptor-positive, HER2-negative invasive ductal carcinoma. Margins are clear. Two of three sentinel nodes contain macrometastases measuring 4 mm and 6 mm, without gross extranodal extension. Preoperative axillary ultrasonography was normal. She will receive whole-breast irradiation with appropriate systemic therapy and had no neoadjuvant treatment. What is the best next axillary management?

A 58-year-old man undergoes emergency laparotomy for perforated small-bowel obstruction within a large midline incisional hernia. Twelve centimeters of necrotic ileum are resected, and enteric contents have contaminated the hernia sac. After irrigation and source control, the fascial edges can be approximated without excessive tension. He is hemodynamically stable but has diabetes and active smoking history. What is the most appropriate abdominal-wall strategy during this operation?

A 58-year-old man has rectal bleeding and altered bowel habit. Colonoscopy identifies a nonobstructing adenocarcinoma 6 cm from the anal verge. Pelvic MRI stages it as cT3cN1 with threatened mesorectal fascia but no sphincter or levator invasion; CT shows no distant metastases. His performance status is good, continence is normal, and the multidisciplinary team considers sphincter preservation technically possible. What is the most appropriate treatment sequence?

A 76-year-old man with moderate aortic stenosis presents with recurrent painless maroon stools and iron-deficiency anemia. Colonoscopy after adequate preparation shows no cancer, diverticular inflammation, or active colitis. The displayed cecal lesion begins oozing during irrigation and is considered responsible for three bleeding admissions in the past year. Platelet count and coagulation studies are normal, and he is hemodynamically stable. What is the most appropriate treatment?

A 72-year-old man with diabetes and peripheral vascular disease presents with 18 hours of right upper-quadrant pain, fever, and vomiting. Temperature is 39.1°C, leukocyte count is 19.4 × 10⁹/L, and lactate is 2.7 mmol/L. He becomes hemodynamically stable after fluids and antibiotics, and anesthesia assessment considers him operable. The displayed CT and ultrasound provide the decisive gallbladder finding. The common bile duct is not dilated, bilirubin is normal, and there is no pancreatitis. What is the most appropriate definitive management?

A 44-year-old woman underwent the bariatric operation shown four years ago. She initially lost 42 kg but now has severe daily reflux, nocturnal regurgitation, and erosive esophagitis despite maximal proton-pump inhibition. Contrast imaging shows an intact tubular stomach without obstruction, and manometry excludes a major motility disorder. A small hiatal hernia is present, and she remains medically fit. What is the most appropriate revisional operation?

A 46-year-old man with chronic kidney disease undergoes massive transfusion during surgery for ruptured iliac aneurysm. Surgical bleeding is controlled, but hypotension and diffuse microvascular oozing persist. Ionized calcium is 0.72 mmol/L, potassium is 6.4 mmol/L, temperature is 34.5°C, and the displayed ECG provides the decisive combined electrolyte effects. Fibrinogen replacement and active warming are underway. What is the most appropriate immediate additional treatment?

A 28-year-old woman sustains blunt abdominal trauma in a road collision. After initial fluids, blood pressure is 116/72 mmHg, heart rate is 94/min, lactate is 1.9 mmol/L, and abdominal tenderness is localized to the left upper quadrant without guarding. The displayed contrast CT shows a splenic laceration with a subcapsular hematoma and a focal arterial contrast blush. There are no other injuries requiring laparotomy, and interventional radiology is immediately available. What is the most appropriate management?

A 71-year-old woman taking apixaban 5 mg twice daily for atrial fibrillation is scheduled for elective open colectomy with planned epidural analgesia. Renal function is normal, platelet count is normal, and her last apixaban dose was taken 24 hours ago. Surgery can safely be postponed, and she has no active bleeding or indication for urgent anticoagulant reversal. What is the most appropriate anesthetic plan?

A 37-year-old woman has a 2.8-cm right thyroid nodule, normal vocal-cord movement, and normal serum TSH. Fine-needle aspiration confirms papillary thyroid carcinoma. The displayed ultrasonographic image also includes the most suspicious right lateral cervical node; needle sampling of that node is positive for metastatic papillary carcinoma. CT shows no distant metastases or invasion of the trachea or esophagus. What is the most appropriate initial operation?

A 49-year-old man develops a symptomatic recurrent right inguinal hernia two years after an open Lichtenstein repair. Examination confirms a reducible medial recurrence, and ultrasound shows no femoral component. He has no previous pelvic surgery, can tolerate general anesthesia, and an experienced minimally invasive hernia surgeon is available. The patient wants the approach associated with less dissection through the previous scarred operative plane. What is the most appropriate repair?

A 47-year-old man with poorly controlled diabetes presents with severe deep perianal pain, fever, and urinary difficulty. External inspection shows minimal swelling, but digital examination is intolerable. Leukocyte count is 18.4 × 10⁹/L, and blood pressure remains stable after fluids. The displayed pelvic MRI reveals the decisive extent of infection. There is no crepitus, skin necrosis, or physiological evidence of necrotizing infection. What is the most appropriate management?

A 71-year-old woman taking warfarin for a mechanical mitral valve presents with melena, dizziness, and hypotension. Hemoglobin is 65 g/L, INR is 5.8, and platelets are normal. She remains tachycardic after initial crystalloid but improves with packed red-cell transfusion. Urgent endoscopy is planned once resuscitation and anticoagulant reversal are underway. Which strategy is most appropriate for rapid warfarin reversal?

A 64-year-old woman undergoes surgery for recurrent right upper-quadrant pain and intermittent jaundice. Preoperative MRCP shows a large stone impacted in the gallbladder neck, producing extrinsic compression of the common hepatic duct without a cholecystocholedochal fistula. During laparoscopy, dense inflammation obscures Calot triangle, but the posterior gallbladder wall separates safely from the liver. Intraoperative assessment shows no bile-duct transection, and an experienced biliary surgeon is present. What is the safest operative strategy?

A 52-year-old man is postoperative day 3 after laparoscopic sleeve gastrectomy. He develops persistent tachycardia of 126/min, left shoulder pain, fever, and increasing oxygen requirement. Blood pressure remains 104/66 mmHg after fluids, and C-reactive protein is markedly elevated. CT with oral and intravenous contrast is equivocal, showing only a small perigastric fluid pocket without definite extravasation. What is the most appropriate next management?

A 35-year-old motorcyclist arrives after a high-speed collision with blood pressure 78/46 mmHg, heart rate 132/min, cool extremities, and an unstable pelvis on gentle examination. FAST shows no intraperitoneal fluid, breath sounds are equal, and there is no external hemorrhage. The displayed pelvic radiograph supplies the decisive injury pattern. Two large-bore intravenous lines are functioning, and blood products are immediately available. What is the most appropriate immediate resuscitative action?

A 40-year-old construction worker falls onto a metal rod that penetrates the left upper abdomen. He arrives with the object still embedded, blood pressure 104/66 mmHg, heart rate 108/min, and localized guarding. FAST shows a small amount of intraperitoneal fluid, and distal pulses are intact. The rod is stable, and a trauma operating theatre is ready. What is the most appropriate immediate management?

A 48-year-old man requires urgent laparotomy for complete small-bowel obstruction. He has vomited repeatedly, cannot confirm when he last ate, and nasogastric insertion has been unsuccessful. Oxygenation and blood pressure are currently stable. The displayed point-of-care gastric ultrasound provides the decisive aspiration-risk finding. There is no predicted difficult laryngoscopy, and experienced anesthesia support is present. What is the most appropriate induction strategy?

A 66-year-old woman has recurrent nephrolithiasis, osteoporosis, calcium of 3.02 mmol/L, elevated parathyroid hormone, and normal renal function. Cervical ultrasonography is negative. The displayed localization study identifies the only convincing lesion. There is no family history of endocrine neoplasia, and no additional hyperfunctioning gland is seen. After hydration and correction of vitamin D deficiency, what is the most appropriate operative approach?

An 81-year-old man has a permanent end colostomy and the displayed CT was obtained during surveillance for unrelated renal disease. He reports a slowly enlarging bulge around the stoma but no pain, appliance leakage, obstructive episodes, or difficulty irrigating the colostomy. The hernia is soft and reducible, the stoma remains healthy, and he has severe chronic obstructive pulmonary disease with limited exercise tolerance. What is the most appropriate current management?

A 32-year-old woman with extensive ulcerative colitis is admitted with ten bloody stools daily, fever, tachycardia, and abdominal distension. After 48 hours of intravenous corticosteroids, venous thromboprophylaxis, fluids, and electrolyte correction, her heart rate is 124/min, hemoglobin is 86 g/L, leukocyte count is 19.5 × 10⁹/L, and C-reactive protein continues rising. The displayed abdominal radiograph provides the decisive colonic finding. There is no free intraperitoneal air, but tenderness is becoming generalized. What is the most appropriate management?

A 79-year-old woman presents with fever, jaundice, right upper-quadrant pain, and new confusion. Blood pressure is 88/54 mmHg despite initial fluids, bilirubin is 132 µmol/L, leukocyte count is 18.7 × 10⁹/L, and creatinine is rising. Blood cultures are obtained and broad-spectrum antibiotics are started. The displayed MRCP supplies the decisive obstructing finding. Following initial cardiorespiratory stabilization, what is the most appropriate next intervention?

A 48-year-old man is eight weeks after alcohol-associated acute pancreatitis. He now reports early satiety, persistent epigastric discomfort, and vomiting after solid meals. Serum inflammatory markers are normal, and there is no fever or organ dysfunction. The displayed CT shows the decisive characteristics of a 10-cm collection directly apposed to the posterior gastric wall. Endoscopic ultrasonography confirms a mature wall, predominantly fluid content, no pseudoaneurysm, and minimal internal debris. What is the most appropriate treatment?

A 48-year-old woman underwent the bariatric procedure shown seven years ago. She presents with progressive dysphagia, nocturnal regurgitation, and inability to tolerate liquids. She is dehydrated but has no peritonitis or sepsis. Chest radiography shows an abnormally horizontal device orientation with proximal gastric enlargement, and contrast passes only slowly into the distal stomach. What is the most appropriate immediate management?

A 62-year-old woman develops fever, severe lumbar pain, dyspnea, and dark urine fifteen minutes after a red-cell transfusion begins during colectomy. Blood pressure falls to 82/48 mmHg, the surgical field becomes diffusely oozy, and the transfusion label does not match the patient’s identification details. General anesthesia prevents assessment of subjective symptoms. What is the most appropriate immediate management?

A 29-year-old man sustains circumferential full-thickness burns of the forearm during an industrial fire. Four hours after fluid resuscitation, pain increases, the hand becomes cool, capillary refill is delayed, and Doppler signals at the wrist progressively weaken. There is no associated fracture, and systemic blood pressure is normal. The displayed technical image demonstrates the required release procedure. What is the most appropriate immediate intervention?

A 56-year-old woman taking buprenorphine-naloxone for opioid-use disorder is scheduled for major abdominal-wall reconstruction. Her treatment has been stable for three years, she has no current illicit opioid use, and the addiction team is available. Severe postoperative pain is expected, but regional techniques and nonopioid analgesics can be used. She is worried that stopping treatment may trigger craving and relapse. What is the most appropriate perioperative pain plan?

A 45-year-old man has episodic headache, diaphoresis, palpitations, and blood pressure surges to 220/120 mmHg. Plasma metanephrines are more than five times the upper limit of normal, and CT shows a localized 4.6-cm left adrenal mass without metastases. He currently takes propranolol prescribed for palpitations but has received no alpha blockade. Resting blood pressure is 168/96 mmHg, and echocardiography shows preserved ventricular function. What is the most appropriate next step before adrenalectomy?

A 41-year-old man presents with a slowly enlarging, firm plaque containing several nodules on the lower abdominal wall. It has recurred after a previous office excision reported only as a spindle-cell lesion. MRI shows dermal and subcutaneous involvement without muscle invasion, and staging CT shows no metastases. The displayed biopsy provides the decisive pathological pattern; immunohistochemistry is diffusely CD34-positive. What is the most appropriate definitive treatment?

A 74-year-old woman with chronic constipation presents with 18 hours of colicky pain, vomiting, and progressive abdominal distension. She has no previous abdominal surgery. Heart rate is 108/min, lactate is 2.8 mmol/L, and examination shows right-sided tenderness without generalized rigidity. The displayed CT demonstrates the decisive colonic configuration and mesenteric twist, with no pneumatosis or free air. After fluid resuscitation and antibiotics, what is the most appropriate management?

A 45-year-old woman is postoperative day 3 after difficult laparoscopic cholecystectomy at a district hospital. She has abdominal pain, fever, bilious drain output of 500 mL daily, and bilirubin of 74 µmol/L. CT shows a controlled subhepatic collection without generalized peritonitis. MRCP suggests complete division of the common hepatic duct close to the biliary confluence. The operating surgeon has limited hepatobiliary reconstruction experience. What is the most appropriate management?

A 61-year-old woman presents with weight loss and persistent left upper abdominal discomfort. Pancreatic-protocol CT shows a 3.1-cm solid mass in the pancreatic tail without celiac-axis, superior mesenteric artery, or portal-venous involvement. Endoscopic ultrasound biopsy confirms pancreatic ductal adenocarcinoma. Chest and abdominal staging show no metastases, CA 19-9 is moderately elevated without jaundice, and her performance status is excellent. What is the most appropriate treatment?

A 35-year-old woman is six weeks after Roux-en-Y gastric bypass and has vomited daily for three weeks because of a gastrojejunal stricture awaiting dilation. She develops confusion, gait instability, horizontal nystagmus, and distal paresthesia. Sodium and glucose are normal, and brain CT shows no acute lesion. She has received dextrose-containing intravenous fluids but no vitamin replacement. What is the most appropriate immediate treatment?

A 29-year-old man continues diffuse microvascular bleeding during damage-control laparotomy after major trauma. Eight red-cell units and eight plasma units have been given. Temperature is 35.6°C, ionized calcium has been corrected, platelet count is 104 × 10⁹/L, and Clauss fibrinogen is 0.9 g/L. The displayed rotational thromboelastometry trace supplies the decisive clot-quality abnormality. Surgical arterial bleeding has been controlled. What is the most appropriate additional hemostatic treatment?

A 45-year-old man with 55% total-body-surface-area burns receives protocol-guided resuscitation. Twelve hours later, peak airway pressures rise, urine output falls despite adequate mean arterial pressure, and the abdomen becomes tense. Bladder pressure is 29 mmHg, lactate is increasing, and neuromuscular blockade plus gastric and colonic decompression do not improve organ function. The displayed operative image demonstrates the definitive intervention. What is the most appropriate next action?

A 69-year-old man is assessed before elective gastrectomy for an early gastric tumor that is not obstructing or bleeding. He reports new exertional chest pressure and one episode of presyncope during the previous week. Troponin is normal, but the displayed ECG shows a new conduction abnormality that limits ischemia interpretation. Functional capacity has declined markedly, and surgery can safely be delayed for cardiac evaluation. What is the most appropriate next step?

A 34-year-old woman who is three weeks postpartum presents with increasing left breast pain, fever, and reduced milk drainage despite 48 hours of oral flucloxacillin. Examination shows a tender fluctuant area lateral to the areola without skin necrosis or systemic instability. Her temperature is 38.2°C, leukocyte count is 14.6 × 10⁹/L, and the displayed ultrasound provides the decisive anatomical finding. She wishes to continue breastfeeding. What is the most appropriate next management?

A 36-year-old woman notices an enlarging painless mass in the medial thigh. It measures 8 cm, lies deep to the fascia, and has increased noticeably during the past three months. MRI shows a heterogeneous lesion abutting but not encasing the femoral vessels. There is no regional lymphadenopathy, and no biopsy has been performed. A local surgeon proposes removing it through a transverse incision and obtaining pathology afterward. What is the most appropriate next step?

A 61-year-old man undergoes endoscopic removal of a 22-mm pedunculated sigmoid polyp found during investigation of iron-deficiency anemia. Pathology shows moderately differentiated adenocarcinoma invading the submucosa of the stalk. The lesion was removed in one piece, but cancer is 0.4 mm from the cauterized margin, lymphovascular invasion is present, and tumor budding is high. CT shows no metastases, and he is medically fit. What is the most appropriate next management?

A 56-year-old man is four weeks after severe gallstone pancreatitis. He now has fever, early satiety, leukocytosis, and persistent organ dysfunction. CT shows a 13-cm mature encapsulated collection containing fluid and substantial necrotic debris, closely apposed to the posterior stomach. Blood cultures grow enteric organisms, and antibiotics have not produced clinical improvement. There is no active hemorrhage or free perforation. What is the most appropriate initial intervention?

A 39-year-old woman presents with five days of epigastric pain and low-grade fever following an uncomplicated splenectomy for hereditary spherocytosis three weeks earlier. Platelet count is 890 × 10⁹/L, lactate is normal, and there is no gastrointestinal bleeding or peritonitis. The displayed contrast CT provides the decisive vascular finding, extending from the splenic-vein stump into the main portal vein without bowel-wall ischemia. Liver function is preserved, and there is no active postoperative bleeding. What is the most appropriate management?

A 46-year-old woman presents nine months after Roux-en-Y gastric bypass with burning epigastric pain, nausea, and intermittent melena. She recently resumed smoking and takes ibuprofen for knee pain. Hemoglobin is 103 g/L, vital signs are stable, and CT shows no free air or internal hernia. Endoscopy identifies a 14-mm ulcer at the gastrojejunal anastomosis without active bleeding or foreign material. Helicobacter pylori testing is pending. What is the most appropriate initial management?

A 51-year-old woman collapses ten days after elective abdominal surgery. Blood pressure is 72/44 mmHg, heart rate 138/min, oxygen saturation 79%, and neck veins are distended. Bedside echocardiography shows severe right-ventricular dilatation, while the displayed CT pulmonary angiogram provides the decisive vascular finding. There is no active surgical bleeding, intracranial disease, or other major contraindication to thrombolysis. What is the most appropriate immediate reperfusion treatment?

A 37-year-old man sustains rapid deceleration trauma. CT angiography shows a small contained injury at the aortic isthmus with an intimal flap and limited pseudoaneurysm, but no free rupture. Blood pressure is 142/86 mmHg, heart rate is 108/min, and distal perfusion is intact. He also has a stable pelvic fracture but no intracranial bleeding. A vascular center with thoracic endovascular capability accepts transfer. What is the most appropriate interim and definitive plan?

A 79-year-old woman becomes hypoxemic immediately after induction for emergency laparotomy. The tracheal tube passed without difficulty, capnography confirms exhaled carbon dioxide, but breath sounds are markedly reduced on the left. Peak airway pressure is elevated, blood pressure is stable, and lung ultrasound shows bilateral pleural sliding. The displayed portable radiograph provides the decisive tube-position finding. What is the most appropriate immediate action?

A 59-year-old woman reports six months of unilateral nipple irritation and intermittent blood-stained discharge. Two courses of topical corticosteroid prescribed for presumed eczema produced no improvement. There is no palpable breast mass or axillary lymphadenopathy, and her last screening mammogram was two years ago. The displayed clinical image shows the current nipple abnormality. What is the most appropriate next step in her assessment?

A 52-year-old man develops severe lower chest and upper abdominal pain immediately after repeated forceful vomiting. Eight hours later, he is febrile, tachycardic, and hypotensive despite initial fluids. Examination shows epigastric guarding and reduced left basal breath sounds. The displayed contrast-enhanced CT supplies the decisive anatomical finding and shows mediastinal contamination with a left pleural collection. He has no known esophageal malignancy. What is the most appropriate definitive management?

A 38-year-old woman reports eight months of severe pain during and after defecation with small-volume bright-red bleeding. Examination using gentle separation reveals the abnormality displayed, and digital examination is deferred because of pain. She has used fiber, stool softeners, topical diltiazem, and sitz baths consistently for twelve weeks without improvement. She has no inflammatory bowel disease, previous anorectal surgery, or continence impairment. What is the most appropriate definitive treatment?

A 34-year-old man sustains blunt left upper-quadrant trauma in a motorcycle collision. After two units of packed red cells, blood pressure is 118/72 mmHg, heart rate is 96/min, and lactate is decreasing. He has localized tenderness without generalized peritonitis. The displayed contrast-enhanced CT demonstrates a high-grade splenic injury and the decisive vascular finding. No other abdominal injury requires laparotomy, and interventional radiology is immediately available. What is the most appropriate management?

A 58-year-old man presents with abrupt generalized abdominal pain six hours after several days of taking high-dose anti-inflammatory medication. He is confused, blood pressure is 86/52 mmHg, heart rate is 128/min, and lactate is 5.6 mmol/L. Examination reveals a rigid abdomen with rebound tenderness. The displayed CT provides the decisive finding, with free fluid but no localized drainable abscess. Broad-spectrum antibiotics, blood products, and vasopressors are being initiated. What is the most appropriate next step?

A 38-year-old man is seven weeks after Roux-en-Y gastric bypass. He has progressive postprandial vomiting, intolerance of solid food, and a 6-kg additional weight loss. He can swallow liquids slowly and has no fever, tachycardia, abdominal tenderness, or gastrointestinal bleeding. CT shows no internal hernia or bowel obstruction. Endoscopy demonstrates a short concentric narrowing at the gastrojejunal anastomosis that the standard gastroscope cannot traverse; no ulcer or leak is present. What is the most appropriate treatment?

A 74-year-old man taking dabigatran presents with a perforated sigmoid colon and generalized peritonitis requiring immediate laparotomy. His last dose was four hours ago, creatinine clearance is 28 mL/min, thrombin time is markedly prolonged, and there is persistent bleeding from venipuncture sites. Delaying surgery for drug clearance is unsafe. What is the most appropriate anticoagulant-reversal strategy?

A 32-year-old man sustains blunt chest trauma in a vehicle collision. CT shows the abnormality displayed, with several rib fractures but no pneumothorax, major hemothorax, or aortic injury. Six hours later, oxygen saturation falls to 84% despite high-flow oxygen, respiratory rate is 36/min, and arterial oxygenation continues to worsen. He is becoming exhausted, while blood pressure remains stable and repeat ultrasound shows no pleural collection. What is the most appropriate respiratory management?

A 65-year-old man is undergoing elective colorectal resection. Cefazolin and metronidazole were administered 35 minutes before incision. The operation has lasted four hours, estimated blood loss is 1.8 L, and another two hours of surgery are expected. Hemodynamics are stable, renal function is normal, and no allergic reaction occurred. What is the most appropriate antimicrobial-prophylaxis action?

A 46-year-old woman presents with a painless breast mass that enlarged from 2 cm to 6 cm over five months. Mammography shows a circumscribed mass, while ultrasound demonstrates a heterogeneous solid lesion without abnormal axillary nodes. Core biopsy is reported as a fibroepithelial neoplasm, and the displayed histology provides the decisive classification. Staging studies show no distant disease, and breast conservation remains technically feasible. What is the most appropriate surgical treatment?

A 60-year-old man has three months of early satiety, nonbilious vomiting, and a 9-kg weight loss. Nasogastric drainage produces 1.8 L of retained food and fluid. After electrolyte correction, endoscopy shows a tight pyloric stenosis with no visible tumor; multiple biopsies are benign, and CT shows no extrinsic mass. Helicobacter pylori has been eradicated, acid suppression has been optimized, and two endoscopic balloon dilations produced only brief improvement. What is the most appropriate definitive treatment?

A 67-year-old man presents with left lower-quadrant pain, fever, and reduced appetite. CT shows sigmoid diverticulitis with a 2.2-cm pericolic abscess, no distant free air, and no obstruction. He is hemodynamically stable, tolerates fluids, and has no generalized peritonitis. His leukocyte count is 14.1 × 10⁹/L, renal function is normal, and the collection is too small for safe catheter placement. What is the most appropriate initial management?

An 84-year-old woman with atrial fibrillation and chronic kidney disease presents with vomiting, abdominal distension, and obstipation. She is dehydrated but becomes hemodynamically stable after resuscitation. The displayed CT provides the decisive cause of the small-bowel obstruction. There is no free air, bowel-wall nonenhancement, or generalized peritonitis. At laparotomy, a 3.5-cm stone is impacted in viable distal ileum; the cholecystoenteric fistula is densely adherent, without active biliary sepsis. What is the most appropriate operation?

A 55-year-old woman with two previous laparotomies presents with vomiting, distension, and cramping abdominal pain. CT shows adhesive small-bowel obstruction with one transition point, no closed loop, and no ischemic features. She receives intravenous fluids, nasogastric decompression, electrolyte replacement, and a water-soluble contrast challenge. After 48 hours, contrast has not reached the colon, nasogastric output remains 1.7 L daily, and she continues to have pain and no flatus. What is the most appropriate management?

A 29-year-old man undergoes reduction of a posterior knee dislocation after a motorcycle collision. Two hours later, the foot remains cold and pale, with absent pedal Doppler signals, reduced plantar sensation, and weak toe movement. Compartment pressures are not elevated, and no intracranial or active internal bleeding is present. The displayed CT angiogram provides the decisive vascular finding. A vascular surgeon and operating theatre are immediately available. What is the most appropriate next management?