surgery

A 64-year-old woman presents for an elective abdominal ultrasound. Several months ago, she experienced a few episodes of intermittent, moderate-to-severe right upper quadrant pain that resolved spontaneously within a few hours each time. She denies any associated fever, chills, nausea, vomiting, or jaundice during those episodes or currently. She has no significant past medical history other than well-controlled hypertension. On examination today, she is afebrile, her vital signs are stable, and her abdomen is soft and non-tender. Routine blood tests performed prior to the ultrasound, including full blood count, liver function tests (bilirubin, alkaline phosphatase, AST, ALT, GGT), amylase, and lipase, are all within their respective normal reference ranges. The provided image is a representative view obtained during her ultrasound examination. Considering the patient's history, current clinical status, and the findings demonstrated in the image, what is the most appropriate next step in the management of this patient?

A 68-year-old male presents with abdominal distension, obstipation, and vomiting. He has a history of prior abdominal surgery. An upright abdominal X-ray is performed. What is the MOST appropriate next step in management?

A 68-year-old male presents to the emergency department complaining of abdominal pain, distension, and obstipation for the past 3 days. He reports a history of multiple abdominal surgeries for adhesions. His vital signs are: HR 110 bpm, BP 110/70 mmHg, RR 22 breaths/min, SpO2 97% on room air, and temperature 37.8°C. Physical examination reveals a distended abdomen with high-pitched bowel sounds. An upright abdominal X-ray is performed, as shown. Given the clinical context and the findings on the imaging, what is the MOST appropriate next imaging investigation to guide management?

A 55-year-old female presents to the emergency department with a 24-hour history of severe right upper quadrant pain radiating to her back, associated with nausea, vomiting, and subjective fever. On examination, she is febrile (38.5°C) and has marked tenderness and guarding in the right upper quadrant. Her vital signs are otherwise stable. Blood tests reveal a white cell count of 15 x 10^9/L and C-reactive protein of 120 mg/L. Liver function tests, including bilirubin, are within normal limits. She is initiated on intravenous fluids and broad-spectrum antibiotics. Imaging is subsequently performed. Considering the patient's clinical presentation and the findings demonstrated in the provided imaging, what is the most appropriate definitive management strategy?

A 64-year-old woman with a history of intermittent, self-resolving right upper quadrant pain presents for evaluation. She denies fever, chills, or jaundice, and her physical examination is unremarkable. Routine blood tests, including liver function tests and amylase, are within normal limits. An abdominal ultrasound was performed, and a representative image is shown. Based on the findings in this image and her clinical presentation, what is the most appropriate next step in management?

A 63-year-old man presents with dysphagia and early satiety. His BMI is 21. A CT scan is performed. Based on the image, and assuming conservative measures have failed, what surgical approach is MOST appropriate?

A 3-week-old male infant is brought to the emergency department by his parents due to persistent, non-bilious vomiting after each feeding for the past week. The vomiting has become increasingly forceful. The infant appears mildly dehydrated, and his weight has remained stable since birth. On examination, an olive-shaped mass is palpated in the epigastric region when the infant is not actively vomiting. An upper GI series is performed, and the image is shown. What is the most appropriate next step in the management of this patient?

A 78-year-old male presents to the emergency department with a 6-hour history of sudden onset, severe pain and swelling in his right groin. He reports nausea but no vomiting. On examination, there is a tender, firm, non-reducible lump in the right inguinal region. Bowel sounds are present. Vitals are stable: BP 130/80, HR 75, Temp 36.8°C. A CT scan of the pelvis is performed, shown in the image. Considering the patient's acute presentation, physical examination findings, and the specific anatomical relationship demonstrated in the image, what is the most critical potential complication requiring urgent surgical assessment?

A 68-year-old woman presents with a persistent rash on her chest wall at the site of a previous mastectomy performed 8 years ago. She denies pain or itching. What is the MOST appropriate next step in management?

A 65-year-old woman presents with a chronic, non-healing lesion at the site of her mastectomy scar, performed 7 years ago. She denies pain but reports occasional itching. What is the MOST appropriate next investigation?

A 55-year-old woman presents with 2 days of worsening right upper quadrant pain radiating to her back, nausea, and subjective fever. On examination, she is tender in the RUQ. Vitals are stable. Labs show WCC 15.0, CRP 120. This image is obtained. Based on the clinical presentation and imaging findings, what is the most appropriate next step in management?

A 68-year-old male presents to the ED with severe groin pain and a palpable mass. He reports constipation and inability to pass flatus for 24 hours. Examination reveals tenderness and erythema. A CT scan is performed. What is the MOST appropriate next step in management?

A 45-year-old male with a known history of Blue Rubber Bleb Naevus Syndrome, characterised by recurrent gastrointestinal bleeding and multiple cutaneous vascular lesions, presents to the emergency department with acute onset severe, colicky abdominal pain, nausea, and vomiting. On examination, his abdomen is distended and diffusely tender with reduced bowel sounds. Vital signs are within normal limits. An urgent abdominal CT scan is performed. Considering the patient's history, acute presentation, and the findings on the abdominal CT scan, what is the most appropriate immediate management strategy?

A 6-week-old male infant presents with increasing frequency of non-bilious vomiting after feeds for the past week. He is otherwise well, afebrile, and has wet nappies. On examination, he is alert and interactive. Abdominal examination is unremarkable. Vitals are stable. You order an ultrasound, which is shown. Based on the clinical presentation and the provided image, what is the most appropriate immediate next step in management?

A 78-year-old male presents to the emergency department with a 6-hour history of sudden onset, severe pain and swelling in his right groin. He reports nausea but no vomiting. On examination, there is a tender, firm, non-reducible lump in the right inguinal region. Bowel sounds are present. Vitals are stable: BP 130/80, HR 75, Temp 36.8°C. A CT scan of the pelvis is performed, shown in the image. Based on the clinical presentation and the findings demonstrated in the image, what is the most appropriate immediate next step in the management of this patient?

A 72-year-old male presents with a painful, irreducible right groin mass. He reports vomiting and abdominal distension. His vitals are: HR 110, BP 100/60, RR 22, SpO2 96% RA. The provided image was obtained. What is the next step?

A 68-year-old male presents to the emergency department complaining of abdominal pain, distension, and obstipation for the past 3 days. He reports a history of multiple abdominal surgeries for adhesions. His vital signs are: HR 110 bpm, BP 110/70 mmHg, RR 22 breaths/min, SpO2 97% on room air, and temperature 37.8°C. Physical examination reveals a distended abdomen with high-pitched bowel sounds. An upright abdominal X-ray is performed, as shown. Given the clinical context and the findings on the imaging, what is the MOST appropriate next step in management?

A 9-month-old presents with the abdominal finding shown. It is soft and reducible. Parents are concerned. What counseling is most appropriate?

A 63-year-old woman with a 20-year history of Crohn's disease presents with a one-month history of worsening colicky abdominal pain, bloating, and occasional non-bilious vomiting, associated with a 3kg weight loss. She reports reduced stool frequency. She is currently managed with mesalazine and azathioprine. Her vital signs are stable (BP 120/75, HR 82, Temp 36.8), and physical examination reveals mild right lower quadrant tenderness without guarding or rebound. Bowel sounds are hyperactive. Imaging is performed. Considering the clinical presentation, her current therapy, and the findings suggested by the provided images, which of the following represents the most appropriate next step in this patient's management?

A 72-year-old male presents to the clinic complaining of a painless swelling in his right groin that has been present for several years. He reports that the swelling occasionally increases in size with prolonged standing or heavy lifting, but it usually reduces when he lies down. He denies any acute pain, nausea, vomiting, or changes in bowel habits. His past medical history includes well-controlled type 2 diabetes mellitus and a remote appendectomy. On physical examination, his vital signs are within normal limits. Abdominal examination is unremarkable. Examination of the groin reveals the finding shown in the image. The swelling is easily reducible when the patient is supine. Which of the following is the MOST appropriate initial management strategy for this patient?

A 68-year-old male presents to the ED with abdominal distension, obstipation, and vomiting. He reports a history of multiple abdominal surgeries. An upright abdominal X-ray is performed. Based on the image, what is the MOST appropriate next step in management?

A 59-year-old male presents with a painful right groin bulge that has progressively worsened over the past week. He denies fever, chills, nausea, or vomiting. Vitals are stable. The provided image was obtained. What is the MOST appropriate next step?

A 4-week-old male presents with projectile vomiting after feeding. He is irritable and appears mildly dehydrated. An abdominal exam reveals a palpable, olive-shaped mass in the epigastrium. An upper GI contrast study is performed, and relevant images are shown. What is the MOST appropriate initial step in managing this patient's electrolyte imbalance?

A 68-year-old man presents to the emergency department with sudden onset of severe pain and tenderness in his right groin, associated with nausea. He reports a long history of an intermittent swelling in this area, similar to the appearance shown, which he could previously push back. On examination, the swelling is firm, exquisitely tender, and irreducible. Vital signs are stable. What is the most appropriate immediate management?

A 68-year-old male presents to the ED with severe groin pain and a palpable mass. He reports a history of a reducible bulge in the same area, but today it is firm and tender. He denies fever, nausea, or vomiting. Examination reveals stable vital signs. Review the provided image. What is the MOST appropriate next step in management?

A 58-year-old woman presents with persistent fatigue, muscle weakness, and vague abdominal pain. Her serum calcium is 3.2 mmol/L (2.1-2.6 mmol/L), and PTH is 190 pg/mL (10-65 pg/mL). Renal function is normal. She denies any family history of endocrine disorders. Imaging studies are performed, as shown. Based on the clinical context and the imaging findings presented, which of the following represents the definitive management strategy for this patient?

A 6-week-old male infant presents with a 2-week history of progressively worsening projectile non-bilious vomiting after feeds. He has lost weight and appears lethargic. Initial bloods show a hypochloremic, hypokalaemic metabolic alkalosis. After fluid resuscitation, the image is obtained. What is the most appropriate definitive management for this patient?

A 64-year-old woman presents for an elective abdominal ultrasound. Several months ago, she experienced a few episodes of intermittent, moderate-to-severe right upper quadrant pain that resolved spontaneously within a few hours each time. She denies any associated fever, chills, nausea, vomiting, or jaundice during those episodes or currently. She has no significant past medical history other than well-controlled hypertension. On examination today, she is afebrile, her vital signs are stable, and her abdomen is soft and non-tender. Routine blood tests performed prior to the ultrasound, including full blood count, liver function tests (bilirubin, alkaline phosphatase, AST, ALT, GGT), amylase, and lipase, are all within their respective normal reference ranges. The provided image is a representative view obtained during her ultrasound examination. Considering the patient's history, current clinical status, and the findings demonstrated in the image, what is the most appropriate next step in the management of this patient?

A 78-year-old man presents to the emergency department with acute, severe right groin pain and a palpable, non-reducible mass. He reports associated nausea but denies vomiting or changes in bowel habit. His vital signs are within normal limits, and bowel sounds are audible. A CT scan of the pelvis is performed, the findings of which are depicted in the image. Given the clinical context and the information revealed by the imaging study, what is the most appropriate immediate management strategy?

An 80-year-old male presents to the emergency department with sudden onset of severe right groin pain and a non-reducible bulge. He has a history of a reducible inguinal hernia. Vitals are stable. A CT scan of the pelvis is performed. Considering the clinical presentation and the provided imaging, what is the most appropriate immediate management step?

A 68-year-old male presents to the ED with a painful lump in his groin that has been present for 3 days. He reports nausea but denies vomiting. His vital signs are stable. An abdominal CT is performed, and a slice is shown. What is the MOST appropriate next step in management?

A 68-year-old male presents with abdominal pain, distension, and obstipation for 3 days, with a history of multiple abdominal surgeries. Vitals are HR 110, BP 110/70, T 37.8. Exam shows a distended abdomen with high-pitched bowel sounds. An upright abdominal X-ray is shown. Considering the clinical context and the imaging findings, which of the following is the MOST likely expected outcome with initial non-operative management?

A 60-year-old man presents with a reducible right groin bulge, as seen in the image. He reports mild discomfort. What is the most appropriate initial management?

A 55-year-old man presents to his GP complaining of a long-standing, intermittent swelling in his right groin that becomes more noticeable when he coughs or lifts heavy objects. It is usually painless and he can push it back in. His vital signs are normal. Considering the clinical presentation and the appearance shown, what is the most appropriate initial management?

A 68-year-old male presents to the ED with abdominal distension, obstipation, and vomiting. He reports a history of multiple abdominal surgeries. An upright abdominal X-ray is performed. Based on the image, what is the MOST appropriate next step in management?

A 6-week-old male infant presents with a 1-week history of progressively worsening non-bilious vomiting, often projectile, occurring shortly after feeds. His parents report he is constantly hungry and irritable but has had poor weight gain. On examination, he is alert but appears thin. Vital signs are stable. Abdominal examination is soft, non-tender, with no palpable mass. An abdominal ultrasound is performed, the image of which is shown. Considering the clinical presentation and the findings depicted, what is the most appropriate initial management strategy?

A 9-month-old presents with a noticeable abdominal protrusion, more prominent when crying. The child is feeding well and has regular bowel movements. Examination reveals a soft, easily reducible bulge at the umbilicus, as shown. Parents are concerned about potential complications. What is the MOST appropriate parental advice?

A 65-year-old male with recently diagnosed gastric mixed adenoneuroendocrine carcinoma presents with unintentional weight loss. Endoscopy confirmed the diagnosis. Staging imaging is provided. His ECOG performance status is 1. Considering the extent of disease demonstrated, which of the following represents the most appropriate initial therapeutic approach?

A 6-month-old infant presents for a routine check-up. The mother reports the infant is feeding well and has normal bowel movements. On examination, you observe the finding in the image. The mass is soft and easily reducible. What is the MOST appropriate next step in management?

A 68-year-old male presents to the ED with left lower quadrant abdominal pain, fever, and leukocytosis. A CT scan of the abdomen and pelvis is performed. Based on the image, what is the MOST appropriate next step in management?

A 72-year-old male presents with abdominal distension, vomiting, and inability to pass flatus for 48 hours. He has a history of prior bowel resection. Examination reveals a tympanitic abdomen and tenderness to palpation. His vitals are stable. An abdominal X-ray is performed, as shown. Considering the clinical context and the radiographic findings, what is the MOST likely underlying cause of this presentation?

A 72-year-old woman presents with a 2-day history of worsening right upper quadrant pain radiating to her back, associated with nausea and a low-grade fever. On examination, she is jaundiced and has tenderness in the right upper quadrant. Laboratory tests show a total bilirubin of 75 µmol/L, ALP 350 U/L, ALT 200 U/L, and WCC 13.5 x 10^9/L. An urgent ERCP is performed, during which the image is captured. Following successful endoscopic clearance and clinical improvement, which of the following is the MOST appropriate long-term management strategy?

A 68-year-old male with a history of multiple abdominal surgeries presents to the emergency department complaining of abdominal pain, distension, and obstipation for the past 3 days. His vital signs are: HR 110 bpm, BP 110/70 mmHg, RR 22 breaths/min, SpO2 97% on room air, and temperature 37.8°C. Physical examination reveals a distended abdomen with high-pitched bowel sounds. An upright abdominal X-ray is performed, as shown. Given the clinical context and the radiographic findings, which demonstrate significant intraluminal gas accumulation proximal to the likely site of obstruction, what is the predominant source of this gas?

A 64-year-old woman reports intermittent RUQ pain. She denies jaundice or fever. An abdominal ultrasound was performed, image shown. Besides referral for surgery, what is the MOST appropriate next step in management?

A 68-year-old man with a history of diverticulosis presents with recurrent, large volume rectal bleeding. Initial colonoscopy failed to identify or control the source. He remains haemodynamically stable after resuscitation. What is the most appropriate next step in management?

A 68-year-old male presents to the emergency department with a 12-hour history of severe, constant left groin pain. He reports a bulge in his groin that has been present for several years, which he can usually reduce himself. However, today he has been unable to push it back in, and the pain has become excruciating. He denies any fever, nausea, or vomiting. On examination, his vital signs are stable: temperature 37.0°C, heart rate 88 bpm, blood pressure 130/80 mmHg, respiratory rate 16 breaths/min, and oxygen saturation 98% on room air. Abdominal examination is unremarkable. Palpation of the left groin reveals a firm, tender mass that is non-reducible. The overlying skin is erythematous, but there is no crepitus. A CT scan of the abdomen and pelvis is performed, and an axial slice is shown. Considering the clinical presentation and the findings demonstrated in the image, what is the MOST appropriate next step in management?

A 6-week-old male presents with projectile vomiting after feeds. He is otherwise well-appearing, with normal vital signs. An abdominal ultrasound is performed (image attached). What is the MOST appropriate next step in management?

A 62-year-old woman presents to her general practitioner complaining of fatigue, bone pain, and constipation for the past several months. She denies any significant past medical history and is on no regular medications. Physical examination is unremarkable, and vital signs are within normal limits. Initial laboratory investigations reveal an elevated serum calcium level of 3.1 mmol/L (reference range: 2.1-2.6 mmol/L) and an elevated parathyroid hormone (PTH) level of 180 pg/mL (reference range: 10-65 pg/mL). A 24-hour urine calcium excretion is also elevated. The patient is referred for further imaging, the results of which are shown. Based on the available information, what is the MOST appropriate next step in the definitive management of this patient?

A 60-year-old man presents with a 6-month history of intermittent aching discomfort in his right groin, exacerbated by standing and lifting. He reports noticing a bulge in the area, similar to the appearance shown, which usually disappears when he lies down. On examination, the bulge is reducible. Vital signs are normal. Considering the clinical presentation and the image, which anatomical structure is the most likely primary site of the fascial defect?

A 62-year-old woman presents to her general practitioner complaining of fatigue, bone pain, and constipation for the past several months. She denies any significant past medical history. Initial laboratory investigations reveal an elevated serum calcium level of 3.1 mmol/L (reference range: 2.1-2.6 mmol/L) and an elevated parathyroid hormone (PTH) level of 180 pg/mL (reference range: 10-65 pg/mL). A 24-hour urine calcium excretion is also elevated. The patient is referred for further imaging, the results of which are shown. Considering the clinical presentation and the findings from the imaging studies, which of the following surgical approaches is MOST likely to be indicated?