Approximately 36 hours after undergoing an elective abdominal hysterectomy for symptomatic… — USMLE Step 2 CK

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

Incentive spirometry and early ambulationAnswer
B
Administration of broad-spectrum intravenous antibiotics
C
Computed tomography of the abdomen and pelvis
D
Urinalysis and urine culture
E
Venous duplex ultrasonography of the lower extremities

Answer

Incentive spirometry and early ambulation

The correct response is incentive spirometry and early ambulation. This patient's presentation of a low-grade fever and decreased basilar breath sounds approximately 36 hours after an abdominal surgery is classic for postoperative atelectasis. Atelectasis is the most common cause of fever on postoperative days 1 and 2 (the 'Wind' in the '5 Ws' of postoperative fever). It occurs due to shallow breathing from post-surgical pain, leading to alveolar collapse and a subsequent localized inflammatory response that drives the fever. The management is entirely supportive and prophylactic, focusing on re-expanding the alveoli via deep breathing exercises (incentive spirometry), adequate pain control, and early ambulation.

Step-by-Step Solution

Analyze the timing of the patient's fever in relation to the surgery.

The fever is occurring approximately 36 hours (postoperative day 1 to 2) after the procedure.

The postoperative day (POD) is the most critical factor in narrowing down the differential diagnosis for a postoperative fever (the '5 Ws').

Evaluate the clinical signs and physical examination findings.

The patient has decreased breath sounds at the lung bases but lacks symptoms or signs of UTI, DVT, or wound infection.

Physical findings help confirm the suspected etiology. Decreased basilar breath sounds are highly indicative of alveolar collapse (atelectasis).

Determine the appropriate management for the identified etiology.

Management of atelectasis focuses on supportive care and lung expansion rather than diagnostic imaging or antimicrobials.

Atelectasis is a non-infectious, inflammatory process driven by shallow breathing (often secondary to pain); lung expansion maneuvers resolve the underlying mechanical issue.

Key Concept

Postoperative atelectasis is a common, non-infectious cause of early postoperative fever (days 1-2) managed with targeted lung expansion exercises and early mobilization.

Estimated Time:1m 0s

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