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Difficulty: MediumPreoperative and Postoperative Care

A 62-year-old woman is evaluated on postoperative day 6 following an open total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometrial cancer. She reports the sudden onset of right-sided chest pain that worsens with deep inspiration, accompanied by mild shortness of breath. She has a medical history of chronic obstructive pulmonary disease, hypertension, and type 2 diabetes mellitus. Her current medications include inhaled tiotropium and subcutaneous prophylactic enoxaparin. Vital signs are:

Temperature: 37.8°C (100.0°F)
Blood pressure: 118/76 mmHg
Pulse: 114/min
Respirations: 22/min
Oxygen saturation: 90% on room air

Physical examination reveals a patient in mild respiratory distress. Jugular venous pressure is normal. Lung auscultation reveals clear breath sounds bilaterally without wheezes or crackles. Cardiac examination shows tachycardia with a regular rhythm; no murmurs, rubs, or gallops are heard. The abdominal incision is clean, dry, and well-approximated without erythema. Her right calf is visibly swollen, erythematous, and tender to palpation compared to the left.

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

  1. Computed tomography pulmonary angiographyAnswer
  2. B
    Administration of intravenous furosemide
  3. C
    Initiation of intravenous piperacillin-tazobactam
  4. D
    Bedside incentive spirometry and chest physiotherapy
  5. E
    Measurement of serum D-dimer level

Answer

Computed tomography pulmonary angiography
The correct answer is computed tomography pulmonary angiography. This patient presents with hallmark features of a pulmonary embolism: sudden-onset pleuritic chest pain, dyspnea, tachycardia, hypoxia, and a low-grade fever. Her presentation on postoperative day 6, combined with an active malignancy and a clinically evident deep vein thrombosis (unilateral calf swelling), gives her a very high pretest clinical probability for a pulmonary embolism. According to the standard diagnostic algorithm for suspected pulmonary embolism, patients with a high pretest probability should proceed directly to definitive imaging with a computed tomography pulmonary angiography (CTPA).

Step-by-Step Solution

1
Assess the clinical timeline and physical examination findings.
The patient developed sudden-onset pleuritic chest pain, tachycardia, hypoxia, and unilateral calf swelling on postoperative day 6.
Recognizing the timeline helps rule out early postoperative complications like atelectasis (typically POD 1-3) and highlights the risk window for venous thromboembolism.
2
Calculate the pretest probability for a pulmonary embolism.
The patient has a high pretest probability (Wells score > 4) due to recent major surgery, active malignancy, tachycardia, and overt signs of deep vein thrombosis.
The clinical pretest probability determines the appropriate diagnostic algorithm for a suspected pulmonary embolism.
3
Select the appropriate diagnostic intervention.
Computed tomography pulmonary angiography is the definitive next step.
In patients with a high pretest probability for PE, D-dimer testing lacks sufficient negative predictive value to rule out the disease. Direct vascular imaging is required.

Key Concept

In patients with a high pretest clinical probability for a pulmonary embolism (e.g., recent major surgery, malignancy, signs of DVT), the most appropriate next step in management is to proceed directly to diagnostic imaging with a computed tomography pulmonary angiography, bypassing D-dimer testing.
Estimated Time:1m 30s
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Topics

Preoperative and Postoperative Care

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