During morning rounds, the surgical team assesses a 48-year-old man who is recovering from… — USMLE Step 2 CK

During morning rounds, the surgical team assesses a $48$ -year-old man who is recovering from an elective open ventral hernia repair performed yesterday (postoperative day $1$ ). He notes some mild incisional discomfort but denies shortness of breath, dysuria, or calf pain. Vital signs show a temperature of $38.2^\circ\text{C}$ ( $100.8^\circ\text{F}$ ), a pulse of $88/\text{min}$ , a blood pressure of $128/82\text{ mm Hg}$ , and a respiratory rate of $18/\text{min}$ . Oxygen saturation is $96\%$ on room air. Auscultation of the chest demonstrates diminished breath sounds at the bilateral bases, but no crackles are heard. The abdominal incision is well-approximated, dry, and lacks any surrounding redness. Which of the following are the most appropriate management steps for this patient's current condition? (Select two)

Encourage frequent use of an incentive spirometerAnswer
Initiate early mobilization and out-of-bed activitiesAnswer
C
Administer empiric broad-spectrum intravenous antibiotics
D
Order a computed tomography scan of the abdomen and pelvis
E
Obtain a urinalysis and urine culture

Answer

The most appropriate steps are to encourage frequent use of an incentive spirometer and to initiate early mobilization and out-of-bed activities.

Fever within the first

48

hours after surgery is extremely common and is usually mediated by the normal release of inflammatory cytokines (e.g., IL-1, IL-6, TNF-alpha) due to tissue trauma, combined with pulmonary atelectasis. Shallow breathing secondary to incisional pain leads to basilar alveolar collapse, presenting as diminished breath sounds. Because this is an expected, physiologic response rather than a systemic infection, the standard of care relies on pulmonary toilet. Encouraging incentive spirometry and early mobilization expands functional residual capacity, clears secretions, and resolves the atelectasis, typically normalizing the temperature.

Step-by-Step Solution

Identify the timeline and severity of the patient's fever.

The patient has a low-grade fever (

38.2^\circ\text{C}

) on postoperative day

1

Timing of postoperative fever is crucial for narrowing the differential diagnosis (the '5 Ws').

Correlate the physical examination findings with the timeline.

Diminished breath sounds at the bases suggest atelectasis, which aligns with 'Wind' (pulmonary causes), the most common etiology of fever on postoperative days

1

and

2

Normal postoperative inflammatory cytokines and shallow breathing due to pain frequently lead to atelectasis.

Select the appropriate non-pharmacologic interventions.

Incentive spirometry and early ambulation are chosen.

These conservative measures effectively open collapsed alveoli and improve ventilation, resolving the fever.

Key Concept

Early postoperative fever (days 1-2) is most commonly caused by normal inflammatory responses and atelectasis, which are best managed conservatively with incentive spirometry and early ambulation.

Estimated Time:1m 0s

Question

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Topics

More questions from this topic