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Difficulty: MediumPreoperative and Postoperative Care

A 62-year-old man is assessed on the surgical ward 72 hours after undergoing an open sigmoid colectomy for complicated diverticulitis. He reports feeling fatigued but denies shortness of breath, chest pain, dysuria, or nausea. He is tolerating a clear liquid diet and passed flatus this morning. His medical history includes chronic obstructive pulmonary disease (COPD) and essential hypertension.

His vital signs are:
Temperature: 38.6°C (101.5°F)
Blood pressure: 132/84 mm Hg
Heart rate: 96/min
Respiratory rate: 18/min
Oxygen saturation: 94% on room air

Physical examination reveals a soft abdomen with mild, localized tenderness at the surgical incision site. There is no rebound tenderness or guarding. The midline incision is well-approximated, clean, and dry without erythema or discharge. Pulmonary auscultation reveals mild, scattered expiratory wheezes bilaterally that are unchanged from his preoperative baseline examination. There are no crackles, and jugular venous distension is absent. His indwelling urethral catheter was removed 24 hours ago, and he has voided spontaneously since then. Bilateral calf examination shows no edema or tenderness.

Which of the following are the most appropriate next steps in the management of this patient? (Select 3)

  1. Order a urinalysis and urine cultureAnswer
  2. Perform a portable chest radiographAnswer
  3. Advise the patient to continue incentive spirometry and ambulationAnswer
  4. D
    Order a computed tomography scan of the abdomen and pelvis with intravenous contrast
  5. E
    Administer an intravenous dose of furosemide

Answer

The correct steps are to order a urinalysis and urine culture, perform a portable chest radiograph, and advise the patient to continue incentive spirometry and ambulation.
Postoperative fever is a common clinical challenge, and its etiology can often be deduced from the timeline of onset, classically remembered as the '5 Ws': Wind (pulmonary, days 1-2), Water (urinary tract, days 3-5), Walking (venous thromboembolism, days 4-6), Wound (surgical site infection, days 5-7), and Wonder drugs (drug fever, days 7+). This patient is on postoperative day 3 and recently had an indwelling urethral catheter removed, making a urinary tract infection highly suspicious. Therefore, obtaining a urinalysis and urine culture is a necessary diagnostic step. Additionally, while atelectasis usually peaks on days 1-2, true pneumonia can develop concurrently or slightly later. Given his baseline chronic obstructive pulmonary disease (COPD), he is at higher risk for pulmonary complications, justifying a portable chest radiograph to evaluate for an infiltrate. Regardless of the specific diagnosis, encouraging continued incentive spirometry and ambulation remains essential standard-of-care prophylaxis to prevent further pulmonary and thromboembolic complications.

Step-by-Step Solution

1
Analyze the timing of the patient's postoperative fever.
The fever is occurring at 72 hours (postoperative day 3).
The postoperative day helps narrow the differential diagnosis using the classic '5 Ws' mnemonic.
2
Assess the patient's clinical signs and risk factors.
The patient had a Foley catheter removed 24 hours ago and has a history of COPD.
Recent catheterization puts him at risk for a urinary tract infection ('Water'), while his COPD puts him at risk for pulmonary complications ('Wind').
3
Select the appropriate diagnostic and prophylactic interventions.
Diagnostic tests for UTI (urinalysis and culture) and pneumonia (chest radiograph) are indicated, along with continued pulmonary prophylaxis.
These steps directly address the most likely etiologies of fever at this stage in a patient with these specific risk factors.

Key Concept

The evaluation of postoperative fever is guided by the timeline of symptom onset. Fever on days 3-5 often points to a urinary tract infection, particularly following catheter removal, while pulmonary complications must also be ruled out in patients with underlying lung disease.
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Topics

Preoperative and Postoperative Care

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