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Difficulty: MediumPreoperative and Postoperative Care

A 68-year-old female is evaluated on postoperative day 5 following a robotic-assisted hysterectomy and bilateral salpingo-oophorectomy for endometrial cancer. She reports a 2-hour history of sudden-onset shortness of breath and right-sided chest pain that worsens when she takes a deep breath. She has a history of type 2 diabetes mellitus, hypertension, and obesity. Her current medications include subcutaneous enoxaparin and oral oxycodone as needed. Temperature is 38.2∘C38.2^\circ\text{C} (100.8∘F100.8^\circ\text{F}), blood pressure is 118/76 mmHg, pulse is 114/min, and respirations are 24/min. Pulse oximetry shows 92% on room air. Physical examination reveals clear breath sounds bilaterally and a regular, rapid heart rhythm. The abdomen is soft and non-tender, and the surgical incisions are well-approximated with no erythema. There is no lower extremity edema or calf tenderness. Electrocardiogram shows sinus tachycardia. Which of the following is the most appropriate next step in management?

  1. A
    Echocardiography and intravenous furosemide
  2. B
    Incentive spirometry and chest physiotherapy
  3. Computed tomography angiography of the chestAnswer
  4. D
    Sputum culture and empiric broad-spectrum antibiotics
  5. E
    Urgent exploratory laparotomy

Answer

Computed tomography angiography of the chest
This patient's presentation of sudden-onset dyspnea, pleuritic chest pain, tachycardia, hypoxia, and low-grade fever on postoperative day 5 is highly suspicious for a pulmonary embolism (PE). Fever is a common, often overlooked manifestation of PE due to tissue infarction and inflammation. The classic timeline for postoperative deep vein thrombosis and PE is between days 4 and 6 (the 'Walking' phase of the 5 W's of postoperative fever). Because the patient is hemodynamically stable, the most appropriate next step in management is diagnostic imaging with computed tomography angiography (CTA) of the chest.

Step-by-Step Solution

1
Analyze the timing of the fever and patient presentation
The patient has a low-grade fever, tachycardia, hypoxia, and pleuritic chest pain on postoperative day 5.
Establishing the postoperative day helps narrow down the differential diagnosis using the '5 Ws' of postoperative fever.
2
Correlate symptoms with the postoperative timeline
Postoperative day 5 falls into the 'Walking' phase, making deep vein thrombosis (DVT) and pulmonary embolism (PE) highly likely, especially given the classic triad of sudden dyspnea, pleuritic pain, and tachycardia.
Fever is a frequently overlooked symptom of PE resulting from tissue infarction and local inflammation.
3
Determine the appropriate diagnostic approach
The patient is hemodynamically stable (blood pressure 118/76 mmHg), meaning diagnostic imaging can be safely performed.
In a hemodynamically stable patient with a high clinical suspicion for PE, computed tomography angiography (CTA) of the chest is the gold standard next step.

Key Concept

Postoperative pulmonary embolism typically presents around postoperative days 4-6 and can manifest with low-grade fever alongside sudden dyspnea, tachycardia, and pleuritic chest pain. Hemodynamically stable patients should be evaluated with CT pulmonary angiography.
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Topics

Preoperative and Postoperative Care

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