Examkin

Question

Difficulty: HardPreoperative and Postoperative Care

A 74-year-old man is evaluated on postoperative day 3 following an open partial colectomy for colon cancer. He reports new-onset shortness of breath and a cough productive of yellowish sputum that started this morning. His medical history is significant for ischemic cardiomyopathy with an ejection fraction of 40% and chronic obstructive pulmonary disease. His temperature is 38.9°C (102.0°F), blood pressure is 118/74 mmHg, heart rate is 112/min, and respiratory rate is 24/min. Oxygen saturation is 90% on room air. Physical examination reveals a patient in mild respiratory distress. Jugular venous pressure is not elevated. Auscultation of the lungs reveals bronchial breath sounds and crackles over the right lower lung field. The surgical incision is clean, dry, and intact. There is no lower extremity edema. Based on the most likely diagnosis, which of the following are the most appropriate next steps in this patient's management? (Select 2)

  1. Obtain a portable chest X-rayAnswer
  2. Acquire sputum and blood cultures, then start empiric intravenous antibioticsAnswer
  3. C
    Administer intravenous furosemide
  4. D
    Encourage incentive spirometry and continue clinical observation
  5. E
    Perform a CT pulmonary angiogram

Answer

The most appropriate next steps in management are obtaining a portable chest X-ray and acquiring sputum and blood cultures followed by the initiation of empiric intravenous antibiotics.
The patient's presentation of high fever, dyspnea, purulent sputum, and focal consolidation signs (bronchial breath sounds, crackles) on postoperative day 3 is highly suspicious for hospital-acquired pneumonia. The standard of care requires confirming the presence of a lung infiltrate with a chest X-ray and promptly obtaining respiratory and blood cultures before initiating empirical broad-spectrum intravenous antibiotics.

Step-by-Step Solution

1
Evaluate the timeline of the patient's postoperative fever and respiratory symptoms.
The patient developed a high fever, dyspnea, and purulent sputum on postoperative day 3.
The timing of postoperative fever provides a critical clue to its etiology. Fever on days 1-2 is often due to atelectasis, whereas day 3 is a classic timeline for hospital-acquired pneumonia.
2
Analyze the physical examination findings.
The patient has bronchial breath sounds, crackles, and purulent sputum, with a normal jugular venous pressure and no peripheral edema.
Focal lung findings such as bronchial breath sounds and crackles strongly indicate lung consolidation (pneumonia). The absence of elevated jugular venous pressure makes an acute heart failure exacerbation less likely.
3
Determine the most appropriate diagnostic and therapeutic management bundle.
The combination of chest imaging and empirical treatment (cultures and antibiotics) is selected.
Suspected hospital-acquired pneumonia requires prompt confirmation with imaging and rapid initiation of empirical antibiotics following appropriate cultures to reduce morbidity and mortality.

Key Concept

The classic presentation and initial management bundle (imaging, cultures, and antibiotics) for hospital-acquired pneumonia in the postoperative setting.
Rate this question

Topics

Preoperative and Postoperative Care

More questions from this topic