A physician is called to the surgical ward to evaluate a 59-year-old female patient for a … — USMLE Step 2 CK

A physician is called to the surgical ward to evaluate a 59-year-old female patient for a new-onset fever. The patient underwent a laparotomy and small bowel resection for a strangulated ventral hernia six days ago. Over the past 12 hours, she has developed a fever of $38.9^\circ\text{C}$ ( $102.0^\circ\text{F}$ ), chills, and worsening abdominal pain. Vital signs show a blood pressure of $105/65\text{ mmHg}$ , pulse of $118/\text{min}$ , and respirations of $18/\text{min}$ . Physical examination reveals a moderately distended abdomen with marked tenderness in the periumbilical region and hypoactive bowel sounds. The surgical incision is completely closed with surgical staples intact; there is no surrounding erythema, warmth, or purulent drainage. An indwelling urinary catheter was removed on postoperative day two, and the patient has been voiding without difficulty. Cardiopulmonary examination is unremarkable, and there is no lower extremity edema or calf tenderness. A complete blood count reveals a leukocyte count of $17,000/\text{mm}^3$ . Which of the following is the most appropriate next step in management?

Computed tomography scan of the abdomen and pelvisAnswer
B
Bedside opening of the surgical incision
C
Administration of intravenous antibiotics and continued observation
D
Chest radiograph and sputum Gram stain
E
Urinalysis and urine culture

Answer

The most appropriate next step in management is to perform a computed tomography (CT) scan of the abdomen and pelvis.

This patient's presentation—fever, tachycardia, marked abdominal pain, and leukocytosis on postoperative day 6 following a small bowel resection—is highly suspicious for a deep space surgical site infection, such as an intra-abdominal abscess or an anastomotic leak. The most appropriate next step in management is to obtain a computed tomography (CT) scan of the abdomen and pelvis. A CT scan with intravenous contrast is highly sensitive for identifying the presence, size, and exact anatomical location of any intra-abdominal fluid collection. Once an abscess is visualized, the CT scan also guides definitive source control, typically via CT-guided percutaneous radiologic drainage, which is generally preferred over surgical re-exploration if the patient is hemodynamically stable.

Step-by-Step Solution

Analyze the timing of the postoperative fever.

The fever is occurring on postoperative day 6, which correlates with the 'Wound' timeline of postoperative fever (typically days 5-7).

Different etiologies of postoperative fever reliably present during distinct timeframes (the 5 Ws: Wind, Water, Walking, Wound, Wonder drugs).

Correlate the timeline with the physical examination findings.

The superficial wound is clean, ruling out a superficial incisional infection. However, the patient has prominent abdominal distension, tenderness, and leukocytosis following a bowel resection.

These findings localize the infection to a deep space, raising high suspicion for an intra-abdominal abscess or anastomotic leak.

Determine the optimal diagnostic step for a suspected deep space infection.

A CT scan of the abdomen and pelvis is required to visualize the deep abdominal spaces.

Imaging is necessary to confirm the diagnosis, locate the fluid collection, and plan for percutaneous drainage or surgical re-exploration.

Key Concept

Fever on postoperative days 5 to 7 accompanied by significant abdominal pain and leukocytosis following an intra-abdominal procedure strongly suggests a deep space surgical site infection (e.g., intra-abdominal abscess or anastomotic leak), which requires a CT scan of the abdomen and pelvis for diagnosis and management planning.

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