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Difficulty: EasyPreoperative and Postoperative Care

A 72-year-old woman is seen by the surgical team on the fifth day following a right total hip arthroplasty. She complains of new, progressive aching pain in her right thigh and calf that began the previous evening. Her temperature is 38.3°C (100.9°F), blood pressure is 135/85 mm Hg, pulse is 96/min, and respiratory rate is 14/min. Pulse oximetry shows 98% on room air. Physical examination reveals asymmetric edema of the right lower extremity from the mid-thigh down to the ankle, along with localized tenderness over the posterior calf. The surgical incision over the lateral hip is well-approximated with no erythema, warmth, or discharge. Cardiopulmonary examination is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

  1. Perform compression ultrasonography of the right lower extremityAnswer
  2. B
    Administer intravenous broad-spectrum antimicrobial therapy
  3. C
    Obtain computed tomography angiography of the chest
  4. D
    Remove the surgical dressings and proactively probe the incision
  5. E
    Obtain a portable chest radiograph

Answer

Perform compression ultrasonography of the right lower extremity
The patient's clinical presentation of unilateral lower extremity edema, calf tenderness, and low-grade fever on postoperative day 5 following major orthopedic surgery is highly suspicious for a deep vein thrombosis (DVT). DVT represents the 'Walking' component of the classic '5 Ws' of postoperative fever and typically occurs between days 4 and 6. The most appropriate initial step in evaluating a suspected DVT is compression ultrasonography of the affected extremity. This noninvasive test is highly sensitive and specific for detecting proximal venous thrombosis.

Step-by-Step Solution

1
Identify the primary clinical problem.
The patient is on postoperative day 5 after major orthopedic surgery and presents with a new-onset low-grade fever, tachycardia, and unilateral lower extremity pain and swelling.
Recognizing the timing and specific physical findings is essential to formulating a differential diagnosis for postoperative fever.
2
Correlate the findings with the '5 Ws' of postoperative fever.
The presentation strongly aligns with 'Walking' (deep vein thrombosis), which typically manifests around postoperative days 4 to 6 with unilateral leg edema and can cause a mild fever.
Connecting the clinical signs to common timeline-based postoperative complications prevents unnecessary diagnostic testing for unrelated conditions.
3
Determine the best initial diagnostic step.
Compression ultrasonography of the lower extremity is selected.
It is the standard, noninvasive, and most appropriate first test to confirm or rule out a deep vein thrombosis.

Key Concept

Postoperative fever etiology and deep vein thrombosis diagnosis
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Topics

Preoperative and Postoperative Care

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