Nursing staff pages the surgical provider on call at 10:00 PM regarding a patient who rece… — USMLE Step 2 CK

Nursing staff pages the surgical provider on call at 10:00 PM regarding a patient who recently recorded a temperature of $38.4^{\circ}\text{C}$ ( $101.1^{\circ}\text{F}$ ). The patient is a $55$ -year-old female recovering from an uncomplicated right hemicolectomy performed for a large, benign tubulovillous adenoma. The operation was completed approximately $28$ hours ago. Her pain is currently managed with a morphine patient-controlled analgesia (PCA) device. She has remained in bed since the surgery due to generalized fatigue and mild incisional pain. She denies nausea, vomiting, cough, dysuria, or shortness of breath. Vital signs show a heart rate of $88\text{ /min}$ , blood pressure of $128/82\text{ mm Hg}$ , respiratory rate of $16\text{ /min}$ , and oxygen saturation of $97\%$ on ambient air. Physical examination demonstrates clear breath sounds bilaterally. The abdomen is non-distended and moderately tender near the midline incision, without guarding or rebound tenderness. The surgical dressing is clean, dry, and intact. Her indwelling urinary catheter, placed in the operating room, is draining clear yellow urine. Which of the following is the most appropriate next step in the management of this patient's elevated temperature?

A
Send urine for urinalysis and culture, and begin oral ciprofloxacin
B
Initiate empiric treatment with intravenous piperacillin-tazobactam
Assist the patient out of bed and encourage the use of an incentive spirometerAnswer
D
Remove the primary surgical dressing to inspect the deeper fascial layers
E
Administer a dose of intravenous furosemide to promote diuresis

Answer

Assist the patient out of bed and encourage the use of an incentive spirometer

The correct approach for a low-grade fever within the first 48 hours postoperatively is supportive care targeting lung expansion and mobilization. Atelectasis and the physiologic release of inflammatory cytokines secondary to tissue trauma are the most common causes of early postoperative fever (often remembered as the 'Wind' in the classic 5 Ws mnemonic). This patient is at particularly high risk for atelectasis because she has remained in bed and is receiving opioid analgesia via a PCA pump, both of which promote hypoventilation. Early ambulation and the use of an incentive spirometer are the standard of care to open collapsed alveoli, treat the underlying atelectasis, and prevent complications like pneumonia and deep vein thrombosis.

Step-by-Step Solution

Analyze the timing of the fever in relation to the surgery.

The fever is occurring approximately 28 hours postoperatively (Postoperative Day 1).

The timing of postoperative fever is the most critical factor in determining its etiology (the '5 Ws').

Evaluate the patient's symptoms, vital signs, and physical examination.

The patient is hemodynamically stable, has clear breath sounds, and lacks localizing signs of infection (e.g., normal wound, clear urine, no dysuria or cough).

This rules out immediate, life-threatening complications like necrotizing soft tissue infection, severe pneumonia, or sepsis.

Identify the most likely etiology and select the appropriate management.

The fever is most likely due to atelectasis (exacerbated by bed rest and opioid use) or normal postoperative tissue inflammation. The best step is supportive care with lung expansion techniques.

Early ambulation and incentive spirometry directly treat atelectasis and prevent progression to pneumonia.

Key Concept

Fever within the first 48 hours postoperatively is most commonly due to atelectasis or physiologic inflammatory cytokine release from tissue trauma. Management should focus on supportive care, incentive spirometry, and early ambulation.

Estimated Time:1m 0s

Question

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Topics

More questions from this topic