Examkin

Soru

Zorluk: OrtaPreoperative and Postoperative Care

A 54-year-old male is evaluated on postoperative day 5 following a robotic-assisted partial nephrectomy for a localized renal mass. His past medical history is significant for obesity, hypertension, and type 2 diabetes mellitus. The patient complains of a new-onset dull ache and swelling in his left leg that started this morning. He also reports feeling warm. His temperature is 38.4°C (101.1°F), blood pressure is 142/88 mmHg, pulse is 102/min, and respirations are 18/min. Oxygen saturation is 98% on ambient air. Physical examination reveals pitting edema and erythema of the left calf, which is exquisitely tender to palpation. The surgical incisions are well-approximated, clean, and dry, with no surrounding induration or discharge. The abdomen is soft and non-distended with normal active bowel sounds. Which of the following is the most appropriate next step in management?

  1. Perform a compressive duplex ultrasonography of the left lower extremityCevap
  2. B
    Order a urinalysis and urine culture
  3. C
    Initiate empiric therapy with vancomycin and piperacillin-tazobactam
  4. D
    Insert a nasogastric tube for gastric decompression
  5. E
    Reopen the surgical incisions at the bedside to assess for deep infection

Cevap

Perform a compressive duplex ultrasonography of the left lower extremity
The correct action is to perform a compressive duplex ultrasonography of the left lower extremity. This patient's clinical presentation—unilateral calf swelling, erythema, and tenderness on postoperative day 5—is highly suspicious for a deep vein thrombosis (DVT). Postoperative fever commonly follows a predictable timeline categorized by the '5 Ws': Wind (atelectasis/pneumonia, POD 1-2), Water (urinary tract infection, POD 3-5), Walking (deep vein thrombosis, POD 4-6), Wound (surgical site infection, POD 5-7), and Wonder drugs (drug-induced fever, anytime). This patient perfectly fits the 'Walking' timeline and exhibits classic physical signs of DVT. The low-grade fever is secondary to the inflammatory response to venous thrombosis. The standard initial diagnostic step for a suspected DVT is a compressive venous duplex ultrasound.

Adım Adım Çözüm

1
Analyze the patient's postoperative timeline and vital signs.
The patient has a fever (38.4°C) and tachycardia on postoperative day (POD) 5.
Establishing the postoperative day helps narrow the differential diagnosis using the '5 Ws' mnemonic (Wind, Water, Walking, Wound, Wonder drugs).
2
Identify localizing clinical signs on physical examination.
The patient has unilateral left calf swelling, erythema, and tenderness, alongside normal abdominal and surgical site exams.
Localizing signs pinpoint the source of the fever. Unilateral calf swelling and pain strongly suggest a deep vein thrombosis (DVT).
3
Select the appropriate initial diagnostic test for the suspected condition.
Compressive duplex ultrasonography of the lower extremity is chosen.
Duplex ultrasound is the gold standard, non-invasive initial diagnostic test to confirm the presence of a DVT before starting therapeutic anticoagulation.

Anahtar Kavram

The timeline of postoperative fever etiologies ('5 Ws') and the recognition and initial diagnostic workup of postoperative deep vein thrombosis (DVT).
Bu soruyu puanla

Konular

Preoperative and Postoperative Care

Bu konudan daha fazla soru