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Zorluk: ZorPreoperative and Postoperative Care

A 68-year-old man is evaluated for a new-onset fever on postoperative day 7 following an open anterior resection of the rectum for rectal adenocarcinoma. Over the past 12 hours, he has developed right-sided chest pain that worsens with deep inspiration, along with a mild, dry cough. His temperature is 38.9°C (102.0°F), blood pressure is 132/84 mm Hg, pulse is 114/min, and respirations are 22/min. Oxygen saturation is 93% on room air. His medical history includes heart failure with preserved ejection fraction and diet-controlled type 2 diabetes mellitus. Physical examination shows a normal jugular venous pressure. Lung auscultation is notable for a focal pleural friction rub in the right lower lung field, without crackles or wheezing. The abdomen is soft and non-distended; the midline surgical incision is well-approximated with no erythema, induration, or purulent drainage. The right calf is mildly edematous and tender to palpation compared to the left. Laboratory studies show a white blood cell count of 11,200/mm³. A chest radiograph demonstrates a peripheral, wedge-shaped opacity in the right lower lung zone and a small right-sided pleural effusion. There is no cardiomegaly. Which of the following is the most appropriate next step in management?

  1. Computed tomography angiography of the chestCevap
  2. B
    Initiation of intravenous piperacillin-tazobactam
  3. C
    Transthoracic echocardiography
  4. D
    Incentive spirometry and chest physiotherapy
  5. E
    Computed tomography scan of the abdomen and pelvis

Cevap

The most appropriate next step is computed tomography angiography of the chest to diagnose a suspected pulmonary embolism.
The patient presents with fever, pleuritic chest pain, tachycardia, and a peripheral wedge-shaped lung opacity (Hampton hump) on postoperative day 7, a presentation highly suspicious for a pulmonary embolism (PE) with subsequent pulmonary infarction. The concurrent unilateral calf swelling strongly supports a deep vein thrombosis (DVT) as the source. Fever and mild leukocytosis are common manifestations of PE due to tissue infarction and the resulting systemic inflammatory response. In a hemodynamically stable patient with a high clinical probability of PE, computed tomography pulmonary angiography is the most appropriate next step to definitively establish the diagnosis before initiating anticoagulation.

Adım Adım Çözüm

1
Analyze the timing of the patient's postoperative fever and respiratory symptoms.
The symptoms present on postoperative day 7, which makes early complications like atelectasis highly unlikely.
Postoperative complications follow characteristic timelines (the '5 Ws'), helping narrow the differential diagnosis.
2
Evaluate the specific cardiopulmonary and extremity examination findings.
The patient has unilateral calf swelling (deep vein thrombosis) and right-sided pleuritic chest pain with a pleural friction rub.
These findings strongly suggest venous thromboembolism with extension to the pulmonary circulation, causing pleural inflammation.
3
Interpret the chest radiograph findings in the context of the physical exam.
The peripheral wedge-shaped opacity (Hampton hump) accompanied by a small pleural effusion indicates pulmonary infarction.
Pulmonary infarction secondary to a pulmonary embolism often presents with fever and this classic radiographic sign, which can easily be misdiagnosed as pneumonia.
4
Determine the most appropriate next step in management for suspected pulmonary embolism in a hemodynamically stable postoperative patient.
Computed tomography angiography of the chest.
CT pulmonary angiography is the gold standard imaging modality to confirm the diagnosis of a pulmonary embolism before committing to high-risk therapeutic anticoagulation, especially following recent major surgery.

Anahtar Kavram

Evaluation of postoperative fever and recognition of pulmonary infarction secondary to pulmonary embolism.
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Preoperative and Postoperative Care

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