An urgent evaluation is requested for a 42-year-old female on the second postoperative day… — USMLE Step 2 CK

An urgent evaluation is requested for a $42$ -year-old female on the second postoperative day following a laparoscopic Roux-en-Y gastric bypass. Her medical history includes morbid obesity (body mass index $45\text{ kg/m}^2$ ), obstructive sleep apnea, and mild asthma. The nursing staff reports that the patient developed sudden, severe left shoulder pain and a feeling of impending doom $30$ minutes ago. She also reports vague left-sided chest discomfort. Her temperature is $38.4^\circ \text{C}$ ( $101.1^\circ \text{F}$ ), pulse is $135/\text{min}$ , blood pressure is $105/65\text{ mmHg}$ , and respirations are $26/\text{min}$ . Pulse oximetry shows an oxygen saturation of $94\%$ on room air. Physical examination demonstrates an obese, soft abdomen with moderate tenderness located in the left upper quadrant. The laparoscopic port sites appear clean and intact. Lung auscultation reveals diminished breath sounds over the left base, but no crackles or wheezes. Cardiac examination shows regular tachycardia without murmurs. Which of the following is the most appropriate next step in the management of this patient?

Order an abdominal computed tomography scan with oral contrastCevap
B
Order a computed tomography angiogram of the pulmonary arteries
C
Start empiric piperacillin-tazobactam and monitor closely
D
Give intravenous furosemide therapy
E
Provide nebulized albuterol combined with systemic corticosteroids

Cevap

The most appropriate next step is to order an abdominal computed tomography scan with oral contrast.

This patient's presentation of sudden tachycardia, fever, tachypnea, and left shoulder pain on postoperative day 2 following a Roux-en-Y gastric bypass is highly suspicious for a gastrojejunal anastomotic leak. Unexplained tachycardia is often the earliest clinical sign of a leak. The left shoulder pain (Kehr sign) is classic for diaphragmatic irritation from leaked gastric or enteric contents. Since the patient is currently hemodynamically stable, the most appropriate next step is to obtain imaging to definitively diagnose the leak. This is typically accomplished via an abdominal CT scan with oral contrast or an upper gastrointestinal series using water-soluble contrast. If she were hemodynamically unstable, immediate surgical exploration would be indicated.

Adım Adım Çözüm

Analyze the clinical timeline and vital signs.

The patient is on postoperative day 2 following bariatric surgery and has developed sudden tachycardia (

135/\text{min}

), tachypnea, and fever.

Unexplained tachycardia out of proportion to fever is often the earliest and most sensitive clinical sign of a gastrojejunal anastomotic leak in bariatric patients.

Interpret specific physical exam findings.

The patient exhibits left upper quadrant abdominal tenderness and left shoulder pain.

Left shoulder pain (Kehr sign) represents referred pain from subdiaphragmatic irritation caused by leaking acidic fluid or succus entericus from the anastomosis.

Determine the appropriate diagnostic modality.

Because the patient is hemodynamically stable (blood pressure

105/65\text{ mmHg}

), an imaging study is required to confirm the leak.

An abdominal CT scan with oral contrast or an upper gastrointestinal fluoroscopic series with water-soluble contrast is the standard modality to visualize contrast extravasation before operative repair.

Anahtar Kavram

Recognition and diagnostic approach to anastomotic leak following bariatric surgery.

Soru

Cevap

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