A 45-year-old man is evaluated on postoperative day 7 following an emergent exploratory la… — USMLE Step 2 CK

A $45$ -year-old man is evaluated on postoperative day $7$ following an emergent exploratory laparotomy and splenectomy for a grade IV splenic laceration sustained in a motor vehicle collision. For the past $48$ hours, he has reported new-onset left-sided pleuritic chest pain and persistent hiccups. His temperature is $38.9^\circ\text{C}$ ( $102.0^\circ\text{F}$ ), heart rate is $112/\text{min}$ , blood pressure is $118/74\text{ mm Hg}$ , and respiratory rate is $20/\text{min}$ . Pulse oximetry is $94\%$ on room air. Pulmonary examination reveals decreased breath sounds and dullness to percussion at the left lung base. Abdominal examination shows a well-healing midline incision and mild left upper quadrant tenderness without rebound or guarding. Laboratory studies show a leukocyte count of $16,500/\text{mm}^3$ . A chest radiograph reveals an elevated left hemidiaphragm and a moderate left-sided pleural effusion with basilar linear opacities. Which of the following is the most appropriate next step in management?

A
Computed tomography angiography of the chest
B
Chest physiotherapy and incentive spirometry
C
Initiation of empiric broad-spectrum intravenous antibiotics
Computed tomography scan of the abdomenCevap
E
Diagnostic thoracentesis

Cevap

Computed tomography scan of the abdomen

The patient's clinical presentation is highly characteristic of a left subphrenic abscess, a well-known complication following splenectomy. Presenting typically 1 to 2 weeks postoperatively, the accumulating infected fluid irritates the diaphragm, leading to hiccups and referred shoulder or pleuritic chest pain. The associated inflammation frequently crosses the diaphragm, resulting in an elevated hemidiaphragm and a reactive, sympathetic pleural effusion on a chest radiograph. Because the primary pathology is located within the abdominal cavity, the most appropriate next step is a computed tomography (CT) scan of the abdomen. This imaging modality will definitively identify the abscess, define its anatomy, and determine whether it is amenable to CT-guided percutaneous drainage (the standard initial treatment) or if it requires surgical exploration.

Adım Adım Çözüm

Analyze the timeline and nature of the postoperative complication.

The patient has a fever, marked leukocytosis, and localized left-sided symptoms on postoperative day 7 following a splenectomy.

Identifying the 'when' and 'where' narrows down the differential diagnosis for postoperative fever (e.g., 'wound' or 'walking' timeframe, rather than early 'wind' or 'water').

Interpret the specific clinical and radiographic signs.

Hiccups indicate diaphragmatic irritation. The chest radiograph shows an elevated left hemidiaphragm and a sympathetic pleural effusion.

These findings localize the inflammatory process to the space immediately below the diaphragm (the subphrenic space).

Determine the diagnostic modality of choice.

An abdominal CT scan is required to confirm the presence, size, and exact location of a subphrenic abscess.

CT imaging is the gold standard for diagnosing intra-abdominal abscesses and is necessary to plan subsequent percutaneous or surgical drainage.

Anahtar Kavram

Patients who undergo splenectomy are at high risk for developing a left subphrenic abscess. This typically presents 1 to 2 weeks postoperatively with fever, leukocytosis, and diaphragmatic irritation (e.g., hiccups, sympathetic pleural effusion), and is best diagnosed with an abdominal CT scan.

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