During morning rounds, the surgical team evaluates a 68-year-old male who is currently on … — USMLE Step 2 CK

During morning rounds, the surgical team evaluates a 68-year-old male who is currently on his fourth postoperative day following an elective open ventral hernia repair with mesh placement. He has a known medical history of moderate chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy with a left ventricular ejection fraction of 45%. Overnight, the patient developed worsening shortness of breath and an increased production of thick, yellow sputum.

Current vital signs are as follows:

Parameter	Value
Temperature	38.6°C (101.5°F)
Heart Rate	112/min
Blood Pressure	135/85 mmHg
Respiratory Rate	24/min
Oxygen Saturation	91% on room air

Physical examination demonstrates a prolonged expiratory phase with diffuse bilateral wheezing. The jugular venous pressure is estimated at 6 cm $H_2O$ . There is no peripheral edema. The abdominal incision is clean, dry, and fully intact without erythema, warmth, or induration. A sputum culture that was obtained two days ago due to a mild, non-productive cough has just finalized; it demonstrates moderate growth of *Haemophilus influenzae*. Susceptibility testing confirms the organism is sensitive to amoxicillin, azithromycin, and levofloxacin.

Which of the following are the most appropriate next steps in the management of this patient? (Select 2)

Administer targeted antimicrobial therapy with amoxicillinCevap
Initiate nebulized short-acting bronchodilators and systemic corticosteroidsCevap
C
Administer broad-spectrum therapy with intravenous piperacillin-tazobactam
D
Administer a rapid-acting intravenous loop diuretic such as furosemide
E
Remove the surgical staples and open the incision at the bedside

Cevap

The most appropriate next steps are to administer targeted antimicrobial therapy with amoxicillin and to initiate nebulized short-acting bronchodilators and systemic corticosteroids.

The correct interventions address both the acute COPD exacerbation and the underlying bacterial trigger. The patient's presentation of increased dyspnea, increased sputum purulence, and diffuse wheezing signifies a COPD exacerbation. Management requires systemic corticosteroids and short-acting bronchodilators to reduce airway inflammation and relieve bronchospasm. Furthermore, the patient has an identified bacterial source (*Haemophilus influenzae*) causing a postoperative respiratory infection. Because culture and sensitivity data are already finalized and indicate susceptibility to amoxicillin, utilizing this targeted, narrow-spectrum antibiotic is the safest and most effective standard of care.

Adım Adım Çözüm

Analyze the timing and clinical presentation of the postoperative fever.

The patient is on postoperative day 4 with fever, worsening dyspnea, wheezing, and purulent sputum.

Identifying the source of postoperative fever based on the timeline (the '5 Ws') and physical exam is critical for targeted management.

Differentiate between a COPD exacerbation and acute decompensated heart failure.

The presence of purulent sputum, diffuse wheezing, normal jugular venous pressure, and absence of peripheral edema points to a COPD exacerbation triggered by a respiratory infection, rather than volume overload.

Both conditions can cause acute dyspnea in a patient with a history of COPD and ischemic cardiomyopathy, but the therapeutic interventions are opposing.

Select the appropriate antimicrobial strategy.

Amoxicillin is chosen based on finalized culture sensitivities showing efficacy against the isolated *Haemophilus influenzae*.

Antimicrobial stewardship dictates de-escalating to the narrowest effective spectrum agent once pathogen susceptibilities are known.

Anahtar Kavram

Postoperative fever in a patient with COPD presenting with wheezing and purulent sputum signifies a respiratory tract infection triggering a COPD exacerbation. Management requires targeted antibiotics based on final culture data, combined with bronchodilators and systemic corticosteroids.

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Cevap

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