A 52-year-old man is evaluated by the surgical team for an elevated temperature 28 hours a… — USMLE Step 2 CK

A $52$ -year-old man is evaluated by the surgical team for an elevated temperature $28$ hours after undergoing an open partial gastrectomy for a refractory bleeding peptic ulcer. He has a history of type 2 diabetes mellitus and hypertension. His current medications include subcutaneous insulin and intravenous lactated Ringer solution. The patient reports mild, localized pain at the abdominal incision site but denies dyspnea, cough, dysuria, or calf pain. His temperature is $38.4^{\circ}\text{C}$ ( $101.1^{\circ}\text{F}$ ), blood pressure is $135/85\text{ mmHg}$ , pulse is $92/\text{min}$ , and respirations are $18/\text{min}$ . Pulse oximetry shows $96\%$ on room air. Physical examination reveals decreased breath sounds at the lung bases bilaterally, without crackles or wheezes. The abdominal incision is well-approximated, clean, and dry, with no surrounding erythema. His indwelling urethral catheter is draining clear yellow urine at a rate of $45\text{ mL/hour}$ . Which of the following is the most appropriate next step in the management of this patient's fever?

A
Portable chest radiograph
B
Initiation of empiric broad-spectrum antibiotics
Observation and encouragement of incentive spirometryCevap
D
Urinalysis and urine culture
E
Lower extremity venous duplex ultrasonography

Cevap

Observation and encouragement of incentive spirometry

The correct management is observation and encouragement of incentive spirometry. An elevated temperature within the first 48 hours after surgery (postoperative days 1-2) is extremely common and is most frequently a non-infectious, physiologic response to surgical tissue trauma, mediated by the release of inflammatory cytokines. While atelectasis (manifesting as decreased breath sounds at the lung bases) is frequently present concurrently, it is generally an associated finding rather than the direct cause of the fever. In the absence of hemodynamic instability or specific localizing signs of a severe early infection (such as a necrotizing soft tissue infection or bowel leak), no specific diagnostic laboratory or radiographic workup is required. The appropriate management is supportive care, which includes pain control, early mobilization, and continued pulmonary toileting with incentive spirometry to prevent progression to pneumonia.

Adım Adım Çözüm

Analyze the timing of the patient's postoperative fever.

The fever is occurring 28 hours (postoperative day 1) after an open abdominal surgery.

The postoperative timeline is the most critical factor in determining the likely etiology of a fever (the '5 Ws').

Evaluate the patient's symptoms and physical examination findings.

The patient is generally asymptomatic with stable vital signs, a clean surgical incision, and decreased breath sounds at the lung bases.

A targeted physical exam helps rule out early severe infectious complications such as necrotizing wound infections or bowel leaks.

Determine the appropriate management based on the likely diagnosis.

The presentation is consistent with a benign, non-infectious inflammatory response to surgery; therefore, observation and pulmonary toileting are indicated.

Immediate diagnostic testing or antibiotics are unnecessary for early postoperative fever in the absence of localizing signs of infection.

Anahtar Kavram

Fever in the first 48 hours postoperatively is most commonly caused by non-infectious inflammatory cytokine release (often associated with atelectasis) and is managed with observation and pulmonary toileting such as incentive spirometry.

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Cevap

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