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Zorluk: OrtaPreoperative and Postoperative Care

During routine morning rounds on postoperative day 3, a 51-year-old man is evaluated after an elective open reduction and internal fixation of a right tibial fracture. He reports feeling mildly fatigued but is participating in early physical therapy. An indwelling urinary catheter was placed intraoperatively and removed on postoperative day 1. His temperature is 38.6°C (101.5°F), blood pressure is 125/80 mmHg, heart rate is 88/min, and respiratory rate is 16/min. Oxygen saturation is 98% on room air. Physical examination reveals clear breath sounds bilaterally. The right lower extremity surgical dressings are intact, with no surrounding erythema, induration, or unusual swelling. Palpation of the left calf is non-tender. When questioned further, he notes increased urinary frequency and mild suprapubic discomfort since the previous evening. Which of the following is the most appropriate next step in management?

  1. Obtain a urinalysis and urine cultureCevap
  2. B
    Perform a portable chest radiograph
  3. C
    Order a venous duplex ultrasound of the bilateral lower extremities
  4. D
    Remove the surgical dressings to inspect the incision site
  5. E
    Begin empiric intravenous piperacillin-tazobactam therapy

Cevap

Obtain a urinalysis and urine culture
The correct answer addresses the most likely etiology of this patient's presentation. Postoperative fever is commonly evaluated using the '5 Ws' mnemonic (Wind, Water, Walking, Wound, Wonder drugs/What did we do). This patient is on postoperative day 3, a timeline most consistent with 'Water', or a urinary tract infection (UTI). His recent Foley catheter removal and localized symptoms (urinary frequency, suprapubic discomfort) strongly support this diagnosis. The standard next step in management is to confirm the presence of infection and identify the organism via a urinalysis and urine culture prior to starting targeted antibiotics.

Adım Adım Çözüm

1
Evaluate the timing of the postoperative fever.
The patient developed a fever on postoperative day 3.
The postoperative day (POD) strongly correlates with specific etiologies of fever (the '5 Ws': Wind, Water, Walking, Wound, Wonder drugs).
2
Correlate the fever timing with clinical signs and symptoms.
The patient has urinary frequency and suprapubic discomfort following recent Foley catheter removal.
Fever on POD 3-5 ('Water') is classically associated with urinary tract infections (UTIs), especially in patients who had an indwelling catheter.
3
Determine the most appropriate diagnostic intervention.
Urinalysis and urine culture should be ordered.
Before initiating any targeted antibiotic therapy for a suspected UTI, objective evidence of infection and pathogen identification are required.

Anahtar Kavram

The timing of postoperative fever is a critical clue to its etiology. Fever on postoperative days 3 to 5 is highly suggestive of a urinary tract infection (the 'Water' in the 5 Ws), warranting urinalysis and urine culture.
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Preoperative and Postoperative Care

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