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Zorluk: ZorPreoperative and Postoperative Care

During morning rounds on the surgical ward, the team evaluates a female patient who underwent an uncomplicated left hemicolectomy three days ago for early-stage colon cancer. She is 68 years old and reports feeling progressively more short of breath since the previous evening. She also notes a new cough that produces thick, yellowish sputum, along with feeling hot and sweaty. Her past medical history includes hypertension and severe chronic obstructive pulmonary disease (COPD) managed with daily inhaled corticosteroids and long-acting bronchodilators.

Vital signs are:
Temperature: 38.8°C (101.8°F)
Blood pressure: 130/85 mm Hg
Pulse: 110/min
Respirations: 24/min
Oxygen saturation: 91% on room air

On physical examination, the patient appears in mild respiratory distress. Lung auscultation demonstrates crackles at the right lung base, a prolonged expiratory phase, and diffuse bilateral wheezing. The surgical incision is healing well without erythema or induration. The abdomen is soft and non-distended, with normoactive bowel sounds. There is no lower extremity edema or calf tenderness.

Laboratory results show a leukocyte count of 14,500/mm³. A chest radiograph demonstrates a new, patchy alveolar consolidation in the right lower lobe.

Which of the following interventions should be included in the immediate management of this patient? (Select all that apply)

  1. Obtain a sputum sample for Gram stain and culture, and initiate empiric antibiotic therapyCevap
  2. Administer nebulized short-acting bronchodilatorsCevap
  3. C
    Administer intravenous furosemide
  4. D
    Perform a computed tomography scan of the abdomen and pelvis with intravenous contrast
  5. E
    Insert a nasogastric tube for gastrointestinal decompression

Cevap

The most appropriate immediate management includes obtaining a sputum sample for culture and initiating empiric antibiotic therapy, as well as administering nebulized short-acting bronchodilators.
This patient is presenting with two concurrent acute pulmonary issues on postoperative day 3: hospital-acquired pneumonia (HAP) and a COPD exacerbation. Fever in the first three days after surgery is most frequently caused by respiratory complications. Her productive cough, focal right lower lobe crackles, leukocytosis, and new alveolar consolidation on radiography solidify the diagnosis of HAP, which requires immediate sputum sampling and empiric antibiotic therapy. Furthermore, the acute infection has triggered a COPD exacerbation, evidenced by her dyspnea, diffuse wheezing, and prolonged expiratory phase. Nebulized short-acting bronchodilators (such as albuterol and ipratropium) are required to promptly reverse the bronchospasm and improve airflow.

Adım Adım Çözüm

1
Analyze the patient's timeline and vital signs
The patient has a new fever, tachycardia, and tachypnea on postoperative day 3.
Establishing the postoperative day helps narrow the differential diagnosis for fever, with day 3 typically correlating with pulmonary or urinary sources ('Wind' or 'Water').
2
Correlate symptoms, physical exam, and imaging findings
Productive cough, right lower lobe crackles, and a new focal infiltrate on chest radiograph confirm a diagnosis of hospital-acquired pneumonia.
Identifying the infectious source directs targeted therapy (sputum culture and empiric antibiotics).
3
Evaluate the patient's underlying comorbidities in the context of the acute illness
The patient has a history of COPD and presents with diffuse bilateral wheezing and prolonged expiration.
This indicates an acute COPD exacerbation triggered by the pneumonia, necessitating the addition of short-acting bronchodilators.

Anahtar Kavram

Postoperative Day 3 Fever and Respiratory Complications
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Konular

Preoperative and Postoperative Care

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