A 61-year-old man is evaluated on postoperative day 2 following an elective open hepatic r… — USMLE Step 2 CK

A 61-year-old man is evaluated on postoperative day 2 following an elective open hepatic resection for a solitary colorectal metastasis. He reports moderate pain at the surgical site but denies shortness of breath, chest pain, cough, or dysuria. His medical history is significant for chronic obstructive pulmonary disease and heart failure with preserved ejection fraction. His temperature is $38.6^\circ\text{C}$ ( $101.5^\circ\text{F}$ ), blood pressure is $134/82\text{ mmHg}$ , pulse is $102/\text{min}$ , and respirations are $16/\text{min}$ . Pulse oximetry is $96\%$ on room air. Physical examination reveals an intact abdominal incision without erythema, induration, or purulent drainage. Lung auscultation demonstrates fine bibasilar crackles that completely disappear after the patient coughs forcefully. Cardiac examination shows a regular rhythm with no murmurs or gallops. The abdomen is soft, and bowel sounds are hypoactive. There is trace bilateral lower extremity edema that is unchanged from his preoperative baseline. Laboratory studies show a leukocyte count of $11,500/\text{mm}^3$ . Which of the following is the most appropriate next step in management?

Observation and encouragement of incentive spirometryCevap
B
Collection of blood, urine, and sputum cultures
C
Initiation of empiric intravenous broad-spectrum antibiotics
D
Intravenous administration of furosemide
E
Computed tomography pulmonary angiography

Cevap

Observation and encouragement of incentive spirometry

The correct answer is observation and encouragement of incentive spirometry. This patient is experiencing a low-grade fever, mild leukocytosis, and bibasilar crackles on postoperative day 2 following a major open abdominal surgery. This presentation is highly consistent with expected postoperative physiologic inflammation and concurrent atelectasis. Fever occurring within the first 1 to 3 days postoperatively is typically driven by the release of inflammatory cytokines (e.g., IL-1, IL-6, TNF-alpha) in response to surgical tissue trauma, rather than an active infection. Although historical teaching linked early fever directly to atelectasis, modern surgical understanding recognizes that they simply coexist in the early postoperative period. The bibasilar crackles that completely clear with a forceful cough strongly suggest atelectasis, which is common following abdominal procedures due to pain-splinting and reduced tidal volumes. In a hemodynamically stable patient without localizing signs of infection (e.g., clear incision, no dysuria, no purulent sputum), the most appropriate management is observation, adequate analgesia, and targeted pulmonary expansion interventions such as incentive spirometry.

Adım Adım Çözüm

Analyze the timing of the fever and the patient's vital signs.

The patient is on postoperative day (POD) 2 with a low-grade fever (

38.6^\circ\text{C}

) and mild tachycardia, but he maintains normal oxygenation (

96\%

on room air) and stable blood pressure.

Establishing the clinical timeline is critical. Fevers in the first 1 to 3 days after major surgery are most commonly due to the physiologic release of inflammatory cytokines (tissue trauma) rather than an active infection.

Interpret the physical examination findings, specifically the lung auscultation.

The patient has bibasilar crackles that resolve completely after a forceful cough, along with baseline (not worsened) trace lower extremity edema.

Crackles that clear with coughing strongly point to atelectasis (collapsed alveoli popping open) rather than alveolar fluid accumulation from an acute heart failure exacerbation or pneumonia.

Determine the appropriate management based on the likely diagnosis.

The diagnosis is physiologic postoperative fever with concurrent atelectasis. The best step is observation, reassurance, and incentive spirometry.

Without localizing signs of infection (e.g., purulent wound, dysuria, productive cough), an infectious workup or empiric antibiotics are contraindicated. Atelectasis is managed mechanically with pulmonary expansion exercises.

Anahtar Kavram

Fever within the first 1 to 3 days following major surgery is typically a physiologic response driven by the release of inflammatory cytokines (e.g., IL-1, IL-6) due to tissue trauma. In a stable patient without localizing signs of infection, the most appropriate management is supportive care, adequate pain control, and incentive spirometry to address concurrent atelectasis.

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