QuestionSBA
QuestionChoice
This patient may have an underlying diagnosis of COPD given his extensive smoking history and the presence of a productive cough. However, there is no wheeze at present, and his shortness of breath can be explained by the X-ray findings of collapse. As such, it does not seem necessary to treat him as an exacerbation of COPD at present. Bronchodilators are often prescribed to help encourage clearance of secretions, and so whilst this may be an appropriate option, the best initial treatment is chest physiotherapy, and the addition of oral steroids is not necessary.
53154
c
Nebulised salbutamol and oral prednisolone
QuestionChoice
Carbocisteine is a mucolytic sometimes provided to help loosen secretions and allow them to be coughed up. However, in the first instance, chest physiotherapy remains the best treatment option.
53155
d
Carbocisteine
QuestionChoice
This is correct because the goal in atelectasis is to re-expand the collapsed lung, and chest physiotherapy helps to clear the thick sputum and secretions, which are likely contributing to the collapse in this case. Atelectasis is a very common cause of post-operative pyrexia.
53152
a
Chest physiotherapy
QuestionChoice
Bronchoscopy may be used to help remove secretions at a later stage, if initial medical management has failed. As such, this option does not represent the best, next step.
53156
e
Bronchoscopy
QuestionChoice
This is incorrect because this is the management for mild, community-acquired pneumonia. Patients with pneumonia typically present with fever, productive cough with green sputum, and shortness of breath. On auscultation, you would hear crackles. You would also expect the chest X-ray to show consolidation. This patient is at risk of pneumonia, but at present does not display the clinical features suggestive of this. Oral amoxicillin would not be the best choice even if a diagnosis of pneumonia were made, as this would not be  the treatment for a hospital acquired pneumonia.
53153
b
Oral amoxicillin
QuestionComment
But he needs abx too?? Not my fault you only put the wrong one as an option. Shit question
26592
QuestionComment
But he doesnt?
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Twisted Tezzy
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Monoclonal Metabolism
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# Summary

Post-operative pyrexia, or fever following surgery, can be the result of several causes, commonly remembered by the "5 Ws" mnemonic: Wind (pneumonia and atelectasis), Water (urinary tract infection), Wound (infection), Wonder drugs (anesthetic reactions), and Walking (deep vein thrombosis). Timelines for the emergence of these causes can vary, but are typically seen within specific post-op periods. It's essential to recognize these symptoms promptly, carry out the relevant investigations such as cultures, imaging, or blood tests, and initiate appropriate management like antibiotics, anticoagulants, or potentially further surgical intervention.

# Definition

Post-operative pyrexia refers to the development of fever following a surgical procedure, usually classified as a core body temperature above 38 degrees Celsius.

# Epidemiology

Post-operative pyrexia is a common occurrence, especially in the first 48 hours post-surgery due to the systemic inflammatory response. The incidence can vary based on the type and invasiveness of the surgery, patient characteristics, and the perioperative care quality.

# Aetiology

Causes of post-operative pyrexia can be remembered using the **5 Ws** mnemonic:

-   **W**ind: Pneumonia and atelectasis (1-2 days post-op)
-   **W**ater: Urinary tract infection (UTI) (>3 days)
-   **W**ound: Surgical site infections (> 5 days)
-   **W**onder drugs: Drug-induced fever, commonly due to anaesthesia
-   **W**alking: Deep vein thrombosis (DVT) (>1 week)

In addition to these, a developing abscess post-operatively can also cause pyrexia.

# Signs and Symptoms

-   **Pneumonia and atelectasis**: Cough, dyspnea, sputum production, chest pain, decreased breath sounds on examination
-   **Urinary tract infection (UTI)**: Dysuria, urgency, frequency, suprapubic pain, foul-smelling urine
-   **Surgical site infections**: Pain, erythema, swelling at the wound site, purulent discharge
-   **Drug-induced fever**: Fever associated with recent drug use, but typically no other localized symptoms
-   **Deep vein thrombosis (DVT)**: Leg pain, swelling, erythema, warmth

# Differential Diagnosis

-   **Non-infectious causes of fever**: These could include malignancy, collagen vascular disease, thromboembolism, or medication effects. Main symptoms might include widespread symptoms with no localized signs.
-   **Infection not associated with surgery**: Infections elsewhere in the body may cause fever post-operatively. The signs and symptoms would correspond to the organ system affected.
-   **Abscess formation**: This would typically present with localized signs of infection (redness, pain, swelling) at the site of the abscess.

# Investigations

Investigations will depend on the suspected underlying cause. They may include:

-   **Blood tests**: Full blood count, CRP, blood cultures
-   **Cultures**: Urine, wound, or sputum cultures as applicable
-   **Imaging**: Chest X-ray, CT scan, or ultrasound depending on the suspected site

# Management

The management of post-operative pyrexia depends on the underlying cause but could include:

-   **Antibiotics**: For bacterial infections like pneumonia, UTI, or wound infections
-   **Anticoagulants**: For DVT
-   **Modification or cessation of the offending drug**: For drug-induced fever
-   **Further surgical intervention**: In case of abscess formation or severe wound infection
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Post-operative pyrexia
Topic
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General Surgery
10691
A 59-year-old man had an uncomplicated coronary artery bypass graft under general anaesthetic two days ago. During the ward round, he is found to be visibly short of breath. He is occasionally coughing clear, thick sputum, but is struggling to fully expectorate this. He has a 21 pack year smoking history. On examination, there is dullness to percussion and reduced breath sounds in the left lower zone of the lungs. His respiratory rate is 24 breaths per minute, heart rate 103bpm, and temperature 37.8. A chest X-ray shows lung collapse in the left lower zone.

Which of the following is the next best step in the management of this patient?
a