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  #1  
Old 03-24-2012
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Thermometer What is the cause of this post op fever?

A 58-year-old woman is 7 hours status post abdominal hysterectomy with bilateral salpingo-oophorectomy. The nurse calls you because the woman has a fever of 38.3C (101F) and is complaining of severe abdominal pain despite what should be adequate pharmacologic analgesia. She has put out only 40 mL of urine despite having been given 1000 mL of intravenous fluids. On physical examination, you note an ill-appearing woman. She is tachycardic to 120s, and blood pressure, temperature, oxygen saturation, and respiratory rate are within normal limits. Head, ears, eyes, nose, and throat (HEENT), heart, and lung examination are normal. The abdominal examination reveals involuntary guarding over the lower abdomen, extreme tenderness to palpation, and hypoactive bowel sounds. Extremities are without rash, cyanosis, or edema. Her complete blood count (CBC) is normal. The urinalysis is remarkable only for trace ketones. The operative report indicates that the surgery was performed without incident. An intraoperative cystoscopy was not performed.

A. Pulmonary embolus
B. Wound infection
C. Meningitis
D. Drug reaction
E. Endocarditis
F. Urinary tract infection
G. Postoperative ileus
H. Bacteremia
I. Postoperative atelectasis
J. Surgical error
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  #2  
Old 03-25-2012
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j. by exclusion
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Old 03-25-2012
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b.wound infection?
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Old 03-25-2012
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G. Postoperative ileus
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Old 03-25-2012
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Sounds like they're hinting at surgical error - i.e. that the ureters might have been ligated along with the uterine arteries
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Old 03-25-2012
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Default Drug reaction

Post-op fever in the immediate posto-op period is malignant hyperthermia until proven otherwise. Malignant hyperthermia is caused usually as a reaction of volatile anesthetics +/- succinylcholine, as a result of reuptake of calcium by the sarcoplasmic reticulum (the mechanism is similar to NMS & serotonin syndrome). Treatment consists of 100% O2 & the cornesrstone is dantrolene pyrophosphate.
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Old 03-25-2012
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Quote:
Originally Posted by umajeed90 View Post
b.wound infection?


A = Atelectasis; Day one postop
P = Pneumonia; Day three postop
U = UTI; Day three postop
D = Deep thrombophlebitis; Day five postop
W = Wound infection; Day seven postop
P = Pus, abscesses; Around two weeks postop .
it's just 7 hr.
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Old 03-25-2012
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PE would be evident after POD 3-5, although it is always a possibility at any time postoperatively. Surgeries within the pelvis (as in this case) carry a large risk, due to manipulations to the IVC & the inguinal veins.

Wound infection wouldn't be evident until POD 7-15.

Meningitis is highly unlikely in the given setting.

Endocarditis would have a more insidious course.

UTI would be evident after POD 2.

Post-op ileus is not related to fever, unless there is associated bowel perforation, due to extreme intraluminal pressure, followed by peritonitis. Even in this case, the course would be more indolent.

Bacteremia is also a possibility, but would be evident later on.

Postop atelectasis wouldn't be associated with oliguria.

Surgical error is rarely an option in the USMLE.
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Old 03-25-2012
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Quote:
Originally Posted by ath.pantelis View Post
Post-op fever in the immediate posto-op period is malignant hyperthermia until proven otherwise. Malignant hyperthermia is caused usually as a reaction of volatile anesthetics +/- succinylcholine, as a result of reuptake of calcium by the sarcoplasmic reticulum (the mechanism is similar to NMS & serotonin syndrome). Treatment consists of 100% O2 & the cornesrstone is dantrolene pyrophosphate.

Sorry, it's a result of inability of uptake of Ca++
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Old 03-25-2012
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Quote:
Originally Posted by ath.pantelis View Post
Post-op fever in the immediate posto-op period is malignant hyperthermia until proven otherwise. Malignant hyperthermia is caused usually as a reaction of volatile anesthetics +/- succinylcholine, as a result of release and non reuptake of calcium by the sarcoplasmic reticulum (the mechanism is similar to NMS & serotonin syndrome). Treatment consists of 100% O2 & the cornesrstone is dantrolene pyrophosphate.
Oh, I didn't think of MH! That could be it too. Do you think they would leave it so vague, or would they give us a more fulminant presentation, or muscle rigidity and tachypnea etc? I figured they were going for surgical error because of the abdominal tenderness and lack of cystoscopy...
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Old 03-25-2012
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Abd. pain is attributed muscular rigidity (I suppose)
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  #12  
Old 03-25-2012
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G. Postoperative ileus
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  #13  
Old 03-25-2012
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Default Drug reaction

Drug reaction is a cause of post op fever at any time even first 7 hours...
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Old 03-25-2012
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Correct Answer

J. Surgical error
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  #15  
Old 03-25-2012
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Answer is J.
here is the reason from qbank...

Accidental transection of the ureter is one of the dangers of pelvic surgery, and should be suspected in any post-pelvic-surgery patient with decreased urine output. Intraoperative cystoscopy should be performed at the end of abdominal or transvaginal hysterectomy to ensure that the ureters are still intact.
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  #16  
Old 03-26-2012
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Quote:
Originally Posted by tyagee View Post
Answer is J.
here is the reason from qbank...

Accidental transection of the ureter is one of the dangers of pelvic surgery, and should be suspected in any post-pelvic-surgery patient with decreased urine output. Intraoperative cystoscopy should be performed at the end of abdominal or transvaginal hysterectomy to ensure that the ureters are still intact.
This makes sense than malignant hyperthermia because it wouldn't explain the decrease in urine output in this patient.. also, the presentation would have been more dramatic in that case I think.
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  #17  
Old 03-26-2012
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dont make it complicated guys
simle to remember
1.during surgery-malignant hyperthermia
2.after surgery-atelectasis(i.e., 1 st day)
3.wind(pnemonia)-day 1
4.water(UTI)-----day 3
5.walking(DVT)---day 5
6.wound---------day 7
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