Subinternship Surgery · Year 4 · from Subinternship Surgery

Case 1: Managing a Postoperative Patient Panel

Patient Presentation

Demographics: 58-year-old male

Chief Complaint: Post-operative day 2 following open right hemicolectomy for cecal adenocarcinoma

History of Present Illness: You are the surgery sub-intern covering a panel of 8 patients on the general surgery service. Mr. Johnson underwent open right hemicolectomy two days ago for a cecal mass found on screening colonoscopy. Your attending expects you to pre-round on all patients before 6 AM rounds and present concise one-liners.

Overnight Events:

  • Temperature max 38.1C at 0200
  • Required additional doses of IV morphine for pain (total 12mg overnight)
  • No flatus or bowel movement yet
  • Urine output adequate at 0.6 mL/kg/hr

Physical Examination:

  • Vitals: T 37.4C, HR 88, BP 128/76, RR 16, SpO2 97% RA
  • General: Alert, appears tired but comfortable
  • Abdomen: Soft, mildly distended, midline incision with staples intact, no erythema or drainage, minimal tenderness, bowel sounds hypoactive
  • JP drain: 45 mL serosanguinous output over 24 hours
  • Extremities: SCDs in place, no calf tenderness

Current Orders:

  • NPO
  • IVF: LR at 100 mL/hr
  • Morphine PCA 1mg q8min demand
  • Incentive spirometry q1hr while awake
  • Enoxaparin 40mg SQ daily
  • Ambulate with assistance TID

Clinical Questions

  1. Construct a one-liner presentation for this patient:
  • "Mr. Johnson is a 58-year-old male, POD 2 from open right hemicolectomy for cecal adenocarcinoma, progressing well with low-grade fever, adequate pain control on PCA, and awaiting return of bowel function."
  1. What are the key post-operative milestones you should monitor?
  • Return of bowel function (flatus, then bowel movement)
  • Adequate pain control with transition to oral medications
  • Ambulation independence
  • Tolerating oral diet
  • Wound healing without infection
  • Resolution of low-grade fever (common POD 1-2 from atelectasis)
  1. The patient develops a temperature of 38.5C on POD 3. Using the "5 W's," what is your differential?
  • Wind (POD 1-2): Atelectasis - encourage incentive spirometry, deep breathing
  • Water (POD 3-5): UTI - check UA and culture if symptomatic
  • Wound (POD 5-7): SSI - examine wound for signs of infection
  • Walking (POD 5-7): DVT/PE - check for leg swelling, consider duplex
  • Wonder drugs: Drug fever - review medication list
  1. What information must be included in your sign-out for overnight coverage?
  • Current status and POD
  • Anticipated issues: may develop ileus, monitor for anastomotic leak signs
  • Contingency plans: "If temp >38.5, obtain blood and urine cultures, pan-culture and CXR"
  • Code status
  • Contact information for responsible resident

Clinical Image

Image: Intraoperative view of acute appendicitis. Source: Wikimedia Commons. License: CC BY-SA 3.0. This image demonstrates the surgical field during appendectomy, a common procedure the sub-intern may assist with.

Image Attribution: Acute appendicitis surgical specimen. Available at: https://commons.wikimedia.org/wiki/Category:Appendicitis. Licensed under Creative Commons.

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