Option 2: Postoperative fever with stable vital signs

The patient is sitting upright and scrolling through her phone. There is a cool compress on her head. When asked how she's feeling, she says she’s felt “off” since this afternoon. The nurse quickly repeats the patient's vital signs, which are now: temperature 39.1°C (102.4°F), heart rate 98 beats/minute, and blood pressure 112/72 mm Hg. Oxygen saturation is 98% on room air, and the patient appears to be breathing comfortably.

The patient is not crashing, but something’s heating up. Is this an early infection? A drug fever? Or something else entirely? Before you fire up the diagnostics, take a moment to think.

Question: What are your next steps in evaluating a postoperative patient with fever?

Make your choices, then click on the explanation bubbles for more information.

• Take a focused history.
• Perform a targeted physical examination.
• Review the operative note and hospital course.
• Obtain a diagnostic workup.
• Document and monitor.

Check for common postoperative fever sources using the "5 Ws" framework: Wind (pulmonary), Water (urinary tract infection), Wound (surgical site), Walking (DVT/PE), and Wonder drugs (medication-related).

Additional steps

Because this patient is currently stable but the source of fever is still a mystery, you'll want to go ahead with a diagnostic evaluation of fever to identify the source of infection. In addition, you can perform a clinical assessment of volume status to identify signs of hypovolemia. And don't forget about supportive care. Antipyretics will reduce the fever and improve the patient's comfort.

You're patient's fever has you thinking one lap ahead: are postoperative complications preventable?

Question: What are some strategies for preventing postoperative complications?

Think through what each strategy accomplishes, then click on the explanation bubbles for more information.

• Get the patient up and moving early.
• Provide an incentive spirometer at the bedside.
• Remove unnecessary lines and tubes.
• Treat pain effectively.
• Start appropriate prophylaxis.
• Provide wound care.

Calling consults is something you'll do often as an intern. Asking other busy providers for help can be intimidating, but organizing your thoughts ahead of time can go a long way to having a more pleasant conversation. Before you send out that page, use this list to ensure you’re ready to steer the conversation with clarity.

Preconsultation checklist

• What are you asking the consultant to weigh in on?
• What essential patient information will the consultant need to know?
• Have you chosen the appropriate consult service?
• How urgent is your consult?

Imagine you're planning to call an infectious disease consult for this patient. You've already started a workup by ordering a CBC, blood cultures, urinalysis, urine culture, and CXR and would like their recommendations for further diagnostic testing and management.

Question: What will you say to the consulting service?

The ISBAR tool is a common way to structure a consultation request. What would you say for each of the following sections? Think of your answer, then click the explanation bubbles for concise, effective examples.

• I (identification)
• S (situation)
• B (background)
• A (assessment)
• R (recommendation)

Make sure to identify yourself and the service you represent when you call for a consult!

If you haven't explored the other scenario, drift on over to “Option 1: Septic shock.” If you’re ready to cross the finish line, you can also return to the main module; see “Burning up wrap-up.”