An otherwise healthy 67-year-old woman comes to your clinic after being admitted to the hospital for 2 weeks after breaking her hip. She has not regularly seen a physician for the past several years because she has been working hard at her long-time job as a schoolteacher. You wonder if she has not been taking adequate preventative measures to prevent osteoporosis and order the appropriate labs. Although she is recovering from surgery well, she is visibly upset because she is worried that her hospital bill will bankrupt her. Which of the following best describes her Medicare coverage?

Medicare Part A will cover the majority of her hospital fees, including inpatient drugs and lab tests.

Medicare Part C will cover the majority of drug costs during her inpatient treatment.

Medicare is unlikely to cover the cost of her admission because she has not been paying her premium.

Medicare Part B will cover the majority of her hospital fees, including inpatient drugs and lab tests.

Medicare Part D will cover the cost of drugs during her inpatient treatment.

A patient presents to the emergency department with arm pain. The patient recently experienced an open fracture of his radius when he fell from a ladder while cleaning his house. Surgical reduction took place and the patient's forearm was put in a cast. Since then, the patient has experienced worsening pain in his arm. The patient has a past medical history of hypertension and asthma. His current medications include albuterol, fluticasone, loratadine, and lisinopril. His temperature is 99.5°F (37.5°C), blood pressure is 150/95 mmHg, pulse is 90/min, respirations are 19/min, and oxygen saturation is 99% on room air. The patient's cast is removed. On physical exam, the patient's left arm is tender to palpation. Passive motion of the patient's wrist and fingers elicits severe pain. The patient's left radial and ulnar pulse are both palpable and regular. The forearm is soft and does not demonstrate any bruising but is tender to palpation. Which of the following is the next best step in management?

Measurement of compartment pressure

An 86-year-old man is admitted to the hospital for management of pneumonia. His hospital course has been relatively uneventful, and he is progressing well. On morning rounds nearing the end of the patient's hospital stay, the patient's cousin finally arrives to the hospital for the first time after not being present for most of the patient's hospitalization. He asks about the patient's prognosis and potential future discharge date as he is the primary caretaker of the patient and needs to plan for his arrival home. The patient is doing well and can likely be discharged in the next few days. Which of the following is the most appropriate course of action?

Bring the cousin to the room and ask the patient if it is acceptable to disclose his course

Bring the cousin to the room and explain the plan to both the patient and cousin

Explain the plan to discharge the patient in the next few days

Explain that you cannot discuss the patient's care at this time

Tell the cousin that you do not know the patient's course well

Three hours after undergoing open proctocolectomy for ulcerative colitis, a 42-year-old male complains of abdominal pain. The pain is localized to the periumbilical and hypogastric regions. A total of 20 mL of urine has drained from his urinary catheter since the end of the procedure. Temperature is 37.2°C (98.9°F), pulse is 92/min, respirations are 12/min, and blood pressure is 110/72 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Physical examination shows a 20 cm vertical midline incision and an ileostomy in the right lower quadrant. There is no fluid drainage from the surgical wounds. The urinary catheter flushes easily and is without obstruction. Cardiopulmonary examination shows no abnormalities. Serum studies show a blood urea nitrogen of 30 mg/dL and a creatinine of 1.3 mg/dL. Which of the following is the most appropriate next step in management?

Administer intravenous furosemide

Post-procedure follow-up for USMLE Step 2 CK: High-Yield CCS Cases Lessons

Immediate Post-Op - The First 24 Hours

Vitals Monitoring (Rule of 15): Q 15 min x 1 hr → Q 30 min x 2 hrs → Q 1 hr x 4 hrs → 4-hourly.
Key Parameters: Monitor HR, BP, RR, SpO₂, Temp, and Urine Output (U.O.).
- ⚠️ Alert: U.O. < 0.5 mL/kg/hr, significant vital changes.
Core Management:
- Analgesia: IV Paracetamol ± NSAIDs/Opioids.
- IV Fluids: Isotonic crystalloids until oral intake resumes.
- DVT Prophylaxis: Early mobilization is key.
- Wound: Check dressing for soakage/bleeding.

⭐ Post-op Fever: In the first 24-48 hrs, fever is most commonly from the systemic inflammatory response (cytokine release) to surgical trauma, not infection.

📌 Mnemonic for Post-Op Fever Causes (The 5 W's):

Wind (Atelectasis: Day 1-2)
Water (UTI: Day 3-5)
Wound (Infection: Day 5-7)
Walking (DVT/PE: Day 7+)
Wonder Drugs (Anytime)

Wound Care - Site Surveillance

Initial Dressing: Keep dry and intact for 24-48 hours post-op, unless signs of excessive bleeding or infection arise.
Wound Inspection: Regularly monitor for signs of Surgical Site Infection (SSI).
- 📌 REEDA Scale: Redness, Edema, Ecchymosis, Discharge, Approximation of wound edges.
- Discharge: Note character (serous, sanguineous, purulent).
Superficial Incisional SSI:
- Occurs within 30 days post-op.
- Involves only skin and subcutaneous tissue.
- Requires one of: purulent drainage, positive culture, or surgeon deliberately opens wound due to inflammation.
Management: If SSI is suspected, remove sutures/staples, obtain wound culture, irrigate, and pack for secondary intention healing.

⭐ The most common pathogen causing SSIs is Staphylococcus aureus, frequently originating from the patient's endogenous skin flora.

Systemic Support - Meds & Mobility

Analgesia (Pain Control):
- Follow WHO step-ladder: Paracetamol → NSAIDs → Opioids (e.g., Tramadol).
- Consider Patient-Controlled Analgesia (PCA) for major surgeries.
Thromboprophylaxis (DVT Prevention):
- Pharmacological: LMWH (e.g., Enoxaparin 40mg SC OD) initiated post-op.
- Mechanical: Graduated compression stockings, Intermittent Pneumatic Compression (IPC).
- 📌 Mnemonic (Virchow's Triad): SHE - Stasis, Hypercoagulability, Endothelial injury.
Mobility & Physiotherapy:
- Early Mobilization: Crucial to prevent atelectasis, DVT, and pressure sores.
- Chest Physio: Incentive spirometry, deep breathing exercises.
- Limb Physio: Active & passive range-of-motion exercises.

⭐ For patients on LMWH, routine coagulation monitoring (like aPTT) is not required, unlike with Unfractionated Heparin.

Discharge Planning - The Road Home

Initiate Early: Begin planning within 24-48 hours of admission.
Core Components (📌 D-A-T-E-S):
- Diagnosis: Patient understands their condition.
- Appointments: Schedule follow-up within 7-14 days.
- Threats: Clear red flag signs/symptoms to watch for.
- Explanations: Meds, diet, activity levels explained.
- Support: Ensure a safe home environment & caregiver availability.

⭐ The "Teach-Back" Method is the gold standard to ensure patient comprehension and reduce readmission rates. Ask them to explain their care plan back to you.

High-Yield Points - ⚡ Biggest Takeaways

Post-op fever: Atelectasis is the most common cause in the first 48 hours. After 72 hours, suspect wound infection or DVT.

Suture removal times: Face (3-5 days), trunk/scalp (7-10 days), limbs/joints (10-14 days).

Early ambulation is crucial to prevent both atelectasis and venous thromboembolism (VTE).

Discontinue prophylactic antibiotics within 24 hours post-op to prevent antimicrobial resistance.

Maintain urine output > 0.5 mL/kg/hr to ensure adequate renal perfusion.

Always use a multimodal approach for effective post-operative pain control.

Continue reading on Oncourse

CONTINUE READING — FREE

or get the app

App Store|Google Play