POD0 after splenectomy, 28M has persistent tachycardia and hypotension despite 2L fluids; FAST shows free intraperitoneal fluid. Most appropriate next step?
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USMLE Step 2 Quiz
Practice Postoperative Complications in USMLE Step 2 with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.
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POD0 after splenectomy, 28M has persistent tachycardia and hypotension despite 2L fluids; FAST shows free intraperitoneal fluid. Most appropriate next step?
This quiz focuses on Postoperative Complications, giving you a quick way to practice the rules, question types, and explanations that matter most for USMLE Step 2.
Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.
POD0 after splenectomy, 28M has persistent tachycardia and hypotension despite 2L fluids; FAST shows free intraperitoneal fluid. Most appropriate next step?
Explanation: This question tests the ability to identify and manage common postoperative complications in a clinical setting. The concept focuses on recognizing deviation from expected recovery trajectories and applying appropriate management strategies. In this vignette, the patient's symptoms of persistent tachycardia and hypotension post-splenectomy suggest intraabdominal bleeding. The FAST showing free fluid confirms this diagnosis. Choice A is correct because it aligns with the best practice for managing postoperative hemorrhage. Choice D is incorrect because it represents a common misinterpretation of instability as routine. Students often overlook need for re-exploration. Teaching strategies include emphasizing differential diagnosis post-surgery and recognizing early signs of complications. Encourage students to become familiar with common postoperative issues and their management through case studies and clinical rotations.
6 hours after thyroidectomy, 43F has neck swelling, stridor, HR 120, O2 88%; incision tense. Most appropriate initial treatment?
Explanation: This question tests the ability to identify and manage common postoperative complications in a clinical setting. The concept focuses on recognizing deviation from expected recovery trajectories and applying appropriate management strategies. In this vignette, the patient's symptoms of neck swelling, stridor, and hypoxia post-thyroidectomy suggest hematoma. The tense incision confirms this diagnosis. Choice A is correct because it aligns with the best practice for managing airway-compromising hematoma. Choice D is incorrect because it represents a common misinterpretation of swelling as normal. Students often overlook urgency in airway issues. Teaching strategies include emphasizing differential diagnosis post-surgery and recognizing early signs of complications. Encourage students to become familiar with common postoperative issues and their management through case studies and clinical rotations.
POD3 after laparotomy, 62F has tense, violaceous wound edges with severe pain, fever 39.2°C; WBC 22,000; CT shows subcutaneous gas. Next step?
Explanation: This question tests the ability to identify and manage common postoperative complications in a clinical setting. The concept focuses on recognizing deviation from expected recovery trajectories and applying appropriate management strategies. In this vignette, the patient's symptoms of tense violaceous edges, severe pain, and fever post-laparotomy suggest necrotizing fasciitis. The CT showing subcutaneous gas confirms this diagnosis. Choice A is correct because it aligns with the best practice for managing necrotizing infection. Choice B is incorrect because it represents a common misinterpretation of severity. Students often overlook rapid progression. Teaching strategies include emphasizing differential diagnosis post-surgery and recognizing early signs of complications. Encourage students to become familiar with common postoperative issues and their management through case studies and clinical rotations.
A 62-year-old man with poorly controlled diabetes mellitus is on postoperative day 4 following an inguinal hernia repair. He develops a fever of 39.6°C (103.3°F) and complains of severe pain at the incision site that is out of proportion to physical exam findings. The skin surrounding the incision has a dusky, violaceous hue, and palpation reveals subcutaneous gas (crepitus).
Which of the following is the most critical next step in management?
Explanation: The combination of severe pain out of proportion to exam, fever, dusky skin changes, and crepitus is pathognomonic for necrotizing soft tissue infection (necrotizing fasciitis). This is a surgical emergency with high mortality. While antibiotics and fluid resuscitation are crucial, the definitive and most critical intervention is immediate and aggressive surgical debridement of all necrotic tissue. Delaying surgery for imaging can be fatal.
A 62-year-old man is on postoperative day 5 after a low anterior resection for rectal cancer. He develops a fever of 38.8°C (101.8°F), tachycardia to 125/min, and diffuse abdominal pain with rebound tenderness. His previously placed surgical drain, which had been producing minimal serosanguinous fluid, now contains 200 mL of cloudy, brown, foul-smelling fluid.
This clinical presentation is most consistent with which of the following complications?
Explanation: The constellation of systemic inflammatory response (fever, tachycardia), peritonitis (diffuse pain, rebound), and the change in drain output to feculent material is pathognomonic for an anastomotic leak after colorectal surgery. This is a life-threatening complication requiring urgent intervention. While this can lead to an abscess (D), the primary event is the leak itself.
A 68-year-old man is on postoperative day 5 after a total hip replacement. He complains of a dull ache and swelling in his right calf. On examination, his right calf is 3 cm larger in circumference than the left, is erythematous, warm, and tender to palpation. He has been receiving prophylactic enoxaparin.
Which of the following is the most appropriate next step in diagnosis?
Explanation: The patient's signs and symptoms (unilateral leg swelling, pain, erythema) after major orthopedic surgery are highly suspicious for a deep vein thrombosis (DVT). Compression ultrasonography is the first-line, non-invasive imaging modality to confirm the diagnosis. A D-dimer assay is not useful in this setting because the patient's pre-test probability is high, and it will likely be elevated from the recent surgery regardless.
A 45-year-old woman is in the post-anesthesia care unit 2 hours after a total thyroidectomy. A nurse calls you to the bedside because the patient is agitated and complaining of difficulty breathing. On examination, there is a tense, firm swelling in the anterior neck. Stridor is audible. Her oxygen saturation is 92%.
What is the most appropriate immediate step in management?
Explanation: This patient has an expanding neck hematoma causing acute airway compromise, a life-threatening emergency. The hematoma must be evacuated immediately to relieve pressure on the trachea. The most appropriate and time-sensitive intervention is to open the surgical staples or sutures at the bedside to allow the hematoma to decompress. This should be done even before attempting formal intubation, as the external compression may make intubation impossible.
A 72-year-old man with benign prostatic hyperplasia is on postoperative day 1 after a knee replacement. He has received patient-controlled analgesia with morphine. He complains of lower abdominal fullness and has been intermittently agitated. The nurse notes he has not voided since surgery 10 hours ago. On examination, there is a palpable, tender mass in the suprapubic area.
Which of the following factors is the most likely contributor to this patient's postoperative complication?
Explanation: The patient has acute urinary retention. Multiple factors contribute, but in this case, the use of opioids is a major precipitant. Opioids decrease the sensation of bladder fullness and inhibit the detrusor muscle's contractility, leading to retention. This effect is compounded by his underlying BPH and the effects of anesthesia. The other options are less likely to be the primary cause of urinary retention.
A 50-year-old woman is seen in the clinic on postoperative day 10 after an open hysterectomy. She is concerned because a 3-cm portion of her abdominal incision has separated. On examination, there is separation of the skin and subcutaneous layers only. The underlying fascia is visualized at the base of the wound and appears intact. There is no erythema, purulence, or evisceration.
Which of the following is the most appropriate management?
Explanation: This patient has a superficial wound dehiscence, where only the skin and subcutaneous layers have separated, but the fascia remains intact. This is not a surgical emergency. The appropriate management is conservative, involving local wound care. The wound should be gently cleansed and packed with moist gauze, allowing it to heal by secondary intention. Antibiotics are not needed in the absence of infection.
A 74-year-old woman is on postoperative day 3 following a total hip arthroplasty. She develops a fever of 38.9°C (102.0°F) and new-onset confusion. Her indwelling urinary catheter was removed on postoperative day 2. Her surgical incision appears clean with no erythema or drainage. Lung examination is clear. She has no calf tenderness.
Which of the following is the most likely cause of her fever?
Explanation: The timing of the fever (postoperative day 3), recent history of an indwelling catheter, and new-onset confusion in an elderly patient are highly suggestive of a catheter-associated urinary tract infection (CAUTI). While atelectasis is common earlier, it typically occurs on POD 1-2. Surgical site infections usually present later (POD 5-7). Deep vein thrombosis is less likely to cause a high fever as the primary presenting sign.
A 68-year-old obese woman with type 2 diabetes is on postoperative day 7 from an exploratory laparotomy. While coughing, she feels a 'popping' sensation in her abdomen, followed by a large gush of pink, serosanguinous fluid from her midline incision. Examination reveals loops of omentum and small bowel protruding through the fascial defect.
Which of the following is the most appropriate immediate action?
Explanation: This patient has fascial dehiscence with evisceration, a surgical emergency. The immediate priority is to protect the exposed viscera from desiccation and contamination. This is best accomplished by covering the area with sterile gauze soaked in warm saline. The patient should then be prepared for emergent return to the operating room for repair. Manual reduction should not be attempted as it can cause further injury.
A 68-year-old man is on postoperative day 1 following an open cholecystectomy for symptomatic cholelithiasis. He reports mild incisional pain, which is controlled with medication. His temperature is 38.4°C (101.1°F), heart rate is 95/min, blood pressure is 130/80 mmHg, and respiratory rate is 20/min. Oxygen saturation is 94% on ambient air. On physical examination, breath sounds are diminished at both lung bases. The surgical incision is clean, dry, and intact.
Which of the following is the most appropriate next step in management?
Explanation: This patient's presentation of low-grade fever, diminished breath sounds, and mild hypoxemia on postoperative day 1 is classic for atelectasis. This is the most common cause of fever in the first 24-48 hours after surgery, resulting from shallow breathing due to pain, leading to alveolar collapse. The most appropriate management is to improve lung expansion through measures like incentive spirometry, deep breathing exercises, coughing, and early ambulation.
A 55-year-old man with type 2 diabetes mellitus is evaluated on postoperative day 6 after an exploratory laparotomy. He has a persistent fever of 39.1°C (102.4°F) despite two days of broad-spectrum antibiotics. His midline abdominal incision is erythematous, warm, exquisitely tender, and has a small amount of purulent drainage from between two staples.
Which of the following is the most appropriate initial step in managing his wound?
Explanation: This patient has a clear surgical site infection (SSI). The cornerstone of managing an SSI with abscess or purulent collection is source control. This involves opening the incision, draining the purulent material, debriding any necrotic tissue, and packing the wound open to allow it to heal by secondary intention. Antibiotics are adjunctive therapy, and imaging is not necessary with a clinically obvious superficial collection.
A 65-year-old woman is on postoperative day 7 following a total knee arthroplasty. She suddenly develops sharp, pleuritic right-sided chest pain and shortness of breath. Her heart rate is 120/min, respiratory rate is 28/min, blood pressure is 110/70 mmHg, and oxygen saturation is 90% on room air. Her surgical incision is clean and her lungs are clear to auscultation.
Which of the following is the most likely diagnosis?
Explanation: The patient's presentation of acute-onset pleuritic chest pain, dyspnea, tachycardia, and hypoxemia approximately one week after major orthopedic surgery is classic for a pulmonary embolism (PE). Major surgery, particularly orthopedic surgery of the lower extremities, is a major risk factor for deep vein thrombosis and subsequent PE.
An 82-year-old woman is evaluated on postoperative day 2 following a hip hemiarthroplasty. She is disoriented, agitated, and is attempting to pull out her IV lines. Her medical history is significant for mild cognitive impairment. Her vital signs are stable, and her surgical wound is clean. Laboratory studies, including electrolytes and a complete blood count, are within normal limits. Her oxygen saturation is 97% on room air.
Which of the following is the most appropriate initial intervention?
Explanation: This patient is experiencing postoperative delirium, a common complication in elderly surgical patients. After ruling out and addressing underlying medical causes (like hypoxia, infection, or metabolic disturbances), the first-line management is nonpharmacologic. This includes strategies like frequent reorientation, ensuring the patient has their glasses and hearing aids, maintaining a normal sleep-wake cycle, and encouraging family presence. Pharmacologic agents and restraints are reserved for cases where the patient is a danger to themselves or others and nonpharmacologic measures have failed.
A 50-year-old man is on postoperative day 2 after an open sigmoid colectomy. He has not passed flatus and reports mild abdominal bloating. His abdomen is soft and non-tender with hypoactive bowel sounds. He has no nausea or vomiting. Vital signs are stable.
Which of the following is the most appropriate management at this time?
Explanation: This clinical picture is consistent with a normal, physiologic postoperative ileus, which is expected after abdominal surgery. Bowel function typically returns within 2-3 days for the small intestine and 3-5 days for the colon. Management is supportive, including bowel rest (advancing diet as tolerated), intravenous fluids, electrolyte correction, and early ambulation to stimulate gut motility. More aggressive interventions are not indicated unless the ileus becomes prolonged or there are signs of a mechanical obstruction.
A 60-year-old man is 8 hours postoperative from an inguinal hernia repair performed under spinal anesthesia. He reports severe suprapubic pain and an intense urge to urinate, but he is unable to void. His abdomen is tender and distended in the suprapubic region.
Which of the following is the most appropriate next step to confirm the diagnosis?
Explanation: This patient's symptoms are highly suggestive of acute postoperative urinary retention (POUR), a common complication, especially after spinal anesthesia and in older men. The most appropriate next step is to confirm the diagnosis by measuring the bladder volume. A portable bladder ultrasound is a quick, non-invasive way to do this. A volume greater than 300-500 mL confirms the diagnosis and indicates the need for decompression with a catheter.
A 75-year-old man with a history of coronary artery disease is on postoperative day 2 following a right hemicolectomy. He is found to have a new-onset atrial fibrillation with a heart rate of 140/min and blood pressure of 88/50 mmHg. He does not complain of chest pain. An ECG shows ST-segment depressions in the lateral leads. Troponin level is elevated.
This patient's presentation is most concerning for which postoperative complication?
Explanation: Perioperative myocardial infarction (MI) often presents atypically without classic chest pain. Instead, patients may present with arrhythmia (like new-onset atrial fibrillation), hypotension, confusion, or dyspnea. The combination of hemodynamic instability, ECG changes (ST depressions), and an elevated troponin in a high-risk patient undergoing major surgery is highly suggestive of a postoperative MI.
A 58-year-old woman with a long history of Crohn disease maintained on 15 mg of prednisone daily undergoes an ileocecectomy. On postoperative day 2, she develops hypotension (80/45 mmHg) that is refractory to multiple intravenous fluid boluses. She is tachycardic and febrile. Laboratory studies show a sodium level of 128 mEq/L and a potassium level of 5.6 mEq/L.
Which of the following is the most likely cause of her condition?
Explanation: This patient is at high risk for adrenal suppression due to chronic glucocorticoid use. The stress of major surgery can precipitate an acute adrenal crisis. The classic presentation is refractory hypotension, fever, hyponatremia, and hyperkalemia. While sepsis is a consideration, the specific electrolyte abnormalities in a chronic steroid user strongly point towards acute adrenal insufficiency.
A 48-year-old man is on postoperative day 9 after a sigmoid colectomy for perforated diverticulitis. He was discharged but returns with a 3-day history of malaise, anorexia, and a persistent fever of 38.5°C (101.3°F). His abdominal pain is diffuse and poorly localized. His surgical incision appears clean. His white blood cell count is 16,000/mm³.
Which of the following is the most appropriate diagnostic test to perform next?
Explanation: The patient's delayed presentation of fever, leukocytosis, and vague abdominal pain after major abdominal surgery is highly concerning for a deep-space infection, such as an intra-abdominal or pelvic abscess, or a contained anastomotic leak. A CT scan of the abdomen and pelvis with both oral and intravenous contrast is the imaging modality of choice to identify and localize such a collection, which can then guide further management (e.g., percutaneous drainage vs. reoperation).