What is the cause of post-operative pain and hardening around the surgical site in a 76-year-old male following thrombectomy for Pulmonary Embolism (PE) removal?

From the Guidelines

The patient's primary issue is inadequate pain management, and I recommend resuming scheduled acetaminophen 650mg every 6 hours for 3-5 days, then as needed, as suggested by the guidelines for postoperative pain management 1. The 76-year-old male patient is experiencing normal post-thrombectomy pain with some localized induration at the surgical site, but without signs of infection. The chest x-ray finding of an ill-defined density in the right lung with volume loss is concerning for possible right lower lobe pneumonia, which may explain his reported cough with mucus. For pain management, the guidelines suggest that postoperative pain must be recognized and treated as soon as possible and as best as possible in all patients, with a high recommendation and intermediate quality evidence 1. The surgical site appears to be healing normally with expected induration, but should be monitored for any increasing redness, drainage, or worsening pain, as suggested by the guidelines for surgical site infections 1. Regarding the chest findings, I recommend obtaining a CT chest to better characterize the right lung abnormality, as well as checking vital signs including temperature and oxygen saturation. The patient should continue his prescribed Eliquis for anticoagulation post-thrombectomy. Given his age and recent procedure, close follow-up within 3-5 days is warranted to reassess both the surgical site healing and respiratory symptoms. The patient should be educated about warning signs that would necessitate immediate return, including fever, increased pain, drainage from the wound, or worsening respiratory symptoms. Some key points to consider in the patient's management include:

• Postoperative pain assessment, at rest and—if possible—on movement, is strongly recommended, to improve patient management after emergency surgery 1
• Validated pain scales should be included into treatment planning, ongoing evaluation, and adjusting process 1
• Pain management should be adjusted to ensure the greatest effect and the lowest side effects possible 1
• The patient's surgical site infection risk should be monitored, and any signs of infection, such as fever, redness, or drainage, should be promptly addressed 1

From the Research

Patient Assessment

• The patient is a 76-year-old male presenting with post-operative pain after a thrombectomy for pulmonary embolism (PE) removal.
• He has a surgical wound of about 0.5cm on the left groin and reports pain when walking, with hardening on the incision site.
• The patient denies fever, chills, shortness of breath, nausea, vomiting, and dizziness, but reports some cough with mucus since the procedure.
• Physical assessment reveals about 1cm of hardening around the surgical site, with some tenderness but no signs of infection or bleeding.

Laboratory Results

• CBC shows RBC 4.32, hemoglobin 13.1, hematocrit 39.4.
• CMP glucose 128, Chloride 112, otherwise unremarkable.
• The patient is currently on Eliquis.

Chest X-ray Results

• The chest x-ray reads "III-defined density right lung with volume loss in the right hemithorax. Right lower lobe pneumonia cannot be excluded. Correlate with CT chest."

Possible Pneumonia Treatment

• According to the study by 2, ceftriaxone 1g daily is as effective as other antibiotic regimens for community-acquired pneumonia.
• The study by 3 also suggests that 1g once daily of ceftriaxone is as effective as 2g for the common causative organisms of community-acquired and nosocomial pneumonias.
• Additionally, the study by 4 found that ampicillin is associated with comparable clinical outcomes to ceftriaxone for patients hospitalized due to community-acquired pneumonia.
• The study by 5 confirms the efficacy of ceftriaxone in serious and difficult-to-treat community-acquired infections, including pneumonia.
• The study by 6 suggests that ceftriaxone is a useful option in the treatment of aspiration pneumonia, and is not inferior to broad-spectrum antibiotic treatment.

SOAP Note

• Subjective: The patient reports post-operative pain, pain when walking, and hardening on the incision site.
• Objective: The patient has a surgical wound of about 0.5cm on the left groin, with about 1cm of hardening around the surgical site, and some tenderness but no signs of infection or bleeding.
• Assessment: The patient may have pneumonia, as suggested by the chest x-ray results, and may benefit from antibiotic treatment such as ceftriaxone.
• Plan: Further evaluation and treatment will depend on the results of the CT chest and other diagnostic tests. Antibiotic treatment such as ceftriaxone may be considered if pneumonia is confirmed.