What is the best course of action if a metallic object, likely a forgotten surgical instrument, is found on an abdominal x-ray and ultrasound in a middle-aged woman who developed fever and purulent discharge after undergoing pelviabdominal surgery?

Management of a Retained Surgical Foreign Body

The patient should be immediately informed about the finding of a metallic foreign body (option C) as this represents a serious complication requiring prompt intervention to prevent further morbidity and mortality.

Initial Assessment and Management

When a retained surgical foreign body is identified in a patient with fever and purulent wound discharge, this represents a serious post-operative complication that requires immediate attention. The presence of these symptoms strongly suggests an infection related to the foreign body.

Diagnostic Confirmation

1. The abdominal X-ray and ultrasound findings of a metallic object are highly reliable indicators of a retained surgical instrument 1
2. CT scan with IV contrast would be the optimal next imaging study if further characterization is needed before intervention 1
   • CT has superior sensitivity for detecting foreign bodies and associated complications
   • Helps identify the exact location and any related collections or abscesses

Patient Communication

The ethical and medically appropriate first step is to inform the patient about the findings. This is essential for several reasons:

• It allows the patient to make informed decisions about their care
• It establishes trust in the physician-patient relationship
• It acknowledges the patient's right to know about their medical condition
• It enables prompt treatment planning to address a potentially life-threatening condition

Rationale for Immediate Disclosure

1. Medical Priority: The patient has active infection (fever and purulent discharge) with a retained foreign body, which represents an urgent medical condition requiring prompt intervention 1, 2

2. Infection Risk: The presence of fever, tachycardia, and purulent drainage are definitive signs of infection that require immediate attention 2

3. Ethical Obligation: Disclosure of medical findings to patients is a fundamental ethical principle in medicine 3

Management Following Disclosure

After informing the patient about the finding, the next steps should include:

1. Surgical Consultation: Immediate surgical evaluation for removal of the foreign body
2. Antibiotic Therapy: Empiric antimicrobial therapy should be initiated due to the evident infection 1
3. Surgical Planning: Removal of the foreign body should be performed as soon as possible to prevent further complications

Why Other Options Are Not Appropriate

• Option A (Call and inform the first surgeon): While professional courtesy may suggest informing the original surgeon, the patient's welfare takes precedence, and delaying patient notification could worsen outcomes 3

• Option B (Call attorney and ask about legal action): Legal considerations should not delay proper medical care and patient notification 3

• Option D (Tell her it's a possible complication): This is misleading and unethical. A retained surgical instrument is not considered an acceptable complication but rather a preventable adverse event 3

Potential Complications of Retained Surgical Items

• Persistent infection and abscess formation
• Sepsis and systemic inflammatory response
• Intestinal obstruction or perforation
• Fistula formation
• Chronic pain
• Delayed wound healing

In conclusion, immediate disclosure to the patient followed by prompt surgical intervention represents the most appropriate course of action to minimize morbidity and mortality in this scenario.