Question

A patient developed breathlessness and chest pain on the second postoperative day after a total hip replacement. Echocardiography showed right ventricular dilatation and tricuspid regurgitation. What is the most likely diagnosis?

• A. Acute MI
• B. Pulmonary embolism
• C. Hypotensive shock
• D. Cardiac tamponade

Hint:

Day two after hip surgery with a sudden dilated right heart points to a clot in the lungs.

Answer 1

The Correct Option is B

Step 1: Identify the setting. A total hip replacement is a major orthopaedic surgery with prolonged immobilisation, lower limb venous stasis and a hypercoagulable postoperative state. This is one of the highest risk procedures for deep vein thrombosis and pulmonary embolism (PE).

Step 2: Note the timing. Sudden breathlessness and chest pain on the second postoperative day fit the classic window for a clot dislodging from a deep leg vein and travelling to the pulmonary arteries.

Step 3: Use the echo finding. A large or submassive PE acutely raises pulmonary artery pressure. The right ventricle suddenly pumps against a high afterload, so it dilates (acute cor pulmonale) and the tricuspid valve annulus stretches, producing tricuspid regurgitation. Right ventricular dilatation with tricuspid regurgitation is the echocardiographic signature of acute pressure overload from PE.

Step 4: Exclude the distractors. Acute MI typically shows regional left ventricular wall motion abnormality, not isolated right ventricular dilatation. Hypotensive shock is a haemodynamic state, not an echo diagnosis, and would not selectively dilate the right ventricle. Cardiac tamponade shows pericardial effusion with diastolic collapse of the right chambers and a small, compressed right ventricle, the opposite of dilatation.

Step 5: The postoperative timing, the surgery type and the right heart strain pattern all converge on PE. The answer is Pulmonary embolism (option B).