A 61-year-old woman is evaluated in the cardiovascular intensive care unit for acute-onset… — USMLE Step 2 CK

A $61$ -year-old woman is evaluated in the cardiovascular intensive care unit for acute-onset shortness of breath and lightheadedness. She underwent an open surgical mitral valve replacement $4$ days ago. Her postoperative recovery had been unremarkable until $2$ hours ago. Temperature is $37.6^\circ\text{C}$ ( $99.7^\circ\text{F}$ ), blood pressure is $82/64 \text{ mmHg}$ , pulse is $122\text{/min}$ , and respiratory rate is $24\text{/min}$ . Pulse oximetry shows $94\%$ on room air. On examination, the patient appears anxious and diaphoretic. Jugular venous pulsations are visibly distended while she is sitting upright. The lungs are clear to auscultation bilaterally. Heart sounds are distant, and the point of maximal impulse is difficult to palpate. The surgical incision is clean, dry, and intact. Extremities are cool to the touch with delayed capillary refill. A portable chest radiograph reveals a globally enlarged cardiac silhouette without focal pulmonary infiltrates. Which of the following is the most appropriate next step in management?

Perform bedside transthoracic echocardiographyCevap
B
Administer intravenous furosemide and inhaled bronchodilators
C
Transfer the patient for an urgent contrast-enhanced scan of the thorax
D
Obtain blood cultures and administer broad-spectrum intravenous antibiotics
E
Initiate conservative management with prolonged observation and serial examinations

Cevap

Perform bedside transthoracic echocardiography

The correct action is to perform a bedside transthoracic echocardiogram. This patient is exhibiting the classic features of cardiac tamponade (Beck's triad: hypotension, elevated jugular venous pressure, and muffled heart sounds) just days after an open-heart procedure. Postoperative bleeding or fluid accumulation in the pericardial sac restricts right heart filling, leading to obstructive shock. Bedside echocardiography will definitively show the pericardial fluid and any associated right ventricular diastolic collapse, confirming the diagnosis and guiding emergent drainage.

Adım Adım Çözüm

Analyze the clinical presentation and vital signs.

The patient has severe hypotension (

82/64 \text{ mmHg}

), tachycardia (

122\text{/min}

), and a narrowed pulse pressure (

18 \text{ mmHg}

) on postoperative day

4

following cardiac surgery.

Identifying signs of profound shock in a postoperative patient dictates the urgency and direction of the diagnostic workup.

Evaluate the physical examination findings.

The patient demonstrates jugular venous distention, clear lungs, and muffled heart sounds, which together form Beck's triad.

Beck's triad is the classic clinical hallmark of acute cardiac tamponade, a life-threatening form of obstructive shock.

Determine the most appropriate next management step.

Bedside transthoracic echocardiography is indicated to confirm the presence of a pericardial effusion and evaluate for right ventricular diastolic collapse.

Echocardiography is the gold-standard, non-invasive bedside test to rapidly diagnose cardiac tamponade in an unstable patient before definitive intervention (e.g., pericardiocentesis or surgical re-exploration).

Anahtar Kavram

Cardiac tamponade should be suspected in any postoperative cardiac surgery patient presenting with obstructive shock, jugular venous distention, and distant heart sounds; the next best step is bedside echocardiography.

Soru

Cevap

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Anahtar Kavram

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