A 55-Year-Old Man with a History of Hypertension and Obesity

question 395

Multiple Choice

A 55-year-old man with a history of hypertension and obesity is evaluated in the recovery room for hypoxemia after undergoing a sleeve gastrectomy several hours ago.  Although the endotracheal intubation was difficult, the procedure was completed without intraoperative complications.  The patient was then extubated and transferred to the postanesthesia recovery unit.  He was initially stable on ambient air but soon became hypoxemic.  Despite the use of oxygen by nasal cannula, his condition has not improved.  Other issues include gastroesophageal reflux and generalized anxiety disorder.  The patient's medications include omeprazole, paroxetine, chlorthalidone, and lisinopril.  He drinks 3 or 4 beers on most days but does not use tobacco or illicit drugs.  His last alcoholic drink was the night prior to surgery.  The patient's preoperative testing was significant only for a mildly elevated serum bicarbonate at 30 mEq/L.  Temperature is 37.2 C (99 F) , blood pressure is 140/80 mm Hg, pulse is 108/min, and respirations are 12/min.  The patient's pulse oximetry shows 84% on room air.  BMI is 39 kg/m².  Examination shows an obtunded patient who is minimally responsive to stimuli.  Physical findings include 3-mm reactive pupils, moist mucous membranes, normal jugular venous pressure, coarse breath sounds over the lung fields without stridor or wheezing, and normal S1 and S2.  The abdomen is soft and nontender.  Examination shows no edema.  Laboratory results are as follows: ECG shows sinus tachycardia, and chest x-ray reveals bibasilar atelectasis.  Which of the following is the most likely cause of this patient's clinical deterioration?

• A)Acute heart failure
• B)Acute ischemic stroke
• C)Alcohol withdrawal
• D)Obstructive sleep apnea
• E)Pulmonary embolism

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Billion

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