ECG shows tachycardia with a right bundle-branch block and minor ST-segment changes. What is the most likely diagnosis?

An obese 50-year-old woman suddenly develops dyspnoea and hypotension 2 days after undergoing a total abdominal hysterectomy. There is mild jugular venous distension with prominent A waves. The lung fields are clear. ECG shows tachycardia with a right bundle-branch block and minor ST-segment changes.
What is the most likely diagnosis?

  • Acute myocardial infarction
  • Pulmonary embolism
  • Aspiration pneumonia
  • Aortic dissection
  • Pneumothorax

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Pulmonary embolism presents with a raised jugular venous pressure (JVP) and right bundle-branch block due to acute right heart failure. Hypotension in an acute MI would cause gross ST-segment abnormalities on ECG. Clear lung fields on auscultation preclude a diagnosis of pneumonia. Aortic dissection would cause an MI or aortic regurgitation before causing respiratory distress.