Concluded Case

A 30yrs/F WITH BREATHLESSNESS AND CHEST PAIN..

30yrs/F G2P2 patient presented with Complaints of Severe breathlessness,Chest pain and cough since 2 days.H/o Post Caesarian delivery 6 days back,also having H/o DVT 3yrs back. She was apparently normal 2 days back,then she developed Moderate chest pain and fever.presented with unstable haemodynamic status.Endotracheal tube insertion was performed for impending respiratory distress. DIAGNOSIS AND SUGGEST MANAGEMENT PLAN? Chief Complaints Severe breathlessness,Chest pain and cough History DVT - 3yrs back Post Caesarian delivery Vitals BP - 120/80,HR - 130,Spo2 - 85%,RR -35,Temp -102°F Physical Examination Chest - B/l Crepts Investigations Hb -11,TLC -17600, Neutrophils -94,Lymphocytes - 04,CPK MB - 29,Trop I -546,D -dimer ->10000,CRP -21,PCT -0.12

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Concluded answer

ECG - shows Sinus tachycardia Diffuse ST - T wave changes AV conduction defects Ventricular arrhythmias S1 Q3 T3 These changes are suggestive of PULMONARY EMBOLISM and MYOCARDITIS. Chest X- Ray - shows a left liwer lung Opacity- suggestive of viral pneumonia. A Significantly decreased sPO2 85 % Tachypnea,with RR - 35 Temperature- 102 -F . D- Dimer - more than 10000 - Significantly raised Significant lymphopenia, All are features suggestive of Pulmonary embolism- post DVT with COVID-19 disease with viral pneumonia with viral myocarditis. May be it is a case of hospital aquired COVID-19 disease. Management plan A Pulmonary angiography to confirm embolism- LMWH . Mechanical ventilation Inj Dexamethasone 6 mg daily Parenteral antibiotics- 3rd generation cephalosporins. Inj Remdesivir as oer the protocol Supportive care

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ECG - shows Sinus tachycardia Diffuse ST - T wave changes AV conduction defects Ventricular arrhythmias S1 Q3 T3 These changes are suggestive of PULMONARY EMBOLISM and MYOCARDITIS. Chest X- Ray - shows a left liwer lung Opacity- suggestive of viral pneumonia. A Significantly decreased sPO2 85 % Tachypnea,with RR - 35 Temperature- 102 -F . D- Dimer - more than 10000 - Significantly raised Significant lymphopenia, All are features suggestive of Pulmonary embolism- post DVT with COVID-19 disease with viral pneumonia with viral myocarditis. May be it is a case of hospital aquired COVID-19 disease. Management plan A Pulmonary angiography to confirm embolism- LMWH . Mechanical ventilation Inj Dexamethasone 6 mg daily Parenteral antibiotics- 3rd generation cephalosporins. Inj Remdesivir as oer the protocol Supportive care

Valuable opinion
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Ground glass opacity is seen in Lt lower lung along with raired crp ddimer troponin1 all are in favour of covid19 adv Maintain oxygen level by high flow oxygen,iv fluids to maintain hydration, iv antibiotic ,ing enoxaparim LMWH 0.4 mg bd, ind remdesevir 200 mg 1st day then 100 mg od for 5 days ,ing dexona 8 mg tds tab Becomplex ,zinc, vit c, vit d, now it has prooved that tocilizumab has no role.ing methylene blue is having good results but not recognised by who or icmr

Pulmonary embolism
1

Very intriguing case. She has both cardiopulmonary issues. Cardiomeagaly with pneumonitic patch Lt base.cardiac enzymes raised so also d dimer pl get urgent 2d echo done .we can have an idea of pulmonary artery status and atreal & ventricular overload.pl put her on LMWH Give her diuretics. Covid test is also essential in the present scenario. Best way is to go for pulmonary angiography

Cardiomegaly LVH Occasional scattered calcified opacities seen. ECG occ VPBs S1 t3 q3 sugg of RV strain. Evaluate for acute PAE.

S1Q3T3, Sinus Tachycardia in ECG with h/o DVT, post Caesarian S/O : Pulmonary embolism

Valuable opinion
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Pure case of sarscov2 with cardiomegaly admit in covid ward Do hrct 2 decho RT PCR clia il6 trpo i is positivecardiac damage spo2 low oxygen therapy 5 litre 5 minutes maintain spo2 93 LDH ECG serum creatinine ddimer high in favour of cardiac injury & sarscov2 start lmwh bd follow protocol of sarscov2

Ecg ventricular ectopic with SVT
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Acute LVF with Pulmonary embolism & already explain about poor prognosis of patient Low molecular weight heparin with antibiotics with mechanical ventilator support with volume control mode & repeat PT/PTI INR with D-Dimer test after 24 hours

Congratulations! Your case has been selected as Case of the day and you have been awarded 5 points for sharing the case. Keep posting your interesting cases, Happy Curofying!

Feature suggestive of PE. obesity, CS, pregnancy, female, previous history

Valuable opinion
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Suggestive of myocarditis

Thank you doctor
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