COVID-19 or NOT?
A 75-year old man with a history of hypertension, hemorrhagic cerebral infarction one year before, right-sided hemiparesis, and atrial fibrillation was brought to my hospital because of suspicious COVID-19 infection. He was seen in the ER because of a few days of dyspnea which became progressed and bad clinical condition. 7 days before the current presentation patient fell from its bed, and after that, he started to feel pain in his right part of the chest. He also noticed purple discoloration of his feet and left hand, which was painful and progressed further during the next days. He started to have DYSPNOEA, which also progressed. CBC: showed leukocytosis (26,9) and chest X-ray was described as bilateral pneumonia. On exam, the patient was alert, disoriented in time, immobile on the bed, with an obvious right hemiparesis, afebrile, tachypneic (R: 24/min), and bradycardic (P: 55/min), hypoxic (SpO2: 80%), with normal blood pressure. PHYSICAL EXAMINATION: showed dusky purple discoloration of both feet and fingers of the left hand. The patient's right feet showed some darker areas, which could be hematomas. CHEST EXAMINATION: showed the painful right side & we spotted the fracture of the 7th rib. Auscultation of lungs revealed bilateral inspiratory crackles, predominantly on the right side. The heart rhythm was regularly-regular. The rest of the examination was unremarkable. LAB ANALYSIS: revealed elevated urea (11,1) and creatinine (371), hypoalbuminemia (22), elevated LDH (705), and slightly elevated CK (201). The CRP was elevated (272,5), and coagulation panel was highly abnormal - aPTT 85,1s, PT 15%, INR >6,0, fibrinogen 2,4, and D-dimer 162 (normal <0,5). My (differential) diagnosis list for this patient was: - Fat embolism - Warfarin overdose - Bilateral pneumonia - Sepsis He didn't have any criteria for COVID-19, and also, its clinical presentation and disease course was not consistent with COVID-19 infection. The patient was transferred to ICU for further treatment. What do you say on this? I am mostly inclined to fat embolism in the first place, which was complicated, but I do not have experience with this diagnosis. What is your opinion on this case, what would be your further diagnostics and treatment?
Hemiplegic pt with multiple comorbidies on anticoagulants Xray chest do shows GGO bilateral suggestive of pneumonitis There is #ribs Leucocytosis suggest septicemia All probabilities septicemia causing thromboembolic phenomenon with consequent complications Unlikely covid19
A nicely presented case . Your D/D is justified in fat embolism, warfarin overdose, bilateral pneumonia, sepsis, Another addition in D/D could be PULMONARY EMBOLISM Points in favour of pulmonary embolism are 1.Atrial fibrillation 2.Dyspnoea and SPO2- 80 % 3.There may be associated DVT in this case . 4 patient in uraemia,. 5.D - Dimer 162 - significantly raised goes in favour of pulmonary embolism. A CT pulmonary angiography is needed to confirm the Diagnosis.
No stigmata to suggest COVID 19. Blood picture is in favour of septicemia.How much is the BP. Is he in septic shock. No leukopenia or lymphopenia to suggest COVID.Leg picture is suggestive of ischemia both feet left more than rt.There is no long bone fracture to suggest fat embolism.Coagulation factors abnormal with high CRP with significantly deranged RFT, all pointing to septicemia probably with septic shock. elevated INR probably due to warf induced. Needs cardiac evaluation Nephrology opinion broad spectrum antibiotics with FFP. INR is high ,well anticoagulated and unlikly to get AF induced ischemic lesion.Still septic embolism is possible. Septicemia with multi organ involvement can explain most of the lesions including lung lesion
Very nice case presentation Though in today's scenario every critical patient need to be considered as COVID 19 unless proved otherwise COVID 19 need to be kept as top differential diagnosis This patient has few factor which goes against diagnosis of COVID 19 1) No history of fever 2) Leukocytosis - COVID 19 typically has normal WBC count 3) Multiple comorbidities suggest possibilities of many other differential diagnosis - such as warfarin causing raised INR, pneumonia etc
COVID 19 tests must be considered. Investigation and evaluation to conclude as per your DD . Fat embolism and pneumonia Needs regular evaluation and constant monitoring required because pt is suffering from multiple comorbidities your inclination is may be more suited to the condition of the pt.
CONTACT HISTORY OF THE PATIENT, I MEAN WHO WAS TAKING CARE OF THE PATIENT WHEN HE WAS BEDRIDDEN... SHOULD BE TAKEN INTO DETAIL, PATIENT. IS IMMUNOCOMPROMISED AND ALLREADY BED RIDDEN, SEPTICAEMIA, LEUCOCYTOSIS, KIDNEY FAILURE, EVEN FAT METABOLISM POINTS TOWARDS COVID 19 INFECTION.. CONTACTS OF THE PATIENT SHOULD BE QUARENTINED....
Sepsis followed by DIC and fat embolism duo to rib fracture Leads to septic shock Cardiac ishchemia with carcinogenic shock
This is septicaemia with bilateral pneumonia. DD:- atypical pneumonia’s- Legionerre’s or Swine- flue( Influenza).
In this case of an oldman with fracture in 7th Rt rib , leukocytosis, uremia and hypoxia it is quiet possibility of sepsis, although I also consider all points of DD shown by you
Known case of atrial fibrillation Known case of CVA History of dyspnoea One possibility is thromboembolism affecting lungs and limbs Angiogram may help
Cases that would interest you
- Login to View the image
23yrs/M presented to ED with a Generalized painful skin rash over upper and lower extremities for the past 3 days and SOB × 2days and decreased urine output.She developed fever and cough one week prior to developing these rashes for which she took Azithromycin + PCM ,5 hours after taken medicine she developed rashes,The rash progressed over 3 days and get worsen.Patient COVID RAPID ANTIGEN POSITIVE.DIAGNOSIS AND MANAGEMENT PLAN? *Chief Complaints* SOB,FEVER *Vitals* BP - 100/60,Spo2 -82%,RR -25 *Physical Examination* Chest - B/l Crackles *Investigations* Hb -10,WBC -20000,Urea -125,Creat -2.4
Dr. Prashant Vedwan9 Likes17 Answers - Login to View the image
40yrs/F presented to ED with C/o Severe Respiratory distress and altered mental status.Patient started noticing symptoms 5 days after operated for hysterectomy (Uterine fibroid) at some other hospital.Emergently intubated after acute respiratory failure,patient had to be deeply sedated and paralysed. O/e - Crackles and wheezes,BP -140/80,PR -72,Spo2 -98,Temp -103°F. DIAGNOSIS AND SUGGEST MANAGEMENT PLAN?
Dr. Prashant Vedwan6 Likes26 Answers - Login to View the image
34yrs/M admitted with C/o Generalized bodyaches,3 day history of on and off fever which is temporarily relieved by paracetamol,Hypogastric pain,He also experienced nausea and vomitting with loss of appetite.NO PETECHIAE OR RASES present over body.He was tested negative for COVID 19 but positive for dengue.On day 2 admission patient developed dry cough and mild difficulty in breathing. NEED SUGGESTIONS? *Chief Complaints* Fever,bodyaches,NV, Abdomen pain *History* No relevant medical history *Vitals* BP - 120/80,HR -110,Temp -99°F,Spo2 -98% without O2 support,RR - 18 *Investigations* COVID - RT PCR - NEGATIVE DENGUE IGg - Positive Platelet counts -4000,Hb -12,TLC -12000 HRCT chest enclosed
Dr. Prashant Vedwan5 Likes19 Answers - Login to View the image
COVID-19?? 68 year old male with no significant past medical history or surgical history. Presented with shortness of breath, and chest pain. In the emergency department, the patient has a saturation of 79% on room air and is in Moderat respiratory distress. It requires 10 L of nasal oxygen high flow to obtain 93% oxygen saturation. The patient is also febrile to 101°F. Social history: non-smoker, non-drinker. Surgical history: no surgical history. What do you say about the case?
Dr. Shekhar Verma6 Likes41 Answers - Login to View the image
History of present illness Female, 38 years old, presenting for evaluation of Continuous fever. Onset of symptoms was 1 Weeks ago. Patient describes Continuous fever as Clinical course Acute , Clinical course Recurrent , Symptom lasts weeks . Patient has associated symptoms of Chest pain ( Mild to moderate , Radiating to Back , Posterior chest wall , Preceded by Cough , Duration 1 Weeks, Clinical course Acute ). Patient denies: Chest discomfort, Malaise, Retrosternal pain Past medical history: With no pre-existing medical history. Medications: None Family history: No pertinent family history Habits: None Physical Examination Vital signs:pulse rate 126bpm, Normal Respiratory rate, Low Systolic BP, Low Diastolic BP, Low SpO2%96, Normal Body temperature 103 Cardiovascular: No Postural drop in blood pressure, Thready pulse Respiratory: None Gastrointestinal: None Neurological: None Musculoskeletal: None Skin: None Genitourinary: None HEENT: None Other: Cold extremities, No Hypoxemia Laboratory tests CBC - Low Hemoglobin , High Leukocytes 27000 Assessment and Plan Patient presenting for evaluation of Continuous fever, Patient has associated symptoms of Chest pain ( Mild to moderate , Radiating to Back , Posterior chest wall , Preceded by Cough , Duration 1 Weeks, Clinical course Acute ). Vital signs revealed High Heart rate, Normal Respiratory rate, Low Systolic BP, Low Diastolic BP, Low SpO2% 96, Normal Body temperature. Physical examination is normal except for: Cold extremities, Thready pulse. Laboratory test performed: CBC - Low Hemoglobin 7.8 , High Leukocytes *Investigations* Chest xray shows left plueral effusion Ecg wnl
Dr. Arun Sirohi3 Likes15 Answers
20 Likes