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.
A case of ITP DD sepsis with DIC.as scenario going on test throat swab for RT_pcr for covid 19.CVA might be due to thromboembolism
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).
Purpura both feet with Echymotic patches Nails cynosed Most likely warfarin over does leading to DIC
Please rule out covid-19... I don't think it is anyway...I would like to stick with your DDs..
Cases that would interest you
- 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 Ved6 Likes23 Answers - Login to View the image
*Chief complaint* A 64 year old female complained of swelling in her right foot and leg along with numbness of the foot. She is not able to move her leg. This complaint only for 2 days. *History* Past surgical history include c section 32 years back. Family history include CVA in father. *Investigations* NA-124 k-4.2 Cl-91 CO2-21 BUN-14 Creatinine-0.5 Glucose-102 WBC-19.9 PLT-649 *Diagnosis* What is your opinion?
Kunal Shah2 Likes16 Answers - Login to View the image
what is this and what are the other features related to this?
Vishnupriya Anandharaman4 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 Ved4 Likes16 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 Verma5 Likes33 Answers
16 Likes