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The patient is a 61-year-old woman with medical history significant for hypertension, type 2 diabetes mellitus, hyperlipidemia, coronary artery disease, chronic kidney disease, and chronic obstructive pulmonary disease who presented to the hospital with complaints of chest pain and shortness of breath. When the patient arrived at the emergency department, she reported that the first symptom she experienced was shortness of breath. Shortness of breath started about 3 days before presentation with progressive worsening. Chest pain started 36 hours ago with gradual increase in intensity. Chest pain was described as left sided, 10/10, dull like, radiating to the epigastric area, and not improved with aspirin. The patient reported pain was worse with exertion. Symptoms were associated with mild dry cough, body aches, and fever. No runny nose, orthopnea, paroxysmal nocturnal dyspnea, palpitations, or lower extremity edema. She also denied abdominal pain, nausea, vomiting, and changes in bowel or bladder habits. The patient’s husband had fever and cough for the last 2 weeks.

On physical exam, the patient seemed acutely ill and was noted to be short of breath. Initial vital signs recorded her to be febrile to 102°F, with a blood pressure of 92/56 mmHg, heart rate 102 beats/min, and respiratory rate 28 breaths/min. She was initially alert and responsive. Rales were heard in the bilateral lung fields. Cardiovascular examination was significant for tachycardia, S1 was normal, S2 was soft, S3 and S4 were heard, and a 2/6 systolic murmur was audible mostly in the aortic area without rub. Minutes after the first medical interaction the patient became pale and lethargic.

Electrocardiogram (ECG) showed sinus tachycardia and nonspecific ST-T changes. Chest X-ray showed cardiomegaly and pulmonary hilum congestion along with peripheral opacities. The blood work results are shown in Table 9-1. White blood cell (WBC) count was decreased and a significant decrease in the lymphocyte percentage was noted. Thrombocytopenia, elevation in C-reactive protein (CRP), troponin, pro-brain natriuretic peptide (BNP), lactic acid, and ferritin were found. Chemistry panel was suggestive of renal failure with mild elevation in the liver function tests. SARS-CoV-2 nasopharyngeal swab was sent.

TABLE 9-1Laboratory Data on Admission

Point-of-care echocardiogram was significant for severely decreased left ventricular contractility along with a mild amount of fluid in the pericardial space. The patient was taken to the ...

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