Welcome to this month’s What’s Your Diagnosis Challenge!
But before we begin, check to see if you got the previous case on Evaluation and Management of Hypotensive Patients in the Emergency Department correct.
Case Presentation: A Practice-Based Approach to Emergency Department Evaluation and Management of Patients With Postacute Sequelae after COVID-19 Infection: Long COVID
A 35-year-old woman presents to the ED complaining of palpitations and retrosternal chest pain that is mostly relieved by sitting forward…
- The patient, who works as a paralegal and has been healthy all her life (although she smokes a half-pack of cigarettes daily), reports that her symptoms occasionally prompt anxiety so severe that she has self-treated with recreational marijuana. The palpitations have recurred frequently over the past 3 months, but she dates their initial incidence to a PCR-confirmed diagnosis of COVID-19 about 2 weeks before that.
- Her temperature is 37.8°C; heart rate,122 beats/min; blood pressure, 124/84 mm Hg; and respiratory rate, 24 breaths/min, with shallow breathing. Her ECG shows pronounced sinus arrhythmia.
- The patient reports that her initial COVID infection was treated conservatively as an outpatient but caused 2 weeks’ absence from work. Since then, her more-constant symptoms have been dyspnea with even minimal activity such as climbing 1 flight of stairs. She also complains of cough that is sometimes productive of yellowish sputum, with both tussive chest pain and back pain. The palpitations are worse than usual today and make her feel like she is “having a heart attack, or an aneurysm, or something bad.” This is her first ED visit for these symptoms, but she has visited her primary care provider’s office several times and been encouraged to hydrate and take acetaminophen.
- You consider whether there is anything that can be done to pinpoint a treatable cause of her symptoms—always following a “consider the worst case first” (here, perhaps pulmonary embolism), while also assuaging her anxiety…
Case Conclusion
You conducted the ED evaluation calmly, and after her ECG, chest radiography, and vital signs were checked, you reassured the patient that her chest pain and palpitations did not appear to be caused by acute cardiopulmonary pathology. Her anxiety level dropped visibly, but with each loud noise in the ED, she would hyper-respond and experience palpitations. A careful history revealed that she had experienced periodic anxiety in the past, before her COVID diagnosis, but had never sought care for those symptoms. A single dose of alprazolam 0.25 mg orally had a near-immediate beneficial effect on all of her symptoms.
The patient was reassured again about her overall health and the likelihood that her cardiopulmonary symptoms were likely due to long COVID, and her baseline, previously mild anxiety had been exacerbated by long COVID. The patient was ultimately discharged home with a prescription for 6 additional alprazolam to use as needed for severe anxiety, and with instructions to follow up with her primary care provider this week.
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Last Updated on March 4, 2024
