Correct!
2. Continue supportive care
The patient’s symptoms are completely consistent with COVID-19 infection. Apparent clinical worsening with progression of radiographic abnormalities during the second week of COVID infection has been noted, with patients who improve subsequently showing such improvement 3-4 weeks following the diagnosis of COVID-19 infection; this patient is exactly within the time window when clinical and radiographic worsening may be seen. He again has no risk factors for pulmonary embolism, and his D-dimer level is actually lower than presentation, and therefore investigation for suspected acute pulmonary embolism is probably unnecessary. While the patient’s substernal chest pain should raise the possibility of cardiac disease, including ischemic heart disease and myocarditis, the patient’s ECG is normal and unchanged, and his troponin levels are within the normal range, making these diagnoses unlikely. The patient’s substernal chest pain is a common phenomenon in the setting of repeated coughing and may be explainable on that basis. Finally, cardiac MRI would potentially expose transportation staff and technologists to COVID-19 infection, and should be undertaken only if absolutely necessary. Bronchoscopy is not indicated as the patient has an established infection that explains his complaints and imaging findings, and performing bronchoscopy is unlikely to provide management-altering information despite needlessly exposing staff to COVID-19 infection.
The patient underwent CT pulmonary angiography (Figure 5).
Figure 5. A-F: Representative images in lung windows from the CT pulmonary angiography. Left: video of CT pulmonary angiography in lung windows.
Regarding the CT pulmonary angiogram (Figure 5), which of the following statements is most accurate? (Click on the correct answer to be directed to the twelth and final page)