Lesson 2: Case Study COVID-19
- Allergies:
- Wt. 75 kg
- Ht. 165 cm
- Ethnicity: African-American
- Race: Aferican-American
- Sex: Female
- Gender: Female
Emma Jones is a 60-year-old African-American Female presenting to the
ED with SOB, non-productive cough x2 weeks; she was unable to get out
of bed this morning and states that her entire body hurts. She reports
that she is unable to eat because she keeps coughing. She was brought
into the ED by her husband, who speaks for her. Emma works at an assisted living facility that has three COVID-19-positive cases.
Her husband states that she has been out of work for the past 2 weeks
and had a COVID-19-positive home test. Emma is involved in the local
Church and volunteers once a week at the soup kitchen for the homeless.
- DM II
- Depression
- GERD
- HTN
- Smoker 2 PPD for the past 30 years
- Vaccinated with the Johnson and Johnson COVID-19 vaccination 8-15-21 Buster with Pfizer 3-12-22
- Metoprolol
- Simvastatin
- Fluoxetine
- Cimetidine
- Glucophage
- Temp: 102.6 F / 39.22 C
- HR: 120
- RR: 24
- BP: 120/58
- SaO2: 98% on RA
- CBG: 155
- Pain Assessment:
- Provoking Breathing
- Quality: Achy
- Region: around chest
- Severity: 5/10
- Timing: Every deep breath
- General Appearance: Restless, anxiety, and fatigued
- HEENT: PERRLA, mucus membranes tacky, tongue sticking to roof of mouth.
- Neuro: Alert and Oriented to person, place, time and situation. Is using gestures to avoid speaking. Generalized weakness in all extremities.
- Respiratory: Expiratory wheezing, fine crackles over all fields. Accessory muscles being used for breathing.
- Cardiac: No edema, S1S2 present normal rhythm. Pulses thready, tenting present over chest.
- GI: Hyperactive bowel sounds in all quadrants, slight tenderness with light palpation, nausea
- Integumentary: Skin hot, dry and indicted. Mucus membranes pink and tacky dry. Tenting over chest noted.
- Contact-Airborne-Droplet precautions
- Influenza swab
- COVID-19 swab
- Chest x-ray
- Complete blood count (CBC)
- Metabolic panel
- ABG
- Lactate
- Nasal cannula titrate to keep O2 sat >92%
- Peripheral IV access X2
- LR 20 mg/kg bolus Now
- CBC
- WBC: 7.79/mm3
- RBC: 6.01
- Hb: 15.6 g/dL
- HCT: 50
- Neu: 1500 cells/ml
- Lym: 4000 cells/ml
- Mon: 1000 cells/ml
- Eos: 55 cells/ml
- Bas: 160 Cells/ml
- MCV: 80 femtolitres
- Platlet: 180,000/ml
- Bands: 2
- ABG
- PH 7.34
- HCO3: 20 mmol/L
- PCO2: 30 mm Hg
- PO2: 62 mm Hg
