COVID-19 a Clinical Case.
So, let's bring all of what we've
learned about COVID-19 together,
with a patient's clinical case and help
sort of apply some of the clinical aspects,
intervention aspects and a prediction
for severe disease aspects,
with this one case.
So, as the case will do, it'll examine
some distinguishing features for
infection by SARS-Coronavirus
II and also hopefully help us,
look at and differentiate from
risk for influenza either A or B,
parainfluenza, rhinovirus and even
other super infecting organisms
and then we'll look at risks for progression
and what happens if and when that happens.
So, here's the case 62 year old man,
comes to our clinic complaining
of fever cough and malaise,
for the last three days.
He lives in a part of the world,
which, has ongoing active transmission
of sorrows SARS-Coronavirus II
and he has not been vaccinated yet.
He's triaged one of the examination rooms,
which, is used for possible COVID-19 patients
and is seen by staff appropriately wearing,
full personal protective equipment.
His initial exam in triage,
shows that he's alert,
he does have fever or 38.6 Celsius
or 101.5 degrees Fahrenheit,
his respiratory rate is 22 per
minute, blood pressure 143 over 92,
his heart rate 98 per minute
and his oxygen saturation,
by pulse oximetry is 96%, both at rest
and when he ambulates into the room.
His history, he had tactile
fever, so not measured,
because of course there's no thermometer at home,
but reports feeling as if he had fever,
has a dry non-productive cough,
but no associated chest pain or
shortness of breath so no dyspnea
and he feels tired he has
malaise, with decreased appetite
and feels like he has the flu.
So, again, let's pick out the
salient and important features,
as you see on the list on the right.
So, he's a 62 year old man, he's not vaccinated
and is at risk for COVID-19,
he has low grade fever
and tactile fever complaints,
with mild increases in his
respiratory rate and blood pressure
and as a stage two level, but,
he has normal oxygen saturation.
From his history he does have
complaints of a cough but it's dry,
non-productive, without any chest pain
or shortness of breath associated,
he has the non-specific
malaise and flu-like illness
and that's about where he's at,
so, it's now time to start to add some questions
to try and exclude additional possibilities.
So, he denies rhinorrhea,
chest pain which we knew about,
he also denies palpitations dizziness
and sweating denies any GI complaints,
such as, nausea, emesis,
diarrhea or abdominal pain,
denies any rashes, no dermatologic findings,
so, no hives rash petechiae jaundice,
he denies confusion or
hallucinations and he denies,
any concerns for kidney disease
and has no decreased urine output.
However, he does endorse a
headache which is diffuse 5/10
and dull, so not throbbing,
he does have muscle aches, he
does have joint complaints,
his past medical history,
he has hypertension, which is well
it's controlled with losartan,
which is an angiotensin II receptor antagonist,
we don't know how well controlled it is,
but at least his admission blood
pressure is a little bit elevated,
so, it may not be completely well controlled.
He endorses type 2 non-insulin
dependent diabetes mellitus,
which is, controlled with
diet alone, no medications.
He is a certified public accountant,
married, has two adult children that visit,
that don't wear masks or distance themselves
and keep in mind that they are in a
COVID-19 active environment, right now.
He has not traveled since the start of pandemic,
family history is notable for hypertension,
coronary artery disease diabetes
mellitus and there you go.
So that's his clinical presentation,
so, a whole bunch of non-specifics,
but some important complaints which at least,
have our antenna triggering right now.
Physical examination, his temperature
now is 38.6 Celsius 101.5 Fahrenheit,
his heart rate is noted 98 per minute,
his respiratory rate is 22 per minute
and blood pressure 143 over
92 millimeters mercury.
His head and neck examination is normal,
his chest thankfully is cleared,
his cardiac exam is normal,
with no murmurs, no rubs,
his abdomen soft non-tender,
non-distended, no hepatosplenomegaly
and normal bowel sounds.
Extremities and skin exams are normal
and this neurological exam is non-focal.
So, what about an initial assessment.
Does he have risk factors?
Yes, he does, so he's unvaccinated,
he is in a COVID-19 specific area,
what about his presentation?
There are features of non-specific
presentation, fevers, malaise, myalgias,
his examination is non-specific, so
no red flags or smoking guns, so far.
So, as we're interpreting his presentation,
we need to think then about
the differential diagnosis
and we'll start of course with COVID-19,
since this is a COVID-19 case
I've given it away, sorry.
So, COVID-19 typically will start with a
mild upper respiratory tract infection,
which, would certainly would appear
to be similar to what our patient has.
Influenza, will typically
start with a flu-like illness,
with fevers, myalgias,
polyarthralgia, general malaise,
which, our patient has.
Parainfluenza initially will
start as a flu-like illness
and then then may progress to
a croup like cough in children,
the sort of the barky cough, which,
I think we're all familiar with
and in adults it could simply be, a
dry non-specific non-productive cough,
with some respiratory distress
in a prolonged clinical course.
Our patient, of this case
scenario does have a dry cough,
but he it's too early to
say whether or not he has,
a prolonged respiratory illness
and he certainly so far,
does not appear to have respiratory distress,
other than, breathing a little bit
quickly with a respiratory rate of 22.
The rhinovirus, causes the common cold
and also, other coronaviruses
lest we forget those.
The classic description of a
rhinovirus or common cold is,
three days coming at you, three
days with us, three days leaving.
So, it's a seven to nine day
total illness of malaise,
but not significant malaise and typically
a productive or even a dry cough,
with the common cold, would be very unusual,
as, would be life limiting malaise.
And then of course bacterial pneumonias,
the things we really wish not to miss,
can be caused by typical pathogens such as,
Streptococcus pneumoniae, Haemophilus influenzae,
but also, by atypical agents
such as Mycoplasma pneumoniae,
Legionella and unfortunately,
in many parts of the world,
tuberculosis, Mycobacterium tuberculosis.
So, as we look at our patient,
does he need further evaluation,
I hope we all agree, yes,
especially in the days of a COVID-19 pandemic.
So, we will wish likely to test
him in terms of epidemiology
and more importantly for self-quarantine,
test him for SARS-Coronavirus II,
but as of right now, he likely does not
require any further imaging studies.
And if he is SARS-Coronavirus
II positive or even if not,
he may yet not have demonstrated a positive,
this is somebody that we would strongly
wish to recommend self-quarantine,
the following, the watch wait and see approach.
Importantly and why we're not
getting more excited about him,
is that his peripheral oxygenation
is not below 93% and in fact,
if it were, that would get us
excited for possible severe COVID-19
and a need to do further evaluation.
However, this is something
which can be looked for in a
subsequent or a follow-up visit.
So, as life goes on and the case progresses,
our patient comes back to us two days later,
FYI, his PCR or nucleic acid application test,
was indeed positive for SARS-Coronavirus II,
see I told you it was a COVID-19
case, so that was positive,
but he comes to us two days later
with persistent tactile fevers,
with progressive malaise, myalgias,
his cough is now worse, still
not necessarily productive,
but definitely noticeable and a source of
concern and is keeping him awake at night.
As well, he now has shortness of breath
and has anorexia, he's unable to eat.
On examination, he is now
much more highly febrile,
with a temperature of 39.9 degrees
Celsius or a 103.8 Fahrenheit,
his pulse is elevated at 115 per minute,
he's breathing more quickly at 26 per minute,
blood pressure 88 over 55.
His peripheral oxygenation is now 89 on room air,
his lung exam or chest exam demonstrates
diffuse fine crackles throughout,
with only fair air entry, not good air entry
and he demonstrates evidence
of increased work breathing,
with increased use of accessory muscles,
the rest of his exam is unchanged.
Okay, so, we are likely not
considering additional evaluation
and now, we need to think about what we
might see in the setting of COVID-19,
in the complete blood count,
patients with COVID-19,
may have a completely normal
white blood cell count
or they may demonstrate leukopenia,
a lower white blood cell count
they may also demonstrate,
a significant lymphopenia and
even a relative thrombocytopenia.
Relative meaning, in a patient who's
been sick for more than a couple days,
with an inflammatory process,
you would expect the platelet
count to begin to rise,
if their platelet account instead
is normal or even borderline low,
that would be a relative thrombocytopenia.
Inflammatory markers in COVID-19, typically,
will demonstrate elevated
C-reactive protein, creatine kinase,
ferritin and lactate dehydrogenase, many times,
however only one or two of those are
abnormal and the others may still be normal.
Organ dysfunction, is also prominent or can be,
in moderate to severe COVID-19,
patients may present with abnormalities
on their comprehensive metabolic panel
and cardiac enzymes,
they may have elevated prothrombin
or partial thromboplastin times,
fibrinogen may be elevated,
D-dimer definitely may be elevated,
so, coagulation testing as evidence
of possible impending thrombosis,
many times, is abnormal.
And then an arterial blood gas
can be performed to confirm,
the low peripheral oxygenation by pulse oximetry
and also, to evaluate for
acidosis from the blood pH.
Blood culture, probably important,
if one has concern for about
a bacterial co-infection
or super infection and then
of course, COVID-19 testing,
if it hasn't already been performed,
to confirm the suspected diagnosis.
Those patients in whom we suspect COVID-19
or in whom we've confirmed COVID-19,
who are now more sick, like
our current case patient,
would benefit from having an
to look for dysrhythmias, to look
for abnormalities in cardiac function
and then to potentially predict
the potential of adverse effects
and infection severity.
And then again if one is still
dealing with a diagnostic unknown,
one can consider, serologic
testing for other infections,
primarily viruses, that may contribute
to abnormalities on the organ function,
So, looking for hepatitis B or
hepatitis C and certainly HIV,
might be appropriate.
The chest radiograph, the X-ray always
easy to obtain, perform and interpret,
certainly, a tiny dose of radiation,
when compared to the chest CT
scan, the computed tomography scan,
although the CT scan will be
more specific and sensitive,
for the interpretable lesions seen with COVID-19.
So, going back to our case,
here's our patient's results, his complete
blood count demonstrates leukopenia,
a white blood cell count of
2,700 per cubic millimeter,
he has you know relative lymphopenia,
25% lymphocytes, 5% monocytes,
his haemoglobin haematocrit are normal,
his platelets however, are not
just relatively, but they are low,
85,000 per cubic millimeter.
His C-reactive protein is elevated at
4.7 with normal in this particular assay,
of being less than 3,
his lactate dehydrogenase, also elevated,
at 360 with normal being up to 280.
His organ function demonstrates a slight
increase in his blood urea nitrogen, his BUN,
at 24 and an elevated creatinine of 1.4,
definitely elevated for a 62 year old man.
His transaminases, AST and ALT are both elevated,
at 85 and 79 respectively
with normal being up to 40,
with this assay, although
his total bilirubin is 0.6,
so at least from the bilirubin perspective,
his liver function so far is normal.
He has mildly elevated troponin,
0.5, with normal being up to 0.4,
so, there are the abnormalities
on the evaluation testing
of his organ function so far.
Arterial blood gas, you see the
results here with a pH of 7.47,
the PaO2 of 55, PaCO2 of 32, with a bicarb of 25
and confirming the peripheral oxygenation of 87%.
Blood culture obtained and fast
forwarding 48 hours, is sterile.
Here is his chest radiograph,
infrahilar airspace opacities,
without any blunting of his costovertebral angles,
so, not seeing evidence of a
pulmonary or pleural effusion.
Chest CT scan demonstrates, not
surprisingly, bilateral nodules,
along with, peripheral ground
grass opacities throughout,
again, these two findings would
strongly suggest COVID-19,
if we hadn't already confirmed his
positivity by his prior testing.
There also is some mild
interlobular septal thickening,
which, could be the start of an ARDS,
an acute respiratory distress syndrome,
with inflammatory burst, causing
thickening of his pulmonary parenchyma.
So, we go ahead and test him for
other things just to be safe,
his rapid influenza is negative,
his respiratory viral panel
which detects multiple targets
by molecular diagnostics is negative, excellent,
and a repeat SARS-Coronavirus II,
nucleic acid amplification assay,
typically, again performed by reverse
transcriptase polymerase chain reaction,
so, RT-CPR in his case is positive.
So, that would be at least a diagnosis,
although his differential diagnosis,
could still potentially include
bacterial super infection,
with pneumonia and even potentially influenza,
because the sensitivity of rapid
influenza tests is not 100%.
So, that's our diagnosis, we
have a patient with COVID-19,
who's coming back to us with a persistent
symptoms and some concerning features.
What is his risk of severe or critical disease?
Let's think about that for a second,
before I go on to the next slide.
Okay, so hopefully you've thought
about it and or paused the slide,
but here we go.
Risk of severe critical
disease, he is 62 years old,
so, he is in an age demographic which
increases his risk of hospitalization,
intensive care unit and even
death, quite significantly,
when compared to the young child
to adolescent patient population.
He has hypertension, which
is partially controlled,
but, not perfectly controlled
and he has diabetes mellitus,
which is, controlled by a diet although
we don't know exactly how well.
He presented, with a peripheral
oxygenation of less than 93%,
in fact you know, 88%, 86%, 84%,
would be very concerning features,
he has evidence of end organ dysfunction,
by elevated transaminases,
worsening renal function with
an elevated BUN and creatinine
and also, he had a slightly elevated
troponin as we noticed before.
So, his risks of course for
severe COVID-19 are significant,
yes, we made it to the end of the case,
however, our patient has not made it
to the end of his hospitalization,
as you can imagine, he likely
will require hospitalization
with oxygen therapy, potentially
he would qualify for other interventions,
which you should think about
and if you are not immediately thinking of them,
go back to the COVID-19 session
on therapeutic treatments
and he will likely be in hospital
potentially for one to two weeks.
So, our patient has a ways to go,
hopefully though, you've been
able to sort of re-synthesize
some of your memory and your thought processes
and put together some of the
prior sessions on COVID-19.
So, with that, we will sign off
and thank you for your time.