COVID-19: Clinical Case

00:08 COVID-19 a Clinical Case.

00:11 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.

00:25 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.

00:51 So, here's the case 62 year old man, comes to our clinic complaining of fever cough and malaise, for the last three days.

00:58 He lives in a part of the world, which, has ongoing active transmission of SARS-Coronavirus II and he has not been vaccinated yet.

01:06 He's triaged to one of the examination rooms, which, is used for possible COVID-19 patients and is seen by staff appropriately wearing, full personal protective equipment.

01:16 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.

01:42 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.

02:03 So, again, let's pick out the salient and important features, as you see on the list on the right.

02:09 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.

02:29 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.

02:49 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.

03:17 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.

03:47 He endorses type 2 non-insulin dependent diabetes mellitus, which is, controlled with diet alone, no medications.

03:54 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.

04:07 He has not traveled since the start of pandemic, family history is notable for hypertension, coronary artery disease diabetes mellitus and there you go.

04:19 So that's his clinical presentation, so, a whole bunch of non-specifics, but some important complaints which at least, have our antennae triggering right now.

04:30 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.

04:45 His head and neck examination is normal, his chest thankfully is cleared to, auscultation throughout, his cardiac exam is normal, with no murmurs, no rubs, his abdomen soft non-tender, non-distended, no hepatosplenomegaly and normal bowel sounds.

05:01 Extremities and skin exams are normal and his neurological exam is non-focal.

05:08 So, what about an initial assessment.

05:11 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.

05:32 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.

05:46 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.

05:55 Influenza, will typically start with a flu-like illness, with fevers, myalgias, polyarthralgia, general malaise, which, our patient has.

06:03 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.

06:24 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.

06:41 The rhinovirus, causes the common cold and also, other coronaviruses lest we forget those.

06:47 The classic description of a rhinovirus or common cold is, three days coming at you, three days with us, three days leaving.

06:53 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.

07:09 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, Chlamydia pneumoniae, Legionella and unfortunately, in many parts of the world, tuberculosis, Mycobacterium tuberculosis.

07:33 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.

07:44 The next step would be to test for COVID as well as Influenza A and B, especially if during flu season, because the management of these infections is based on virus specific medications.

07:55 The preferred rapid PCR test takes less than one hour and can test for all three viruses at once.

08:01 While antigen testing is less sensitive.

08:04 No additional imaging would be necessary.

08:06 Remember, no COVID specific therapy is needed for unvaccinated individuals without risk factors or in asymptomatic COVID infections.

08:16 In this case, oral nirmatrelvir-ritonavir was prescribed because he is unvaccinated and has diabetes, a risk factor for severe disease.

08:25 Here's a reminder of the current treatment recommendation guidelines.

08:28 But the guidelines may be different depending in your region and available supplies.

08:34 General management of mild to moderate COVID consists primarily of self-quarantine and continued evaluation for the development of more severe symptoms 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.

09:18 As well, he now has shortness of breath and has anorexia, he's unable to eat.

09:25 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.

09:43 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.

10:05 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.

10:33 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.

10:49 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.

11:05 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.

11:31 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.

11:43 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.

11:58 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 electrocardiogram performed, to look for dysrhythmias, to look for abnormalities in cardiac function and then to potentially predict the potential of adverse effects and infection severity.

12:21 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, especially transaminases.

12:36 So, looking for hepatitis B or hepatitis C and certainly HIV, might be appropriate.

12:43 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 intraparenchymal lesions seen with COVID-19.

13:03 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.

13:28 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.

13:42 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.

13:55 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.

14:12 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.

14:27 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%.

14:41 Blood culture obtained and fast forwarding 48 hours, is sterile.

14:45 Here is his chest radiograph, demonstrating, bilateral infrahilar airspace opacities, without any blunting of his costovertebral angles, so, not seeing evidence of a pulmonary or pleural effusion.

14:59 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.

15:16 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.

15:32 So, we go ahead and test him for other things just to be safe, his rapid influenza is negative, negative cultures, Sputum and RSV panel.

15:40 And a SARS-Coronavirus II, nucleic acid amplification assay, typically, again performed by reverse transcriptase polymerase chain reaction, so, RT-CPR in his case is positive.

15:53 It should be noted that although the patient's condition continued to deteriorate after the antiviral treatment, the medication still reduces the likelihood of severe illness and death by 89%.

16:05 The COVID 19 diagnosis is supported by the positive PCR test, positive chest CT findings and negative cultures, Sputum and RSV panel.

16:14 The differential diagnosis at this point could include a bacterial superinfection or a co-infection with other pneumonias.

16:21 Okay, so hopefully you've thought about it and or paused the slide, but here we go.

16:26 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.

16:42 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.

16:53 He presented the second time with a peripheral oxygenation of less than 93%.

16:59 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.

17:17 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 non-invasive ventilation, 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.

17:52 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.

18:04 So, with that, we will sign off and thank you for your time.