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Weitzman ECHO on COVID-19

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An interactive learning session led by an infectious disease expert and primary care providers to discuss epidemiology, screening, diagnosis, and treatment options for COVID-19. We will walk through realistic scenarios of patients presenting with COVID-19. This session is designed for primary care providers and care teams.

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Weitzman ECHO on COVID-19

  1. 1. Weitzman ECHO on Coronavirus Daren Anderson, MD Kara Lewis, PharmD Stephen J. Scholand, MD Daniel Wilensky, MD March 4, 2020
  2. 2. Case Report #1 • On January 19, 2020, a 35-year-old man presented to an urgent care clinic with a 4-day history of cough and subjective fever. • On checking into the clinic, the patient put on a mask in the waiting room. • After waiting approximately 20 minutes, he was taken into an exam room and underwent evaluation by a provider. Source: Holshue ML, DeBolt C, Lindquist S, et al; Washington State 2019-nCoV Case Investigation Team. First case of 2019 novel coronavirus in the United States. N Engl J Med. Published online January 31, 2020.
  3. 3. Case Report #1 • He disclosed that he had returned to Washington State on January 15 after traveling to visit family in Wuhan, China. • The patient stated that he had seen a health alert from the CDC about the Coronavirus outbreak in China and, because of his symptoms and recent travel, decided to see a health care provider. Source: Holshue ML, DeBolt C, Lindquist S, et al; Washington State 2019-nCoV Case Investigation Team. First case of 2019 novel coronavirus in the United States. N Engl J Med. Published online January 31, 2020.
  4. 4. • Four day history of dry cough, fevers, and two days of nausea and vomiting • Hx of hypertriglyceridemia • No smoking, drug or alcohol • PE: temp 98.9°F, BP 134/87 mm Hg, pulse 110 BPM, RR 16 BPM, and O2 sat 96% on room air • Lung auscultation revealed rhonchi, and chest radiography was performed, which was reported as showing no abnormalities (Figure 1). Case Report #1 Source: Holshue ML, DeBolt C, Lindquist S, et al; Washington State 2019-nCoV Case Investigation Team. First case of 2019 novel coronavirus in the United States. N Engl J Med. Published online January 31, 2020.
  5. 5. Source: Holshue ML, DeBolt C, Lindquist S, et al; Washington State 2019-nCoV Case Investigation Team. First case of 2019 novel coronavirus in the United States. N Engl J Med. Published online January 31, 2020.
  6. 6. • A rapid nucleic acid amplification test (NAAT) for influenza A and B was negative. • A nasopharyngeal swab specimen was obtained and was negative for influenza A and B, parainfluenza, respiratory syncytial virus, rhinovirus, adenovirus, and four common coronavirus strains known to cause illness in humans (HKU1, NL63, 229E, and OC43). • Based on his symptoms and travel history the patient was classified as a Person Under Investigation (PUI) Case Report #1 Source: Holshue ML, DeBolt C, Lindquist S, et al; Washington State 2019-nCoV Case Investigation Team. First case of 2019 novel coronavirus in the United States. N Engl J Med. Published online January 31, 2020.
  7. 7. Coronavirus (COVID-19) A Primary Care Perspective Stephen J. Scholand, MD Infectious Disease Consultant
  8. 8. Thanks Professor Majid Sadigh Trefz Family Endowed Chair in Global Health Director of Global Health Program, Nuvance Health
  9. 9. Objectives • Briefly review the novel coronavirus (2019-nCoV, SARS-CoV-2) emergence and epidemiology • Seek to understand viral pathogenicity and disease • Develop and maintain awareness of clinical clues and laboratory indicators for this disease • Recognize the impact of this new disease • Remain vigilant for community cases • Be prepared!
  10. 10. ‘Perfect storm’ of viral spread
  11. 11. Specific Clinical Characteristics • Fever (44% on admission and 89% during hospitalization) • Cough (68%) • Diarrhea was uncommon (4%) • Median incubation 4 days (range 2 to 7) • Ground-glass opacity was the most common finding on CT (56%). • No imaging abnl in 157 of 877 (18%) • Lymphocytopenia was present in 83%
  12. 12. Approach to Management and Treatment
  13. 13. Avoid being over-run
  14. 14. What to do if you have a potential patient? Patient Under Investigation (PUI)?
  15. 15. Don’t Panic! • Instruct patients to call first (*PROACTIVE) – Avoid waiting room exposures – Staff exposures • Triage – Can the patient stay at home? – Do they need to be seen? – Should they go right to the ER? **Call ahead**
  16. 16. Communicate • Local and State health departments – CT: website, emails – Phone numbers
  17. 17. Real World • Patient presentation: – Personal Protective Equipment • Masks, with eye protection • Gloves • Gowns? – Isolation • Dedicated staff: ensure self protection, use of PPE
  18. 18. Real World • History: – No longer a ‘travel’ history to affected zones • China, S. Korea, Iran, Italy, Japan • Add (?) Washington State – Other clues? INFLUENZA season • Physical: – Vital signs (pulse ox) – Respiratory findings
  19. 19. Real World • Testing: – Influenza – Other viruses (?) – Labs: renal failure? • Imaging – Chest X-ray
  20. 20. Summary • New virus on the loose – Expect to see patients • Make sure preparations are in place – Office / Clinic protocol – PPE: Masks! Gloves… – Hand Hygiene; equipment cleanliness • COMMUNICATION – Colleagues, other health care facilities – State and local health departments Dr. Li Wenliang
  21. 21. Staying up to date • https://www.cdc.gov/coronavirus/2019-ncov/index.html https://emergency.cdc.gov/coca/calls/2020/callinfo_030520.asp • https://www.who.int/emergencies/diseases/novel- coronavirus-2019 • Travel? – https://travel.state.gov/content/travel/en/traveladvisories/ea/novel- coronavirus-hubei-province--china.html
  22. 22. There is still hope “We are in unchartered territory. We have never before seen a respiratory pathogen that is capable of community transmission, but which can also be contained with the right measures.” WHO Director-General Dr. Tedros Adhanom Ghebreyesus
  23. 23. Emerging Treatments • Antivirals: lopinavir/ritonavir, remdesivir, favipiravir • nitazoxanide (antiprotozoal) • chloroquine phosphate (malaria/autoimmune disease tx) • camostat mesylate (protease inhibitor) • Vaccine Timeline- 4 vaccines in development, 1-2 will go into human trials in 3-4 months then ~12-18 months before available for wider use
  24. 24. Case Report #1 Wrap-Up • Pt was initially discharged to home isolation • One day later, his swab results returned positive for 2019-nCoV • He was admitted to an airborne isolation unit at the local hospital • Treatment: IV NS, ondansetron, acetaminophen, ibuprofen, guaifenesin • Day 5-6: O2 sat dropped to 90% • CXR showed atypical pneumonia • Hospital Day #8; symptoms improved, O2 discontinued
  25. 25. Case Report #2 • A 61-year-old homeless man walked in to a Healthcare for the Homeless clinic in Connecticut complaining of worsening malaise, cough, fever, and chills • The Medical Assistant immediately provided him with a mask and brought him in to the exam room
  26. 26. Case Report # 2 • He disclosed that he lives on the streets, and sleeps in a local homeless shelter on colder nights • He smokes and has a history of IV heroin abuse • Medical history was notable for COPD and recurrent staph skin infections
  27. 27. • The physical examination revealed a body temperature of 100.8°F, blood pressure of 155/87 mm Hg, pulse of 112 beats per minute, respiratory rate of 18 breaths per minute, and oxygen saturation of 93% while the patient was breathing ambient air. • Lung auscultation revealed rhonchi Case Report #2
  28. 28. Thank You! For questions or to join our mailing list: Contact us at WeitzmanLearning@chc1.com www.weitzmaninstitute.org

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