This document provides a summary of a continuing medical education event on COVID-19 cases in primary care. It includes three patient case studies - a 46-year-old woman diagnosed with COVID-19 who was monitored with pulse oximetry, a 51-year-old man hospitalized for COVID-19 pneumonia who later developed a hydropneumothorax, and an almost 3-month old infant who tested positive for COVID-19 along with their mother. It also discusses pediatric COVID-19 cases and protocols for monitoring COVID-19 patients at the community health center using pulse oximetry. Resources on COVID-19 from various organizations are also listed.

1. COVID-19 in Primary Care: Cases and
Discussions from the Front Lines
June 10, 2020

2. CME Credit
• Bridgeport Hospital Yale New Haven Health is accredited by the Connecticut State
Medical Society to sponsor continuing medical education for physicians. The
Bridgeport Hospital Yale New Haven Health designates this live activity for a
maximum of one (1) AMA PRA Category 1 CreditsTM. Physicians should claim only
credits commensurate with the extent of their participation in the various
activities.
• This activity has been planned and implemented in accordance with the Essential
Areas and policies of the Accreditation Council for Continuing Medical Education
through the joint sponsorship of Bridgeport Hospital Yale New Haven Health and
the Weitzman Institute. Bridgeport Hospital Yale New Haven Health is accredited
by the Connecticut State Medical Society to provide continuing medical education
for physicians.
• The content of this activity is not related to products or services of an ACCME-
defined commercial interest; therefore, no one in control of content has a relevant
financial relationship to disclose and there is no potential for conflicts of interest.

4. COVID-19 cumulative cases in the U.S.
1,985,670 cases on 6/9/20 – up from 1,680,913 cases last week (6/3/20) –
111,989 deaths https://coronavirus.jhu.edu/map.html

5. Not to lose hope!

6. Any good news?
• AstraZeneca and Oxford University researchers
pressing ahead with vaccine (AZD1222):
– mass-producing the vaccine before it has been
proved effective
– Bill Gates $750 million
– Could be ready by September

7. Resources
• Nuvancehealth:
https://spark.adobe.com/page/sfiiwxxjnI8yc/
• CDC:
https://www.cdc.gov/coronavirus/2019-ncov/index.html
https://emergency.cdc.gov/coca/calls/2020/
• WHO:
https://www.who.int/emergencies/diseases/novel-coronavirus-2019
• Johns Hopkins:
https://coronavirus.jhu.edu/map.html
• Others
https://www.thelancet.com/coronavirus
https://covidactnow.org/

8. COVID-19 in Primary Care: Cases and
Discussions from the Front Lines
Marwan Haddad, MD, MPH; Medical Director, Center for Key
Populations, CHC, Inc.
Dan Wilensky, MD; Medical Director, ConferMED, CHC, Inc.
Ho-Choong Chang, MD, FAAP; Chief of Pediatrics, CHC, Inc.

9. • 46 year old white female
• Medical History:
– Asthma
– Opioid Use Disorder on MAT
– Bipolar Affective Disorder
– Back Pain
– Hepatitis C (Treated and
Cleared)
– GERD
– Housing Insecurity (in
rooming house)
• Medications:
– buprenorphine-naloxone
– venlafaxine
– lamotrigine
– gabapentin
– hydroxyzine
– amitriptyline
– esomeprazole
– ibuprofen
– albuterol
– fluticasone
COVID-19 Diagnosis and Monitoring Case

10. • May 11, 2020
– Presented with 3 days of feeling feverish, myalgias, loss of smell and
taste, runny nose, cough, SOBOE, headache, and abdominal pain.
– Had some wheezing initially but has improved.
– Had a rash about 3 weeks prior but that has cleared up.
– Her roommate tested positive for COVID
– Using albuterol only; not been using fluticasone for several days
• May 12, 2020
– Brought in for COVID testing
• May 15, 2020
– COVID test POSITIVE; called and informed; set up to come back in 6-12
days for a pulse oximetry reading.
COVID-19 Diagnosis and Monitoring Case

11. • May 21, 2020
– Resting pulse ox in car: 96%, pulse 88 (usual pulse ox 96-99%)
– Walked around the care for 2 minutes: pulse ox 91%, pulse 119
– Sat in the car for a few minutes: pulse ox 95%, pulse 99
– Sent home with close monitoring
• May 22, 2020
– Nurse spoke to her on the phone, found still symptomatic with
SOB and SOBOE
– Brought her back in for exertional pulse oximetry again
– Resting pulse ox 97%, pulse 102
– Walked around the car for 4 minutes: pulse ox 97%, pulse 123
• Sent home and checked in after a few days – was almost
back to normal.
COVID-19 Diagnosis and Monitoring Case

12. • June 5, 2020
– Called complaining of SOB, worried if she should be retested.
– Was using only the albuterol.
– Offered to come in for pulse ox reading– declined June 8 visit;
wanted June 9.
• June 9, 2020
– Spoke to her on phone; was feeling better except still getting SOB.
– Was not using fluticasone, only albuterol.
– Informed her to start back up with fluticasone; use albuterol as
needed.
– She was reassured.
– Missed her appt for pulse ox.
COVID-19 Diagnosis and Monitoring Case

13. Pulse Oximetry Protocol at CHC
• COVID patients may develop severe disease quickly despite initially
having no or mild symptoms.
• An early indication may be low oxygen saturation.
• Severe respiratory symptoms usually occur 6-12 days after infection.
• All presumed and confirmed COVID + patients are given a nursing visit
(outside in parking lot) for pulse oximetry reading 6-12 days after start
of symptoms or after diagnosis if no or vague symptoms.
• Resting pulse oximetry done first.
• If <90%, sent to ER for evaluation.
• If >90%, exertional pulse ox is done.
– Walk in place or around car to get a rise in pulse of about 20 beats.
– If desaturates below 90%, sent to ER for evaluation.
– If desaturates but remains above 90%, close monitoring by clinical team.

14. Adult Case
• 51 year old man with HTN, who does maintenance work in
an apartment building, presented to the ED 6 weeks ago
after appx. day 5 of illness.
– Seems that he was tested at work when symptoms began and on
ED presentation +COVID already documented.
• Shortness of breath, vomiting, fatigue, feverishness
• Required 6 liters by O2 mask.
• Bilateral groundglass opacities on CXR – COVID Pneumonia.
• Transferred to a regional hospital that was doing more
COVID at the time.

15. • Treated with Tocilizumab and convalescent plasma and self-proning
• Within days he transferred to ICU.
• Abnormal D-Dimer. CTA neg for PE. Given Lovenox and then 1 month
of low dose Apixiban on discharge.
• 15 day admission - sent home without requiring intubation.
• 2 days post discharge, patient represented to the ED with increasing
shortness of breath and chest pain
• Large cystic pulmonary finding on right with a large
hydropneumothorax which required chest tube placement
• Sent home with chest tube in place 2 days later to be followed by
thoracic surgery and Pulmonology
Adult Case

16. Pediatric Case
• Almost 3 mo healthy, hx/o benign GER
• CC/O “fussiness”
• No fever, cough. PO well. Output stable
• Mom works at daycare (+COVID coworkers),
currently sick, being tested
• 2d later, mom’s test +, pt tested
• 3d later, pt test +

17. Pediatric Case—Follow Up
• Pt with ongoing mild cough. Feeding and
voiding well. No F, V
• Intermittent Rash on face noted—”small red
bumps come and go”
• PCP visit 1 week later, sx resolved

18. Pediatric Case-Discussion
• Children less infected, milder symptoms
– Coronavirus Disease 2019 in Children — United States, February 12–April 2, 2020. MMWR
Morb Mortal Wkly Rep 2020;69:422–426. DOI:
http://dx.doi.org/10.15585/mmwr.mm6914e4external icon
• Are they (“super”) spreaders or not?
– Lee B, Raszka Jr WV. COVID-19 transmission and children: the child is not to blame.
Pediatrics. 2020; doi: 10.1542/peds.2020-00487
– Children are not COVID-19 super spreaders: time to go back to school. Arch Dis Child
2020;0:1–2. doi:10.1136/archdischild-2020-319474
– Changes in contact patterns shape the dynamics of the COVID-19 outbreak in China.
Science 29 Apr 2020:eabb8001. DOI: 10.1126/science.abb8001
– An analysis of SARS-CoV-2 viral load by patient age. Terry C. Jones, Barbara
Mühlemann , Talitha Veith , Marta Zuchowski , Jörg Hofmann , Angela Stein, Anke
Edelmann, Victor Max Corman, Christian Drosten

19. 19
Free COVID-19 eConsults
• Web-based portal
• Free to all Safety Net Primary Care Practices
– FQHC, FQHC-look alike, Migrant Clinicians, Healthcare for the
Homeless, Free Clinics
• No Protected Health Information (PHI)
• Consults Addressed by:
– Infectious Disease Specialists
– Public Health Nurses
* This initiative is supported by

20. 20 * This initiative is supported by

21. Thank You!
www.weitzmaninstitute.org/coronavirus