Welcome to this month’s What’s Your Diagnosis Challenge!
Case Presentation: An Evidence-Based Approach to Abnormal Vision
A 42-year-old man presents to your ED triage area with a high-grade fever (39.6?C [103.3?F]), cough, and fatigue for 1 week. He said that the week prior, he was at an emergency medicine conference in New York City, and took the subway with some people who were coughing excessively. The triage nurses immediately recognize the infectious risk, place a mask on the patient, place him in a negative pressure room, and inform you that the patient is ready to be seen. You wonder what to do with the other 10 individuals who were sitting near the patient while he was waiting to be triaged, and what you should do next?
Later in your shift, a steady flow of patients with varying degrees of upper and lower respiratory symptoms arrive. Additionally, there are several ?worried well? patients without symptoms, who are requesting testing for COVID-19, based on varying degrees of perceived exposures. What do you tell them? How do you handle the throngs of patients now potentially contaminating higher-risk patients?
You recognized the need for immediate and proper donning of personal protective equipment. You and a nurse put on your complete PPE and obtained the patient?s vital signs, which confirmed a temperature of 39.6?C [103.3?F], pulse of 106 beats/min, respirations of 22 breaths/min, blood pressure 102/68 mm Hg, and pulse oximetry 89% on room air. You performed bedside lung ultrasound using the ?lawnmower? technique to visualize as much lung as possible, which confirmed bilateral B-lines in the posterior lungs with confluence producing a characteristic ?waterfall sign.? You placed him in a negative pressure isolation room, starting him immediately on supplemental oxygen, and confirmed his travel history and possible contacts with people who may have been exposed to COVID-19. After careful, proper doffing of your PPE, you contacted your hospital infectious disease and infection prevention team, who directed you to also contact your local department of public health, who then sent a representative to find out his possible contacts. You deferred obtaining a CT, as it would not have changed this patient?s management. You sent a battery of lab tests, including a D-dimer, procalcitonin, and LDH, started empirical coverage for bacterial pneumonia, consulted the CDC and WHO for up-to-date guidance on additional treatment recommendations, and remembered to consider steroids only if the patient?s condition deteriorated and he developed ARDS.
The remaining ?worried well? and otherwise clinically stable patients were given the current recommendations of the CDC and, based on their respective risk profiles, offered symptomatic treatment or outpatient testing of COVID-19 with mandatory isolation for 14 days and symptom monitoring. Consultation with your local Department of Health and Infection Prevention department for the current testing and treatment protocols will help guide the management for those well enough to self-isolate at home.
Leave your solution in the comments below and review the issue to find out more of the authors’ recommendations.
Not a subscriber? You can find out the conclusion and if you got it right, next month when a new case is posted, so stay tuned!
Last Updated on July 9, 2020