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.

1. Weitzman ECHO on Coronavirus
Daren Anderson, MD
Kara Lewis, PharmD
Stephen J. Scholand, MD
Daniel Wilensky, MD
March 4, 2020

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. 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. • 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. 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. • 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. Coronavirus (COVID-19)
A Primary Care Perspective
Stephen J. Scholand, MD
Infectious Disease Consultant

8. Thanks
Professor Majid Sadigh
Trefz Family Endowed Chair in Global Health
Director of Global Health Program, Nuvance
Health

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!

11. ‘Perfect storm’ of viral spread

17. 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%

18. Approach to Management
and Treatment

19. Avoid being over-run

20. What to do if you have a
potential patient?
Patient Under Investigation (PUI)?

21. 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**

22. Communicate
• Local and State health departments
– CT: website, emails
– Phone numbers

23. Real World
• Patient presentation:
– Personal Protective Equipment
• Masks, with eye protection
• Gloves
• Gowns?
– Isolation
• Dedicated staff: ensure self protection, use of PPE

24. 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

25. Real World
• Testing:
– Influenza
– Other viruses (?)
– Labs: renal failure?
• Imaging
– Chest X-ray

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. • 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

34. Thank You!
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