Serological antibody testing done on a patient suspected to have severe symptoms of CoViD19 disease. And was medically managed at home…

Introduction:

It is a known and accepted fact that CoViD19 patient/s with severe symptoms and those with critical illness had a high rate of in-hospital mortality and nobody can refute that, as provided by real world data, even patient/s that presented and displayed mild to moderate signs and symptoms of CoViD19 disease unexpectedly worsens and progressed to severe and critical illness in a short period of time which overwhelmed our healthcare industry and occupying the hospital’s intensive care units more than its maximum capacity and unable to function effectively to save patients lives.

The novel coronavirus spread globally which infects miilions and cause the deaths of people by the hundreds of thousands since December of 2019 in Hubei province Wuhan China, and many countries all over the world together with their respective health offices designed preventive protocols and strategies to curbed, stopped or decreased the novel coronavirus spread but to no avail…until now the cases continue to rise in an unprecedented scale. During the early months of the pandemic, the novel coronavirus disease ravaged the the old population with chronic illness or illnesses but 2 to 3 months ago, the novel coronavirus affected and put so much burden on the younger age group although the morbidity and mortality rate was low as shown by local and foreign CoviD19 registry. Many of the Covid19 cases now are in the asymptomatic group and there are a portion with mild to moderate CoViD19 disease…then a few with severe to critical illness.

And usually starting from those person/s with moderate signs and symptoms of CoviD19 disease warrants admission, especially if the patient/s is/are having chronic longstanding disease/s and or comorbidities such as old age, hyperglycemia or uncontrolled diabetes, uncontrolled hypertension, bronchial asthma, chronic kidney disease, liver disease, end stage renal disease (ESRD) in dialysis, cardiovascular disease, immunocompromise and immunosuppress persons, and obesity etc.

And person/s who are having CoViD19 severe disease and critical illness are immediately referred and admitted in a healthcare facility with adequate capability and is well adept enough in managing contagious diseases such as CoViD. CoViD19 positive person/s with mild sign/s and symptom/s and without symptoms are also isolated, quarantined and monitored for disease activity and progression in an assigned quarantine facility or place of confinement. But there are times or instances that a patient with signs and symptoms of anosmia( loss sense of smell ), ageusia( loss sense of taste ), associated with on and off fever, cough and occasional difficulty of breathing for almost seven to ten days was denied/refused of admission by a healthcare facility or hospital due to the above presentation of her disease. And this is her story…

On August 1, 2020, a 74 y.o. old woman was preparing for her daily morning routine activity of selling ” kakanin ” or foods in the neighborhood and after all the foods was sold, she immediately went straight for home. Then at home she felt occasional body malaise, dizziness, chilly sensation and easily gets tired of which… it was all attributed to old age and all in the days work. In the morning, a day before August 1, 2020 her nephew and niece arrived from Manila City and was quarantined for fourteen days since thay are labelled as locally stranded individual or as LSI’s, both underwent serological antibody testing for Sars CoV-2 last August 7, 2020. The niece turned positive for IgG and the nephew turned out negative for the serological antibody test. Then last August 10, 2020 her daughter a policewoman assigned as a local contract tracer for CoViD19 inter -agency task force beginning to felt gradual loss of sense of taste and loss of smell sensation associated with flu-like symptoms, body rashes with itchiness and throat discomfort with epigastric pain. The policewoman sought consult in a government run rural health clinic and was prescribed or given oral medications to a certain number of days which offered relief as claimed.

Approximately seven to ten days prior to the consultation the 74 y.o. woman felt unwell. the dizziness and body malaise with tiredness worsens associated with fever and chills, occasional cough, loss sense of smell and taste with poor appetite accompanied with bouts of difficulty of breathing was also observed, which prompted the patient to sought for consultation to her physician of choice. She wanted to be admitted in the same hospital of choice but was denied and refused as claimed. Then she was sent home that very same day, still with the above symptoms and occasional difficulty of breathing with chest tightness keeps on bothering her even at rest.

So the family contacted a local physician the next day ( August 22, 2020 ) to manage her medically at the comfort of her abode. At home when the local physician saw the patient, the advised was she must be admitted to a local hospital for immediate proper, adequate, quality medical care but she refused to be admitted in a local hospital due to lack of trust and confidence, likewise the local hospital also refused to admit her. And referral to other nearest hospital in the province or city was also refused by her due to a more than two to four hours travel from her place to the province or city respectively. So the best option of her doctor was, she will be managed at home.

The first or initial home visit and checked-up of the patient by her doctor. She was still up and about in this picture.

 The patient’s initial or first visit vital signs ( V/S ):

Blood pressure =130/80mmhg, Cardiac rate =72bpm, Respiratory rate = 24-26cpm, Temperature =36.5 degree celsius.

Initial physical examination ( P.E. ) revealed…patient was acyanotic in mild cardiopulmonary distress, afebrile.

Cardiac P.E.: Adynamic precordium, regular cardiac rhythm, non-accentuated S2, no murmur noted.

Pulmonary P.E.: Symmetrical chest expansion, harsh breath sounds, bibasal crackles with decrease breath sounds,                            vocal and tactile fremitus right lower lung base, no wheeze noted.

Gastrointestinal P.E.: non-distended, normoactive bowel sounds, flabby. non-tender on deep palpation.

Upper and Lower Extremities P.E.: no rashes, hematoma, hyperpigmentation  or discoloration, no clubbing or swelliing/edema noted.

Laboratories:

A ) Initial Chest X-ray ( CXR ) revealed cardiomegaly or enlarged cardiac shadow, pneumonia both lung base,

atherosclerotic aorta and minimal pleural effusion VS. Thickening right lung.

B) Complete Blood Count ( CBC ): Hemoglobin= 108 mg/L, hematocrit= 0.32vol/l, within normal white blood cell count including platelet count, and  lymphocytes ( 17% ).

C) ECG/EKG= within normal limit.

The treatment plan of her doctor that day in August 22, 2020, the day of her checked-up :

1) Started her with intravenous fluids at a rate of one liter per day.

2) Intravenous antibiotic plus one oral antibiotic.

3) Plan of giving Oxygen inhalation if available.

4) Intravenous paracetamol every 4 hours-as needed and intravenous sodium bicarbonate if also needed.

5) Oral antihypertensive tablet since the patient is hypertensive.

6) Probiotic supplements.

7) Oral steroids.

8) Oral statin plus antiplatelet combination tablet.

9) Oral melatonin tablet.

10) Off-label used and giving of oral and injectable form of repurposed drug for CoViD19.

11) Patient was keep on an isolation room with good ventilation and one permanent responsible companion. Physical distancing at 2 meters must be maintain. The companion may stay near the patient within less than 2 meters but not more or longer than fifteen minutes duration during nursing care with wearing of proper personal protective equipment.

12) Proper hand washing, strict wearing of face mask and face shield, off limits to visitor/s temporarily,

13) Acetylcisteine powder or sachet.

14) Although not allowed by her doctor, occasional salbutamol nebulization per patient request because it help or offer relief as claimed by the patient…

Home admission daily treatment history:

August 23, 2020 ( day 1 of home medical treatment ):

The patient was having moderate grade intermittent fever with chills associated with cough and having difficulty of breathing with chest pain and having occasional slightly bluish discoloration of the lips with cold perspiration.

Vital Signs ( V/S):  Blood Pressure=140/90mmhg    Cardiac Rate=119bpm     Respiratory Rate=26 to 34cpm

Temperature= 38.8 degrees celsius

Pertinent Physical Examination findings: Patient was slightly cyanotic, in moderate to severe cardiopulmonary distress, febrile

Head and Neck: Anicteric sclerae, no neck vein engorgement

Lungs: Symmetrical chest expansion, harsh breath sounds, bibasal lung crackles with slightly decrease breath sounds of the right lower lung base, no wheezing noted.

Cardiac: Tachycardic, no murmur or S3 gallop noted.

Abdomen: Non-distended, normoactive bowel sounds, soft, no direct tenderness on deep palpation on all quadrants.

Lower Extremities: No rashes or discoloration and swelling or edema noted.

Random Blood Sugar= 108mg/dl

Treatment was instituted and applied to the patient by her doctor and relief was observed except for occasional bouts of mild difficulty of breathing.

August 24, 2020 ( day 2 of home medical treatment ):

In the morning:

Dexamethasone tablet and injectable forms save lives in severe and critically ill CoViD19 patients admitted in the hospital.

Another episode of difficulty of breathing associated with cough and fever, then additional medical treatment was applied by her doctor and it offered temporary relief, then oral steroid was shifted to intravenous steroid ( dexamethasone ) and loading dose was given as soon as the medication was available with additional off-label used of available oral and repurposed injectable medication for CoViD19.

Vital Signs ( V/S ): Blood Pressure=160/90-130/90mmhg   Cardiac Rate=122-114bpm   Respiratory Rate:36-26cpm

Temperature: 38.9 degrees celsius to 36.8 degrees celsius

Significant Physical Examination Findings: Patient was having episodes/bouts of cyanosis, restless, in moderate to                                                                                                                                                                                                                                  severe cardiopulmonary distress, febrile but oriented and able to conversed.

Head and Neck: Anicteric sclerae, cyanotic lips, no neck vein engorgement

Cardiac: Tachycardic, no murmur and S3 gallop noted

Lungs: Symmetrical chest expansion, harsh breath sounds, bibasal crakles with slightly decrease breath sounds,

decrease vocal and tactile fremitus of the right lung basal area, no wheeze noted.

Upper and Lower Extremities: no rashes or discoloration  and swelling or edema noted.

Note: Oxygen inhalation not started including pulse oximeter due to unavailability in the area during that time. And

treatment was given and offered temporary relief.

In the afternoon:

The patient’s situation suddenly worsened, recurrence of severe difficulty of breathing associated with deep bluish discoloration of the lips, cold clammy sweats, with fever and episodes of near syncope or near loss of consciousness was observed. The patient was in a sitting position beside the table, held and supported by her companion to prevent her from falling. Patient was delirious and in severe cardiopulmonary distress.

Vital Signs  ( V/S ):  Blood pressure=160/100-130/80mmhg   Cardiac Rate=142-112bpm  Respiratory Rate=42-32cpm

Temperature=38.2 degrees celsius, Initial oxygen saturation=67 to 89% with HFNC at 6 liters of

oxygen. HFNC or High flow nasal cannula.

Significant Physical Examination Findings:

Head and Neck: Deep cyanotic lips, with neck vein engorgement at sitting position.

Cardiac: Tachycardic, no murmur noted.

Lungs: harsh breath sounds, fine crackles upper lung fields, course crackles middle to basal areas  ( both lungs ), decrease breath sounds right lung base area, no wheezing noted.

Upper and Lower Extremities: no discoloration or swelling or edema noted.

Emergency Treatment or Therapy was given to the patient by her physician and relief was observed. The Department of Health representative performed a rapid serological test to her and revealed positive for IgM and IgG antibodies for SARS-CoV-2.The patient was constantly monitored by real time video from home by her physician.

August 25, 2020 ( day 3 of home medical treatment ):

Patient coughed out rusty-orange color early morning sputum for 3 episodes. August 25, 2020

The whole day was unremarkable and no worsening of symptoms except for two to three episodes of scanty hemoptysis.

She was awake but weak and able to sit in the bed with assistance and ate her breakfast.

Vital Signs ( V/S ): Blood Pressure=130/80mmhg  Cardiac Rate=92bpm  Respiratory Rate=26-28cpm

Temperature=36,9 degrees celsius  Oxygen Saturation at 90-92% with HFNC at 6 t0 8 liters of                                                          oxygen.

Significant Physical Examination Findings:

Head and Neck: anicteric sclerae, acyanotic lips, no neck vein engorgement

Cardiac: Adynamic precordium, regular rhythm, no murmur, no S2, non-tachycardic

Lungs: Symmetrical chest expansion, bibasal crackles, decrease breath sounds right lung base, no wheeze noted.

Abdominal: non-distended, normoactive bowel sounds, no direct tenderness on deep palpation.

Upper and Lower Extremities: grade 2 bipedal pitting edema

August 26, 2020 ( day 4 to day 9 of home medical ):

The patient was on her fourth day home medical management still attached to oxygen inhalation.

The doctor examined her at home. The patient was awaked and alert, able to stand alone without assistance and was able to render a smile. The patient’s condition was improving daily.

Then in the succeeding days…no subjective complaints was observed by her attending physician. She was gradually weaned-off from her oxygen inhalation and then finally discontinued and stopped.

The patient was seen reading the holy scriptures during her convalescence period from CoViD19 disease.

The patient had good sleep and with good appetite and was able to read her bible at the bedside and attended virtual mass that was offered in the internet. As the days passed by, she recovered fast and can walked around her room and to the toilet without being helped, until such time that… when her physician visited and checked her that day, all the vital signs are within normal range.

.

The patient’s pulse oximeter registered at 95% oxygen saturation with 62 bpm pulse rate, while breathing normal room air.

The oxygen saturation level was 95% at ambient air or patient breathing normal room air with no abnormal

physical findings are observed. The patient was…Going To ” The ROAD Of Recovery !!! ” …

and on August 31, 2020 ( day 10 ), she was discharged by her doctor very much improved.  And was only given oral medications for another 7 days to take by her doctor, she was then adviced to have another clinic visit or check-up after one week.

This is the second serological test taken from the patient last September 1, 2020.

Conclusion: 

The ongoing rampage of the novel coronavirus around the globe which infects millions, kills hundreds of thousands, cripples the economy of so many countries, creates havoc and stigmas to those who survives, and likewise distabilized the unprepared healthcare industry in every country it affects. The true story of that old woman who was denied and refused of proper medical care as claimed by her, was a clear example of CoViD19’s devastating effect to the healthcare industry. The politically clouded healthcare industry was overwhelmed with so many patients infected with the novel coronavirus and sometimes patient/s can’t receive adequate medical attention and care due to the forever changing mind-boggling CoViD19 directives, policies and regulations that can’t easily be understand and comprehend by the laymen…was this case an example of disparity that happened in some countries? The good thing is that there was that good hearted doctor that risked his life and managed her medically at home…her case was a classic example of a CoViD19 patient that initially exhibited a mild to moderate symptoms and then progressed to severe form of CoViD19 disease. The severe form of CoViD19 as mentioned by experts roughly involved 14 percent of the population infected by the novel coronavirus and the chance of progressing to mortality and death is very high even in the most advance and well-equipped hospitals in the world. The use of lifesaving strategies and available repurposed drugs and medicine/s for treatment in CoViD19 patients must be individualize and clearly discuss by the physician in-charge to his or her patient/s, since the novel coronavirus disease has no definite treatment as of the moment. My question is…Can CoViD19 patient/s with severe symptoms be manage at home?. And I think she was very lucky enough to survived…in GOD’s guidance and grace!

By the way, the good doctor that accepted her and managed her medically at the comfort of her home is no other than…………………… your humble servant in health…

the author of this article…

Yours truly,

Laertes B. Amihan MD