Question normal

Guillermo Rodriguez-Nava, M.D.
Grace Zhang, M.D.
Internal Medicine Department
AMITA Health Saint Francis Hospital

Case presentation:
A female in her 70s was scheduled for elective bilateral knee replacement on March 11, 2020. Past medical history was only relevant for osteoarthritis and hypertension. She underwent surgery without major events other than significant blood loss that required transfusion of one packet of red blood cells and one episode of elevated temperature to 99.8 F on day 1 post surgery. During that hospitalization, complete blood count and basic metabolic panel were unremarkable, except for a hemoglobin of 6.3 g/dL and leukocytosis of 12.2 k/mm cu. Hemoglobin stabilized to 8.6 after transfusion and leukocytosis resolved the day after. The patient was discharged on March 14 to sub acute rehabilitation for recovery in stable condition. On March 18, she returned to the ED from sub acute rehab for worsening cough. She denied fever or shaking chills. No known contact with a positive COVID-19 or PUI, no travel, no other respiratory symptoms. The nursing home sent lab work and X-rays prior to presentation, and the primary care physician obtained authorization by the Illinois Department of Public Health (IDPH) for COVID-19 test, hence she was transferred to the emergency department for testing.

Physical exam:
In the ED patient was afebrile with a temperature of 98.3 F. Other vitals were stable: BP 123/60, RR 18 and saturating 100% on room air.

Labs and imaging:
A swab was obtain and the sample was sent to IDPH for COVID-19 testing (March 18). Due to her stable condition no other labs or imaging were obtained.

Treatment and outcome:
The patient was discharged the same day back to the rehab facility with supportive treatment and clear instructions to isolate the patient. However, on March 19, COVID-19 testing was reported positive. Whether the rehab facility followed CDC recommended isolation precautions during this waiting-period is unknown.

Lessons learned:
This case demonstrates that extensive testing with quick results and adequate isolation is imperative to mitigate disease transmission, especially in community hospitals dealing with patients from nursing homes, skilled nursing facilities, and assisted living facilities, (collectively known as long-term care facilities) as many of their residents have many risk factors for severe disease and this could result in catastrophic dissemination of the infection.