Here is what your peers are sharing about coronavirus on Figure 1. 

As the pandemic continues to evolve, healthcare professionals from around the world are sharing their real-time clinical knowledge about COVID-19 on Figure 1.

See how the virus is presenting and being managed in the clinical cases below: 

UPDATED APRIL 4, 2020

Confirmed outpatient COVID-19 case

A 34-year-old woman in Southern California who’s symptoms began in the middle of March with eye and sinus pressure, and loss of taste/smell. 2-3 days later, she developed headache, fatigue, and mild body aches. 1 day later she developed a fever, cough, and shortness of breath. The patient called the city to get tested and was directed to a drive-through testing facility. She self-quarantined for 5 days until a positive SARS-COV-2 test returned. Her fevers resolved in those 5 days, cough is minimal, some headache, sense of smell/taste returned. Her partner at home has since developed symptoms.

See the full case

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UPDATED APRIL 3, 2020

ARDS and Ventilator Management for COVID-19 Case Study

63-year-old woman with COVID-19 is admitted to the hospital for septic shock secondary to CAP. After receiving hydroxychloroquine, antibiotics (which include azithromycin), fluids, and vasopressors, her condition stabilizes. However, she subsequently develops ARDS and is intubated. Her oxygen requirement increases until she is receiving 100% oxygen. Ventilator settings are in the volume-controlled continuous mandatory ventilation mode with RR 22, TV 330 mL (6 mL/kg of ideal body weight), FIO₂ 100%, and PEEP 5. Peak pressure of 25 cm H₂O, and a plateau pressure of 22 cm H₂O... 

 

Thanks to Dr. Raj Dasgupta for sharing this teaching case.

See the full case study

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UPDATED APRIL 2, 2020

A call for chest X-rays to develop new COVID-19 screening tool



Researchers at the University of Waterloo and Darwin AI have launched an open-source project to improve COVID-19 screening using artificial intelligence and chest X-rays.

 

The team is currently looking to collect more chest X-ray data, which is needed to teach the AI models they are building. Do you have chest X-rays (PA or AP view) of patients with COVID-19? Share them on Figure 1 using the hashtag #covid-19 or via the link below to contribute to the project.

 

All data and learnings from this initiative will be made publicly available to the community.

Share a COVID-19 chest X-ray

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UPDATED APRIL 2, 2020

Critical Case of COVID-19



A 42-year-old male patient presented to ED with a two-day history of fever and mild shortness of breath. He had no other symptoms, no past medical history — although he is an ex-smoker.

 He had high-grade fever and O2 Saturation of 91-92 on room air. Chest examinations revealed bibasal fine crepitations. His 

chest X-ray shows cannon ball opacities in both lung fields. 

ABG shows T1RF.

 Basic Blood tests show lymphocytopenia, raised inflammatory markers and stage 1 AKI.
 Patient was initially admitted to the ward but he rapidly deteriorated and developed haemoptysis and severe shortness of breath.

 CT CAP with contrast shows classic COVID-19 infection with CT severe score. No other abnormalities in abdomen or pelvis.

His nose and throat swab tests are positive for COVID-19 four times.



See the full case

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UPDATED APRIL 1, 2020

After three days, he required intubation

A 55-year-old male presented with shortness of breath,progressive cough, and fever over several days. He came back from a holiday in the western part of Austria 5 days earlier. His medical history includes  depression which is being managed with antidepressants. The patient tested positive for COVID-19.
This is his X-ray at admission; PaO2 58 mmHg in room air. After 3 days, respiratory failure occurred leading to intubation.

See the full case

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UPDATED MARCH 31, 2020

Case update: Young adult who required ventilation is now recovering

An update to a case of a 33-year-old male that was shared on March 20. After presenting with a 10-day history of malaise and dry cough, then 3 days of haemoptysis, shortness of breath, and pleuritic chest, he was admitted to ITU for respiratory support, initially for optiflow, but required intubation and ventilation. He completed one week of tazocin and tamiflu. He did not require inotropes or vasopressors during admission. He was successfully extubated and gradually weaned from BIPAP to a nasal cannula. He was fit for ward level management. On the ward his oxygen continued to be weaned and he mobilized independently without oxygen. He improved significantly with complete resolution of inflammatory markers and no oxygen requirement. He was discharged with no medications.

See the full case

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UPDATED MARCH 30, 2020

“CT chest shows extensive bilateral infiltrates”

73-year-old female with a history of cardiac disease, who was admitted for abdominal surgery from a nursing home. She developed shortness of breath and fevers during her hospital stay. CT chest shows extensive bilateral infiltrates, last image shows CT chest compared to three days earlier. She tested positive for COVID-19 and eventually passed away.

See the full case

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UPDATED MARCH 28, 2020

Covid-19 positive and recovering

A 49-year-old male pharmacist presented to the ER with a cough. Flu-like symptoms, sore throat, and mild shortness of breath developed over the next 3-4 days. He has a past medical history of hypertension and no travel history outside the US. The patient was tested for flu and COVID-19 and was sent home to self-quarantine. The next day, the patient was informed that his flu results were negative. He self-dosed with one tab of chloroquine and his symptoms got worse. Two days later, he was confirmed to be #Covid19 positive, at which point he increased his dose and took 2 tabs daily for 7 days. The patient is currently symptom free with residual cough.

See the full case

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UPDATED MARCH 27, 2020

Imaging findings are highly suggestive of COVID-19, but swab is negative

A 67-year-old gentleman came in because of shortness of breath, low-grade fever and general malaise. PMHx asthma. SHx Taxi driver in London. CXR showed bilateral patchy consolidation, with elevated CRP, mildly elevated WCC. Desaturation on room air to 90%. Covid-19 sample came back negative, thus was treated for CAP with Co-amoxiclav. Patient didn’t improve and was still hypoxic on room air 93% saturation. A repeat Covid-19 swab was negative and we did a CT scan to rule out PE. Radiologist reported three features from China and the US highly suggestive of Covid-19: Peripheral distribution, ground glass opacification, bronchovascular thickening, craving paving.These findings were highly suggestive of atypical viral pneumonia COVID-19. (P<0.01).

 

See the full case

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UPDATED MARCH 27, 2020

A young, healthy female now on ECMO

A 27-year-old healthy female presented to the ED with complaints of cough, low-grade fever, and shortness of breath. She was tested for COVID-19 and admitted to the floor and started on Tamiflu, Plaquenil, and Kalentra. After 3 days she developed worsening SOB and was placed on 100% non-rebreather and the critical care team was consulted. She appeared tachypneic, tachycardic, and was using accessory muscles. She was emergently transferred to the ICU and intubated, requiring 100% FiO2 and 10 of PEEP to maintain a saturation above 90%. CXR revealed a mild patchy infiltrate of the RLL. The following morning her oxygenation improved but a decision was made to transfer her to our associate hospital for a higher level of care that offered proning and ECMO.

UPDATED MARCH 26, 2020

A 28-year-old male with confirmed covid-19

28M previously fit and well, not on any regular medications, presented with a 6-day Hx of fever, non-productive cough and SOB for the last 4 days. His symptoms started as sore throat and coryzal symptoms 8 days prior to his presentation. He reported contact with a friend with similar symptomatology.
O/E: T:39.1 HR:87 BP:119/63 RR:38 SpO2 90% on RA. Bilateral nasal crepitations without a wheeze.

See the full case

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UPDATED MARCH 25, 2020

She had recently been on a cruise 17 days earlier

A 49-year-old female with a history of asthma presented with some fatigue, flu-like symptoms, and shortness of breath over a span of a week. Testing came back positive for COVID-19. She was doing well so asked to self quarantine. Images show the spectrum of disease compared to the last COVID case I presented. Here there was only patchy ground glass opacities present on the right lung on CT chest. Only lab finding was mild leukopenia

See the full case

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UPDATED MARCH 24, 2020

"COVID-19 is not a joke"

65-year-old female with uncontrolled type 2 diabetes with HgbA1c 12.8% and hypothyroidism was on a cruise ship, developed cough and altered mental status. She was diagnosed with pneumonia and developed significant respiratory decline requiring mechanical ventilation. Labs showed diabetic ketoacidosis, which has now resolved. Initial chest shown with acute respiratory distress syndrome (ARDS). Found to be #COVID-19 positive. Patient paralyzed, sedated, ventilated and in RotoProne bed without improvement.

See the full case

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UPDATED MARCH 23, 2020

Initial symptoms were flu-like

A 63-year-old patient presented with shortness of breath and chest pain, after returning from a holiday abroad in February. PMH of diabetes and hypertension. Initial symptoms were flu-like for 1 week and on admission, he had a spiking temperature of 39 degrees. Treated for CAP, and within 72 hours Covid-19 was positive. Few days into admission, patient was unable to maintain his saturation and was later intubated and is in ITU, on day 12 now.

See the full case

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UPDATED MARCH 23, 2020

Possible COVID-19

Responded to 32 y/o Female with chief complaint of difficulty breathing and in and out of consciousness. Female had no travel history out of the state and only medical history was asthma. Upon our arrival we took PPE precautions and found the female in her room laying supine sleeping. Female reported she had developed a dry cough within the last couple of weeks. Her fever had progressed and she couldn’t catch her breath...

See the full case

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UPDATED MARCH 23, 2020

He was tested for COVID-19 and admitted

A 80-year-old healthy male presented to the ED with complaints of cough, high-grade fever, and shortness of breath for five days. His O2 saturation is 90% on room and 95% on 8 litres of oxygen via non-rebreather mask.

See the case

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UPDATED MARCH 23, 2020

COVID-19 STEMI

64F transferred from a non-PCI center. Troponin-I 18 and CKMB 70. Cath showed non-obstructive CAD, but was found to be in shock and placed on IABP. Echo with EF 40% and markedly increased wall thickness. No lung pathology. Tested positive for COVID...Thoughts?

Thanks to Dr. Issa Kutkut for sharing this case.

See the case

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UPDATED MARCH 23, 2020

COVID-19 triage protocol best practices

What protocols are you currently using to triage PUI? What are you using for remote (phone/video) vs in-person triage? What thresholds are you using to order testing vs sending home? Related to the above, are you sending samples to the CDC lab or do you have local/private labs available to test specimens?

Join the discussion

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UPDATED MARCH 23, 2020

CT imaging of a 61-year-old female from China with confirmed COVID-19

These CT images demonstrate multiple ground-glass opacities, some of them with reticulation. There are small foci of consolidation involving all pulmonary lobes, with predominant distribution in the posterior and peripheral parts of the lungs, especially in the lower lobes, where most of the opacities spare the immediate subpleural parts of the parenchyma (subpleural sparing).

Case provided by Raioss, a Brazilian startup that works with AI in radiology and PACS that developed Coronacases.org - a platform that allows HCPs worldwide to see and learn from COVID-19 cases.

See the imaging

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UPDATED MARCH 23, 2020

Has anyone seen STEMI mimickers from COVID? 44 yo, predominant GI symptoms, EF 20%, unobstructed coronaries.


Shared by Dr. Balvinder Wasan and posted by Figure 1 on March 23, 2020.

See the case

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UPDATED MARCH 22, 2020

Symptoms started 10 days after returning from Italy

Patient 1977/Male, went on a ski trip in Italy. Came back 08.03.2020. The first signs started after 10 days with temp 40*C, dyspnea, coughing, headache. Went to the testing centers and came positive for COVID-19. Blood work-up is not so dramatic with a very low CRP and PCT. The rtg thorax shows signs of atypical pneumonia. Patient had problems breathing. Without O2 88% with 2L O2 97%. After the first day, the patient was transferred to the ICU and intubated.
No illness history, non-smoker, fit.

See the full case

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UPDATED MARCH 22, 2020

55-year-old with COVID-19

55-year-old man admitted to ICU with positive COVID-19.

*Original case translated from Spanish.

See the full case

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UPDATED MARCH 21, 2020

Prior to being in Colombia, she traveled throughout Europe

26-year-old female who traveled from Colombia to NYC presented to the ED with dyspnea and cough. She wasn’t febrile during triage. HR was 126 and she was saturating at 94% on RA and wearing a face mask. No pertinent PMH. She stated prior to being in Columbia, she traveled throughout Europe from December to February. Immediately placed into COVID isolation after triage. #COVID-19. I apologize for the grainy image.

See the full case

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UPDATED MARCH 21, 2020

A 28-year-old with a history of recent travel to Europe

28-year-old, recent travel to Europe, fever, shortness of breath, cough with later hemoptysis, myalgias. On labs: low WBC, otherwise unrevealing, including negative influenza. Due to strong suspicion of COVID19, CT ordered with following images.

See the full case

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UPDATED MARCH 21, 2020

Early clusters of COVID-19 or something else?

In mid to late January we saw about 15 patients in our clinic with high fever (up to 104), headache, sore throat, dry cough, weakness, and watery diarrhea…several needed IV fluids for dehydration. Do not know if any ended up in hospital. We were not aware or thinking of #COVID-19 at the time.

See the full case

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UPDATED MARCH 20, 2020

Collated imaging findings from #COVID-19 patients

Dr. Daniel Ortiz, a radiologist in Georgia, collated the imaging findings from several #COVID-19 patients at one of his hospitals over five days. See the findings:

See more clinical images

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UPDATED MARCH 20, 2020

He deteriorated and required invasive support

A 33-year-old male presented to the ED with 10 days of malaise and dry cough, then 3 days of haemoptysis, shortness of breath, pleuritic chest pain and dizziness. He has no past medical history but he is morbidly obese (BMI 58.1 kg/m2)...

See the full case

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UPDATED MARCH 20, 2020

How are other 911 systems handling this?

A 51-year-old male, suspected covid patient, was transported by EMS. The patient is awaiting test results from the department of health and was asked to isolate. How are other 911 systems handling this?

 

Join the discussion

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UPDATED MARCH 20, 2020

Would you swab this patient for the virus?

50+ male patient, asthmatic, returning from a COVID-19-affected European country a few days earlier. Started to feel unwell before departure with fever and shortness of breath. No wheeze, hypoxia, tachypnea or tachycardia on assessment, only pyrexial with persistent dry cough. Arterial blood gas readings are all within range. Would you admit this patient? Would you swab this patient for the virus? Does the fact that he is asthmatic make a difference to your decision making? Would you prescribe antibiotics?


Join the discussion

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UPDATED MARCH 19, 2020

No cough, runny nose, or sore throat — Tested positive for COVID-19

A 30-year-old female presented with a history of neck pain and headache for less than a week. No cough, runny nose, or sore throat. My colleague was concerned about meningitis and sent the patient to the emergency department for evaluation. She was assessed, tested for #COVID-19, and discharged home. The test came back positive two days later. Should triage nurses and staff at the front desk be given PPE?


See the case

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UPDATED MARCH 18, 2020

She didn't meet CDC guidelines for COVID-19 testing — how many cases are we missing because of this?

30-year-old healthy female flight attendant presents with a 5 day history of shortness of breath after returning from Australia. Lives in California, US. Non-smoker, no known past medical problems. Initial oxygen saturation on room air was 90%. Chest X-ray showed bilateral basilar infiltrates. Lab results negative. She was given Duoneb HHN, IV fluids, and admitted to telemetry. She didn't meet CDC guidelines for COVID-19 testing (febrile only 99.5) but a sample was collected and sent to a private lab - turnaround is 72 hours. Currently awaiting results. The patient is stable and maintaining oxygen saturation of >95% on 2 liters O2. How many cases of COVID 19 are we missing because they do not meet CDC criteria for testing? See the full case

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UPDATED MARCH 18, 2020

Rapidly developed hypoxemic respiratory failure

44-year-old male with untreated DM2 (A1C 11), no other medical issues or comorbidities, now confirmed #COVID-19. He presented with 1 week of GI-predominate symptoms (epigastric pain, poor PO, 1 episode of vomiting at onset). Progressed to myalgias and non-productive cough but really presented for GI symptoms. Hypoxic to low 90s on RA at presentation, febrile to 101. Rapidly developed hypoxemic respiratory failure over the course of several hours, RA -> max NC -> non-rebreather. So far not requiring intubation. Started on trial of liponavir/ritonavir. Left - CXR at presentation, Right - several months prior.

See the full case

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UPDATED MARCH 17, 2020

Paralyzed, proned, and being considered for ECMO

Female, over 65, with confirmed #COVID-19 who presented with fevers and worsening shortness of breath and diffuse bilateral ground glass opacities and consolidations. She is being treated for ARDS and currently on lung protective ventilation, paralyzed, proned and being considered for ecmo.

See the full case

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UPDATED MARCH 17, 2020

What are your strategies for supportive treatment?

CT thorax of a patient with confirmed COVID-19 sent to me by a colleague from a widely affected country. The patient is in mid 50s and has been otherwise well. CT images obtained 20 days earlier do not demonstrate any pulmonic infiltrates, however there is extensive involvement in current imaging. The patient has the clinical presentation of a case of severe chest sepsis. Knowing what we know thus far, what are your observations and strategies for supportive treatment? [ECMO not available]

 

See the full case

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UPDATED MARCH 17, 2020

A rapid deterioration

Confirmed #COVID-19 crp >300, WBC 11, temperature 38.8, spo2 90% room air, RR 30, terrible wheeze, SOB, sweaty. Rapid deterioration in breathing, intubated and ventilated 24 hours later.

 

See the full case

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UPDATED MARCH 17, 2020

When do you proceed to intubate assuming this is COVID-19?

Patient in early 50s who has a history of SARS when it was going round. Presents with shortness of breath, oxygen saturation in high 80s despite no chronic pulmonary disease. The patient seems to be coping well, but when do you decide to proceed to intubation assuming this is COVID-19? Watch and observe until they begin to deteriorate, or intubate while still well?

 

See the full case

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