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Mr. Rinto, 50 years old, came to emergency room with shortness of breath that has been
worsening since 3 days ago, intermittent fever, sore throat and non-productive cough
since 5 days ago. He went to out of town recently, but denied contact with ill patient. He
had a history of hypertension with amlodipine 10 mg, daily.  He took paracetamol for 2
days. The family brought him immediately to nearest hospital.

QUESTIONS

1.       What are the problems?

 SOB (3 days ago)

 Intermittent fever
 Nyeri tenggorok
 Batuk tidak berdahak
 Riwayat keluar kota
 History of hypertension

2.       What is the hypothesis?

 Pneumonia
 COVID-19
 Pulmonary embolism
 Bronchiolitis obliterans

3.       What is the further information do you need?

 Batuk darah?
 Swab antigen/PCR?
 X-ray chest nya buat liat ada kerusakan pada paru ga
 Pemeriksaan sputum (gramstain, kultur) -> penumonia

4.       What is the most important question that you have to ask?

 Protokol kesehatan
 Gejala lainnya seperti penciuman dan perasa ilang?
 Orang sekitar ada yg serupa ga?
 Ada penyakit bawaan seperti asma ga?
 Obat hipertensi nya rajin diminum ga?
 Riwayat penyakit jantung atau keturunan

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The doctor from Emergency Unit noticed that he was difficult to breathing. Respiratory rate
was 36 breaths per minute, pulse was 110 beats/minute, temperature was 38°C and blood
pressure was 160/100 mmHg. He was alert but confused and agitated. Chest examination
showed symmetrical on both side of the lung, increased tactile fremitus, and bronchovesiculer
sound appear bilaterally on auscultation. Crackles and rhonchi are presence. Cardiovascular
and neurological were essentially normal. His abdomen was soft. According to his wife, he
has history of hypertension but has never taken any drug, and no history of diabetes and
other chronic diseases.

QUESTIONS

1.       What is the problem now?

 Difficult to breathe
 Tachypnea
 Tachycardia
 Fever
 Hypertension
 Confused and agitated
 Peningkatan tactile fremitus
 Suara nafas bronkovesikuler
 Crackles and rhonci

2.       What is the further investigation that you need?

 Chest x-ray
 Swab PCR
 Pemeriksaan sputum -> pneumonia

3.       How does this information help you?

 Dari page ini kita tahu, gada masalah cardiac nya sama neurological, dari organ
abdomen juga gada masalah. Disini ditemuin dia punya hipertensi ga kekontrol.

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Laboratory findings on March 19th, 08 (morning)

Hb                      : 15.4 g/dl (13.2 to 16.6 mg/dl)
Ht                       : 43 ( 38.3 to 48.6 percent)
WBC                  : 12.000 / mm3 (4,500 to 11,000 WBCs per microliter)
Platelet              : 256.000/ mm3 (150-450)
Diff count           :            
Eosinophil                       : 0 (0-6%)
Basophil                         : 0 (0,5% - 1%)
Segment neutrophil          : 85 (40-60%)
Band neutrophil              : 1 (0-5%)
Lymphocyte                    : 10 (20-40%)
Monocyte                        : 5 (2-8%)
NLR                                : 8,5 (0,78-3,53)

ESR                   : 13 mm/h

0 to 10 mm/h in children ·
0 to 15 mm/h in men younger than 50
0 to 20 mm/h in men older than 50

QUESTIONS

1.       How do you interpret the laboratory finding?

 Leukocytosis  infections
 High segmented neutrophils means neutrophilia  inflammatory and infections
 Decreased lymphocyte  lymphocytopenia  infections
 NLR  mild stress
 ESR  masih normal

 
2.       What is the most possible etiology?

 Infection tapi masih belom tau etiology nya  dari WBC nya gabisa suggest ini viral
or bacterial

 
3.       Does this change your diagnosis?

 Ngga, masih tetep pneumonia covid-19

 
4.       What are the further investigations that you need?

 X ray, CRP, D-dimmer (liat faktor pembekuan darah, PCT,

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A chest x ray was done, and the result was showed on figure below. The next laboratory
findings were:
ALT                                 : 63 iu/L (7-55)
AST                                : 61 iu/L (8-48)
Albumin                          : 2,74 g/dL (3,4 – 5,4)
Ureum                            : 22,4 mg/dL (5-20)
Creatinin                         : 0,7 mg/dL (0,74 – 1,35)
LDH  (lactic acid dehydrogenase)     : 895 U/L (140 – 280)
CRP                                : 164 mg/L (kurang dari 10)

Very high levels of CRP, greater than 50 mg/L, are associated with bacterial infections about
90% of the time. In multiple studies, CRP has been used as a prognostic factor in acute and
chronic infections, including hepatitis C, dengue, and malaria.
PCT                                : 0,3 ng/mL (less than 0,05)
D-Dimer                          : 16,2 ug/mL (less than 0,50)
Na/K/Cl                           : 128/ 3,9/ mmol/L (normal Na 135-145, normal K  3,6 – 5,2,
normal Cl  95-106)
RBS                                : 186 mg/dL (70-100)
Swab influenza A, B                    : negative
 

Blood gas analysis: pH   : 7.5; pCO2: 30 mmHg; pO2: 65 mmHg; HCO3: 28; BE: +3; SpO2:
85% with NRM 15 lpm

(dari ABG nya ”Metabolic alkalosis without compensation”, kemungkinan terjadi karena
mineralkortikoid yg berlebih atau untuk balance electrolyte imbalance)

Gram stain and culture of sputum were negative for bacterial but positive for fungal with
resistant with fluconazole; and confirmatory testing was recommended.. The result of RT-
PCR and culture of nasopharyngeal swab from reference laboratory was positive for SARS-
CoV2. 

QUESTIONS

1.       How is his condition now?

  Positif COVID-19
 Ada fungal resistant with fluconazole

2.       What should the doctor do?

 Pantau TTV nya

 Berikan obat untuk symptoms nya
 Kasih oksigen

3.       Why have her lung changed?

 Karena kelebihan inflammatory response

4.       What is the diagnosis now?

 COVID-19 pneumonia

5.       What does support the diagnosis?

 PCR positif saturasi oksigennya turun

6.       What are the important clinical features that suggest viral pneumonia?

 Bilateral interstitial infiltrates pada CXR, positive covid-19, gram-stain sama culture
nya negative untuk bakteri
Bilateral interstital infiltrates and loss of marking di mid dan lower zone.
Kostofrenikusnya tidak tampak

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Because of the respiratory failure, Rinto was intubated and placed on ventilator, prone
position. The doctor gave him remdesivir loading dose 200 mg in first day, continued 100 mg
once daily for maintenance (iv), meropenem 1gr, three times daily, levofloxacin 750 mg,
once daily, dexamethasone 6 mg once daily, enoxaparin 0,6 mg, twice daily (subcutaneous).
Supportive therapy and adequate nutritional were given to her. 

QUESTIONS

1.       What do you think about the treatment?

 Remdesivir (antiviral)
  Meropenem (antibiotik beta-laktam untuk pneumonia yg severe/crtical)
 Levofloxacin (fist line therapeutic agents for the management of severe community-
acquired pneumonia)
 Dexamethasone (sebagai corticosteroid untuk antiinflmmatory dan immunosupressan)
 Enoxaparin (sebagai anticoagulant)

2.       What is the remdesivir?

 Antiviral

3.       How successful are antiviral agents in the treatment of viral pneumonia?

 Antiviral therapy might reduce mortality of patients with pH1N1 pneumonia, even when
initiated more than 48 hours after onset of illness. Greater protective effects might be in
males, patients aged 14–60 years, and patients with PaO 2/FiO2<200.