A Family Doctor’s Clinical-Epidemiological Diary in Spain of the Times of Covid-19. Chapter 3. April 1 to 31: Some Good News and Hope by the End

April 1st

A medical colleague from the health center is positive COVID-19; it started with diarrhea and myalgias and the polymerase chain reaction (PCR) was positive. However, she was not treating respiratory patients and consultations were by telephone... But with her was a family medicine resident who also made guards at hospital... I imagine that the vector of infection was that resident doctor and the hospital... [17]. Spain is the country with the highest number of infections among healthcare personnel, 20% of those infected belong to this group, compared to 10% in Italy and 3% in the USA [18].

In Castilla la Mancha there are 7,047 positive cases and 774 deceased to date. The trend of the epidemic in Spain is descending, but 204,178 people have already been infected and have caused the death of at least 22,282; the number of daily deaths today rises to 430 patients, with 3,968 positive cases more than in the last 24 hours, representing an increase in infections that remains at around 2%.

I put on a cloth gown... although all the consultations are by phone and in the waiting room there are only very few patients go by to control warfarin. I had not won a gown to pass the consultation for 20 years! I was doing the consultation without any medical uniform. Also now I wear a mask all the time...

I have 32 patients on my agenda for the day. They are all telephone consultations. There are various “normal” queries: A 32-year-old man with possible bleeding hemorrhoids, a 26-year-old woman with facial herpes simplex impetiginization, a 57-year-old woman with chronic nasopharyngitis, a 14-year-old man with allergic rhinitis, a male 49-year-old with asthma, a 56-year-old man “who only wants an acetaminophen recipe to have at home”, a 29-year- old woman with renal colic, a 44-year-old woman with low back pain and sick leave, a woman 58 years old and another 70 for hypertension control, a 37-year-old woman, who reports that she is “dizzy again”, another 33-year-old woman, pregnant, a 66-year-old man with gout...

And cases related to COVID-19, among which there are three new cases of respiratory infection, and the rest are follow-ups and related problems: A woman of 54 with anxiety; she works in a kitchen and says that there are “several positives people”; asymptomatic, but very worried about being able to infect her husband (he has COPD), a 44-year-old man with a fever of 38º, cough, malaise and general pain, headache, and asthenia; he says that in his work (assembler of metal structures) there are several colleagues with symptoms of COVID-19, but none has been tested, a 62-year-old woman on the 12th day of evolution of COVID-19 (with PCR performed), and presenting with weakness, headache, persistent anosmia, and insomnia; She says that is very ill because cannot sleep; no fever for 5 days; her husband admitted to the hospital for COVID-19 pneumonia, a follow-up of a 31-year-old man with contact with a (theoretical) case of COVID-19 in the work, a 33-year- old man with a bronchial asthma clinic; no fever; despite salbutamol he has wheezing and dyspnea at night. The cases of respiratory infection continue to be considered all of them COVID-19 “possible”, since PCR is not performed. Can there be some criteria that guide COVID-19 diagnostic in respiratory infections when PCR is not done? [19].

The COVID-19 crisis is dominating our lives... I have a cat at home, “Trotsky”. As soon as I get home, he comes to greet me, and then follows me everywhere; more like a dog than a cat! If I catch COVID-19 and I have to isolate myself at home, how will I deal with Trotsky? It it makes me uneasy to know that the CDC recommends that dogs and cats also follow social distancing guidelines [20]. Does that imply that “Trotsky” should be wearing a mask (and gloves...) and keeping distance from other cats...?

April 2

In Spain, with 950 deaths recorded this date is the hardest since the beginning of the crisis. The deceased reached 10,003 and the registered cases, 110,238. However, these have three consecutive days slowing down the rate of increase. In Castilla La Mancha there are 7,682 positive cases and 854 deaths.

Another PCR test from the nurse working with my patient list is also negative. She is practically asymptomatic. She will join work tomorrow. I find the negativity (twice) of the PCR strange given its symptoms and the epidemiological context... But I have to keep in mind that our sense of urgency to do something may shut down the decision-making process prematurely, before exploring reasonable alternatives [21].

I have 30 patients with telephone consultation (Figure 1). I am seeing patients with an already evolved clinic from previous days, continuations of sick leave also from previous days, and two new cases of respiratory infection:

Click to enlarge

A 61-year-old man who had been admitted to the hospital 5 days ago has died; He had been seen in the emergency department 15 days ago due to a fever of 38.5ºC and a one-day headache, without respiratory symptoms, with normal chest X-ray and discharged with antibiotic therapy and aerosols; he returned to the emergency room for persistent fever without reaching 39ºC, headache and progressive dyspnea from the previous day, despite treatment. No cases of COVID-19 at home. PCR was positive. His medical record included hypertension, type 2 diabetes, moderate COPD, and obesity. He was on enalapril treatment. Bilateral pneumonia was verified. In its evolution, it became secondary respiratory failure, with desaturation despite a reservoir, tachypnea, nervousness, and in poor general condition. He was evaluated by the ICU, ruling out invasive mechanical ventilation. He was exitus 12 days after the onset of symptoms.

I return home at the end of my day. I am tired and still feel strange, I have to drive 30 km. I see the fields next to the river Tagus full of yellow flowers and the trees of a deep green colour… We are in spring. Life is re-emerging as every year ..., but I do not feel reborn and vital like other springs. It is a strange, oppressive time ... And yet the yellow fields are beautiful ... How satisfied am I to be a doctor working with COVID-19 patients during the pandemic?

April 3

Another extension of the mandatory confinement is announced until April 26 at the moment. There are 8,523 positive cases and 916 deaths in Castilla La Mancha.

At 7 AM my computer does not connect to the internet server! I am lost because I do everything by phone and with the computer... I look at the connections... It was the cable of the telephone disconnected... we used it so much... so; the cable must have been pulled...

There are 20 patients with telephone consultation: a few for reasons not related to COVID-19: phlegmon, dermatitis, anxiety, polyposis nasal, rheumatoid arthritis, plantar fasciitis...

And the majority, with 3 new cases of respiratory infection, they are especially a follow-up of previous cases, and anxiety problems (will the epidemic of COVID-19 be followed by an epidemic of anxiety? [22]; and sick leave related to COVID-19:

A 32-year-old male, nurse, asthmatic, with positive COVID-19 PCR, who continues his sick leave, a 62-year-old woman, with COVID-19 confirmed with PCR, who is better, without cough or fever, but insomnia and night headache;

epigastric pain attributed to treatment with amoxicillin prescribed in the hospital, a 51-year-old woman who is better, although slight cough and nasal congestion persists with anosmia and dysgeusia, a 29-year-old woman, no fever for more than a week, who is well , without cough or dyspnea, a 40-year-old woman, on the 17th day of evolution, who reported symptomatic improvement, afebrile for 4 days, but persisted anosmia, ageusia and myalgias; she is a worker in a nursing home with contact with COVID-19, a 41-year- old man with a slight cough and slight general malaise and headache, a 50-year-old woman with anxiety about COVID-19 due to being working in the administrative area of the hospital, a 24-year-old woman whose co-worker is in isolation on suspicion of COVID-19, a 50-year-old man with a cough and several cases of COVID-19 at work, and a 48-year- old woman who wants a request for an X-ray of chest due to fear of COVID-19 pneumonia, although she is asymptomatic … However, patients may have normal chest radiographs and have COVID-19; Physicians should not reassure patients with normal chest radiography [23].

April 8

In Castilla La Mancha 11,788 positive cases and 1,255 deaths. In Spain: 146,690 infected; 14,555 dead and 48,021 recovered. I receive the data of those affected by COVID-19 confirmed with PCR, in the area of the health center (a neighborhood of 20,000 inhabitants): 98 positive and 6 deceased. On my patient list (2,000 patients): 4 positives. Probably in my patient list there are 20 times more positive, and the same regarding the neighborhood: it could be 2,000. Obviously, all patients with symptoms remain untested, except those who go to the hospital with severe symptoms or are admitted [24].

I have 35 patients with telephone consultation.

There are three new cases of respiratory infection / contact and many follow-ups: a 56-year-old woman who reports being better, no fever for more than 5 days, without dyspnea at any time, although he continues with some cough and myalgia persists, a 38-year-old man on the 14th day of evolution, with persistence of some dry cough, anosmia and ageusia, a woman 62 years old, better of the evolution of COVID-19 who cries... “she is depressed by her husband who remains hospitalized with significant deterioration and cannot go with him .., a 60-year-old man who complains of a headache “for having a cold”..., a 53-year-old man -year-old hospital warden, who asks to be discharged from work, after a cure confirmed with PCR, a 40-year-old woman who says she has been taking care of her mother (who was seen in the hospital’s emergency department) and who has had a low fever for 2 or 3 days, without other symptoms, a 71-year-old woman with odynophagia and myalgia, a male of A 31-year-

old woman who refers to “contact with a case”...

In addition, other queries not directly related to COVID-19: anxiety, hypertension, your dog’s bite, dental pain, possible Bartholino cyst, hypercholesterolemia, dyspepsia… April 14th. After Easter In Castilla La Mancha there are 14,329 positive cases and 1,714 deaths. In Spain 172,655 infected, 18,056 dead and 67,504 recovered.

There have been several holidays for Easter. I have been confined at home following government regulations ... In any case; I know I am lucky... I was able to go out, despite the fact that it rained for several days, to my small patio at home where there are four trees; a fig tree, a palm tree, a cypress and a quince tree... This situation started not long ago, but it seems like a century to me... Yesterday April 13 was the first day of returning to work for non-essential activities in Spain.

The medical partner admitted with COVID-19 who did a “cytokine storm” is better... she could be discharged this week [25].

I have put on a cloth cap and gown, as well as a mask... They pass me a protective gown that I keep for the future...; It is disposable, and I only have that... Although in reality I am not currently treating patients face to face, with some exceptions, and never with respiratory symptoms. I find it difficult to decide the appropriate level of protection and to be able to follow it correctly. “It’s better to be lucky than to do it well” [26].

I speak with the Coordinator of the health center and I thank him for not including me in the respiratory care shift following a precautionary principle according to which older doctors are being reassigned to non-contact tasks with respiratory patients [27]. But, I have doubts for the near future, when face-to-face visits begin, not by phone. Since there may be non-respiratory symptoms as the only manifestation of COVID-19, and asymptomatic and pre- symptomatic can be contagious. I ask about the rules on the protective equipment recommended for the doctor, when attending patients not specifically with the COVID-19 clinic [28, 29, 30, 31].

I receive an email with the list of patients with a positive test result for COVID-19 belonging to my health center, which with updated data as of April 13, 2020, are 113 positive with 8 deceased. Of which 6 are from my surgery, with 2 deceased.

There are 60 patients with telephone consultation. There are many more queries than my average! But I understand that it is partly due to the previous holidays. Among the consultations related to COVID-19, there are 3 new cases of respiratory infection, and follow-up of the previous ones:

A 62-year-old woman with COVID-19 calls me to tell me that her husband of 68 has passed away. He had diabetes mellitus, dyslipidemia, and hypertension; he was not on treatment with Angiotensin-converting – enzyme inhibitors or angiotensin-receptor blockers. For 15 days, she presented dry cough without dyspnea, and loose stools; Right upper lobe pneumonia, with an acceptable initial clinical situation, but he presented frank respiratory deterioration with progression of the pulmonary infiltrate, requiring, after objectifying hyper inflammation data, pulses of corticosteroid therapy, and after persistent respiratory failure, tocilizumab and ventilatory support with BiPAP were inserted and high flow (30 l / min); due to the bad evolution, immunoglobulins and anakinra were inserted, with a bad final evolution, dying; he had been repeatedly evaluated by the ICU that rejected his admission.

In addition, I mainly attend follow-ups of possible COVID-19 that started days ago, and three new cases. Men present more biological pathology, but women (caregivers of their children, the elderly and the rest of the family, and also frequently social-health workers) will present greater and more lasting psychosocial problems [32].

I make a face-to-face consultation: a 35-year-old man with dermophicosis of the beard. In addition, other non-COVID-19 consultations by phone: various allergic rhinitis, hearing loss and occasional dizziness, cystitis, anxiety, hypothyroidism, urinary incontinence, dermatitis, insomnia... It has been a hard day. The sky is covered with black clouds and a light rain falls as I drive home… but on the green and yellow expanses of the fields, precious patches of red poppies are appearing.

April 20th

There are 16,796 positives and 2,021 deceased in Castilla La Mancha. The same level of increase is not being seen in the cases that existed previously. In Spain, the death toll drops to 399. I receive the list of patients with a positive test result for COVID-19 from the health center: 126 positives (out of 20,000 inhabitants: 1%), and 8 deaths (8 out of 126 positive tests: 6%). In my consultation 6 positives (out of 2000 patients: 0.3%), and 2 deceased -two males- (out of 6 positives: 33%).

Three doctors have died in 24 hours in Castilla-La Mancha. The nurse on the afternoon shift, who went back to work without having had a PCR before, will not come today; the PCR came back positive and now she is told to remain in isolation at home for five weeks waiting for her COVID-19

test to turn negative to return to work. We still do not know almost anything about immunity [33].

Despite everything, my colleagues and I asked the Directorate to do the test [34]. But I understand the complex context of the tests, including the problem of their validity, but the truth is that the fact that we still do not do diagnostic tests for possible cases, confuses the diagnosis and alters the true incidence rate [35, 36, 37, 38, 39, 40].

I attend 40 patients (by phone). I don’t see any new case of respiratory infection. I am not seeing for days the same level of increase in cases that I had seen previously. Many calls are for follow-up and continuations of work sick leave by COVID-19:

A 40-year-old woman who has been in quarantine due to contact with possible COVID-19 for 15 days, and who “as it is being observed more ... takes her temperature 3 times a day and has 37.3ºC, and spent 2 days with throat discomfort, and then 2 days with loose stools ..., another woman who takes discharge from work after being asymptomatic (presented fever, cough and diarrhea), a 34-year-old woman who also takes discharge from work after being asymptomatic, another 31-year-old woman also discharged, who says that “she is like a rose,” several phone calls to monitor her progress and maintain her sick leave: 6 due to anxiety over COVID-19...

And a few other calls were for reasons not related to COVID-19: a 53-year-old woman recently diagnosed with Hodking lymphoma, an 80-year-old woman with low back pain and paresthesias in the hands and feet, a continuation of sick leave in a woman pregnant, toothache, hypertension...

April, the 21st

Castilla-La Mancha registered the first positive case for coronavirus on March 1 and the first died on 12 of that same month. Today, it faces 17,045 positive cases “detected” and 2,075 deceased “registered”. Lack of diagnostic tests remains the fundamental problem in a crisis that is improving in health centers. However, the nursing homes, with 750 deaths, have entered an escalation that does not stop, since the positives are 3,960 in 218 centers [17].

Perhaps, the difference is that the cases at the beginning of the outbreak were mainly respiratory presentations (and to a lesser extent digestive), but now non-typical or non- respiratory presentations appear [41].

I have 39 telephone inquiries.

Some queries for problems other than COVID-19: Insomnia, tension headache, low back pain, miscarriage, dental pain, vasovagal syncope, a burn when making fritter...

Two consultations for new respiratory infections: A 69-year-old man with a slight cough with expectoration (and a history of COPD), and a 31-year-old man who spent a couple of days with deep cough and dyspnea, was now better (Should patients have a pulse oximeter at home to identify patients who deteriorate earlier?) [42].

And most of them were follow-ups of cases of respiratory infections with and without PCR done, and contacts with proven or possible cases: A 54-year-old woman in follow-up for anxiety due to COVID-19 and on sick leave, a 40-year- old man on his 29th day of evolution, who presented pneumonia with undetectable PCR, and still reports asthenia in convalescence, a 32-year-old man on the 18th day from symptoms onset that he is asymptomatic, another 44-year- old man with 21 days of onset, who presented dyspnea with minimal effort, but reported improvement over previous days, a 53-year-old man on day 20 from the onset of symptoms, with a dry cough and slight diarrhea, a 60-year-old man with a positive COVID-19 PCR, and who continues to have a headache with a cough, a 41-year-old COVID-19 woman who was asymptomatic, another 62-year-old woman also COVID- 19 positive with grief due to the death of her husband in the hospital due to COVID-19, a 40-year-old man with 14 days of evolution and only with ageusia and anosmia; she works in a nursing home, a 55-year-old woman who presented a clinic compatible with COVID-19 for 1 month, asymptomatic, another 26-year-old woman who is asymptomatic on her 17th day of evolution, and who was treated with azithromycin... (Throughout the world, therapeutic management of SARS- CoV-2 has been largely supportive, and to date, no specific therapy has been scientifically proven to reduce mortality) [21].

April 24

In Spain, the daily deceased drop to 367, the lowest number in a long time. The contagion figures remain at 2%, but a month ago we were at 35%. In Spain, more than 34,000 health personnel have been infected (more than 16% of all infections). In Castilla La Mancha: 18,053 positives and 2,255 deaths (832 in nursing homes) [17].

I have 29 patients with telephone consultations. With a new case of respiratory infection, follow-up of previous cases and problems and sick leave related to COVID-19. Perhaps, the difference is that the cases at the beginning of the outbreak were mainly respiratory presentations (and to a lesser extent digestive), but now non-typical or non- respiratory presentations appear [41]:

A follow-up of a 45-year-old man on day 31 of evolution who still reports headache, and comments that he had skin lesions on the hands that he describes as “between blisters and chilblains” of 1-2 weeks of evolution [43].

And to a lesser extent, other problems not related to COVID-19: rhinoconjunctivitis-asthma, hypertension, dental pain, type 2 diabetes...

April 27

There are 19,286 positives and 2,365 deceased in Castilla La Mancha. The Spanish Health Authority has changed its criteria several times in its reports. In any case, the evolution is clearly downward and gives us hope. But although the virus recedes, there are still infections and we do not know where [44].

I have 30 patients for telephone consultation. On many occasions, in addition to those who make an appointment, many patients call me directly (sometimes several times a day!): cystitis, arthritis, arthralgia, malleolar edema, plantar fasciitis, allergic rhiniconjunctivitis, control for prostate cancer, hypertension, low back pain, nail dystrophy, type 2 diabetes...

I have 4 patients with anxiety related to COVID-19, for fear of returning to work.

There is a new case of respiratory infection and 9 patients in follow-up contact who are still asymptomatic (one of them says: “what worries him most is not having a job”; another patient says that she cannot be in isolation because she has her three children with her”).

I have several patients requesting a test for COVID-19. And again, possible cases of COVID-19 with unusual symptoms [41]:

• A 38-year-old man with hip pain after presenting dry cough, ageusia and anosmia in mid-April.
• A 36-year-old man with swollen interphalangeal joints of hands with itching or slight pain on movement, from a couple of days coinciding with a slight cough (arthritis, dermatitis?).
• A 46-year-old woman with an itchy papule-vesicular rash that left crusts on the external aspect of the ankle, anterior region of both legs and anterior aspect of the foot, reappearance of light cough with occasional expectoration and low-grade fever (Initially she presented cough, anosmia, fever with a maximum number of 37ºC); she says that the disease “goes in stages ... at first cough ... then general pain like the flu but less cough and without fever ... and now the skin ...” (she has a brother with COVID-19 pneumonia). This patient seems to be right: COVID-19 is a much longer disease, with ups and downs, compared to the typical cold or flu [45].

And some case of confusion in the diagnosis: a 44-year- old woman, with difficulties with the Spanish language, who started 20 days ago with a fever of 38º, was considered COVID-19, but after the appearance of abdominal pain, and the chest X-ray normal, an abdominal pelvic CT scan showed uncomplicated acute colonic diverticulitis.

April 29

In Spain 2,144 infected more. The rate of new infections up to 1% from 0.6% recorded yesterday. In Castilla La Mancha 277 confirmed new infections [46].

I have 16 patients. The volume of the clinic has dropped significantly. All inquiries are by phone. There is no new case of respiratory infection. The consultations are follow-up and many to give the medical “discharge”.

Some patient whose non-COVID-19 diagnosis and treatment had been delayed or paralyzed [47], already resumed: A 63-year-old woman who received first cycle of chemotherapy for newly diagnosed Hodgkin lymphoma during the “COVID-19 times”, and is doing very well, without fever.

And they begin to become more frequent than consultations on other topics no-COVID-19; a 63-year- old man with ulcerative colitis, an 81-year-old woman with chronic atrial fibrillation, a 45-year-old woman with decompensated autoimmune primary hyperthyroidism “due to all the stress of COVID-19”, a 35-year-old man years with sleep apneas, warfarin controls ...

But I still do not know the true incidence of the epidemic, which is possibly more widespread than current data suggested [48].