Concluded Case

SEVERE COVID 19 PNEUMONIA IN A 53YRS OLD MALE

53yrs/M brought to the emergency department with Suspected Covid 19 following a 1 week H/o Cough,Fever on n off and Progressive SOB worsening Suddenly in the preceding 5hrs.He is Known Diabetic on Insulin therapy. Chief Complaints Cough,Fever,SOB Physical Examination On presentation he was hypoxaemic, with an SpO2 of 84% on 15 L/min oxygen, tachycardic RR -48/min,On a 15 L/min non-rebreathing mask (NRM) he improved to 100% SO2. He had a blood pressure of 150/80 mm Hg with a pulse of 129 beats per minute.Chest - B/l Crackles present. Investigations Report Enclosed,COVID RT PCR CAME POSITIVE Management SUGGEST MANAGEMENT PLAN?

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A case of severe covid pneumonia with cheat severity score of 16 / 25 approximately- but positive aspect is 100 % SECOND 15L % min NRM . It think if aggressive treatment is given- patient can be saved But considering the increased incidence of mucormycosis these days -steroids should be judiciously used on lower dose and for minimum recommended period. Antibiotics - 3rd generation cephalosporins Inj Remdesivir LMWH Steroids in low dose - inj Dexamethasone 6 mg / day to start with and then gradually taper . Non- invasive oxygen support Supportive treatment

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GGOs bilateral Hrct suggest lower lobes are involved D-dimer is increased many fold Crp is positive Covid positive pt ABG suggest phas hyponatremia and pt is hypoxic as sp02 is 84% Pt has leucocytosis ie secondary infection Needs to continue treatment defined for covid with broadspectrum antibiotics 02 support by NRM Compensate hyponatremia Consider steroids in low doses with gradual tappering doses Antivirals like Remdesivir if not given should be considered Anticoagulants inj enoxiparum Sos inj insulin if bsl is high

Thanx dr Pushkar ji Bhomia
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Case of COVID infection B/L Pneumonitis RT PCR + ve Treatment according to ICMR protocol + Inj Remdesivir 200 mg stat followed by 100 mg od for 4 days Inj Medrol 80 mg I V daily Inj Ceftrioxone 1 gm iv bd Levocet + montoleukast bd O2 inhalation 02 % to keep above 94% Seroflo and Duoline rotacap inhalation sos by rotahaler Or Nebulize with Budacort Ambroxol 2 tsf tds Most important is strict control of diabetes Treatment of complications Support build up therapy Vit C Vit D3

Inj.Clexane 40mg -s/c
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Complicated covid pneumonia. CT thorax showing bil GGos and organising pneumonia with fibrosis. Bil mod pleural effusion seen. Possibly acute PAE Hyponatremia and hyperkalemia on ABG. Adv Echo CD to see RA RV status, IVC collapsing or not. Continue same treatment. Slow sodium replacement N acetyl cysteine and sodabicarb. Sos Invasive ventilation.

? ILD..PNEUMONITIS .. RT..PCR..COVID-19 POSITIVE.. WITH .. INCREASED .. LEUKOCYTOSIS .. CRP .. D DIMER .. O2 SATURATION DOWN TO 82 .. NEED'S .. MANAGEMENT AS PER PROTOCOLS FOR COVID-19 .. CRITICAL CASE ..

Tnx Dr Shivraj Agarwal sir
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Definitely high risk Covid pneumonia with Diabetes as comorbidity.... CT severity looks above 20... Same covid protocol but requires ICU admission... ABG acceptable but oxygen requirement will persist... Short course steroids only with B. Sugar monitoring... Remdesivir can be considered...

Sir urea n creatinine raised so avoid Remdesivir
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A case of severe covid pneumonia with cheat severity score of 16 / 25 approximately- but positive aspect is 100 % SECOND 15L % min NRM . It think if aggressive treatment is given- patient can be saved But considering the increased incidence of mucormycosis these days -steroids should be judiciously used on lower dose and for minimum recommended period. Antibiotics - 3rd generation cephalosporins Inj Remdesivir LMWH Steroids in low dose - inj Dexamethasone 6 mg / day to start with and then gradually taper . Non- invasive oxygen support Supportive treatment

Congratulations! Your case has been selected as Case of the day and you have been awarded 5 points for sharing the case. Keep posting your interesting cases, Happy Curofying!

Thank you doctor
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Sir it’s Covid with CO-RADS 6, CT Severity score around 16-25(Severe). May I suggest: 1.Inj.Ceftriaxone 1gm IV BD (ATD) or Piptaz 2.IVF 1 unit NS with Bethadoxine@50ml/hr 3.Inj.Dexa 8mg IV BD or (Methylpred 80mg/day) 4.Inj.Remdesivir 200mg IV stat followed by Inj.Remdesivir 100mg in 100ml NS IV BD 5.Inj.Pantop 40mg IV OD 6.Tab.Ivermectin 12mg OD 7.Tab.Immunoguard C BD 8.Tab.montelukast+levocetirizine HS 9.Tab.Dolo 650mg TID/SOS 10.Tab.Mucinac 600mg SOS(incase of excessive mucous secretion) 11.syp.Ascoril D 5ml TDS 12.Nebulise with Budecort BD 13.Nebulise with Ipravent TDS 14.GRBS charting q8h with supplemental Inj.H Actrapid according to Low dose sliding Scale. 15.Supplemental O2 through NRB and plan for Bipap if saturation falls

Treatment given - inj - Dalacin C 600mg IV 12hrly Inj - Meronem 1gm IV 8hrly Inj - Medrol 250mg stat then 80mg 8hrly Inj - Dytor 12hrly Inj - Ascorjet 1.5gm 12hrly Inj - Mucona 8hrly Inj - Asthamax Iv 12hrly Tab - Limcee 500mg TDS Tab - Zincovit BD Inj - IVIG specifically 450 mL (5mL/kg) at 36 mL/h x 3days Tab - Montair LC OD Tab - Barictinib 4mg BD Inj - Clexone 0.4ml S/c BD nebuliser with Budesonide 8hrly After initiating IVIG patient's respiratory function is significantly improved. Now patient switch to oral anticoagulant,steroids and Anti fibrotic

Sarscov2 Rt pcr positive Hrct Ground glass pneumonitis Tree in bud Do cbc ddimer il6 Oxygen Steriod Lmwh bd if ddimer high Remedesivir 200 mg od 100 mg od iv 4 days Il6 positive then cytolizumab Ivermectol 12 mg od3 days Prone position

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