Rishitha Reddy

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COVID CASES MAY-


This illustration, created at the Centers for Disease Control and Prevention (CDC), reveals ultrastructural morphology exhibited by coronaviruses




Link to Masterchart on COVID-19


9) Covid cases

1) Covid 19 with co morbidity (Pulmonology/Rheumatology)

https://nikhilasampathkumar.blogspot.com/2021/05/covid-pneumonia-in-pre-existing-case-of.html


2) Covid 19 with Diabetes 


Questions:

1) Since patient didn't show any previous characteristic diabetes signs, did the Covid-19 infection aggravate any underlying condition and cause the indolent diabetes to express itself? If so what could be the biochemical pathways that make it plausible?

1.The novel coronavirus enters cell hosts through An- giotensin II Converting Enzyme receptor (ACE2). 
ACE2 receptor is found in the pancreas, both on exocri- ne cells and in the endocrine cells, that constitute pancreatic islets. Interestingly, its expression is also relevant in the endothelial cells of the microvasculature supplying beta-cells that produce insulin.
Deficiency of this receptor compromises the vasculature in pancreatic islets, thus decreasing its endocrine function.
2.Cytokine storm - caused by the severe inflammatory response taking place in the lungs - also targets the pancreas possibly causing diabe- tes 

2) Did the patient's diabetic condition influence the progression of her  pneumonia?

COVID-19 pt with diabetes are at higher risk for severe pneumonia. It is due to release of tissue injury-related enzymes, excessive uncontrolled inflammation responses and hypercoagulable state associated with dysregulation of glucose metabolism when compared with patients without diabetes.

3) What is the role of D Dimer in the monitoring of covid? Does it change management or would be considered overtesting? 

The D-dimer molecule is a product of the degradation of the fibrin protein. a biomarker-based evaluation which identifies the amount of ongoing coagulation at a given point of time .D-dimer has been shown to be an indicator for cardiac injury in COVID-19 patients in a setting of prothrombotic state
D-dimer may be able to predict which COVID-19 patients have poorer outcomes. Hence it is used to estimate the severity of the disease and thus change management.
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3) Covid 19 Severe 


Questions:

1. Why was this patient given noradrenaline?

noradrenaline, is a medication used to treat people with very low blood pressure.  Noradrenaline is a vasoconstrictor that predominantly stimulates α1 receptors to cause peripheral vasoconstriction and increase blood pressure.It also has some β1 receptor agonist activity that results in a positive inotropic effect on the heart at higher doses.

2. What is the reason behind testing for LDH levels in this patient?

LDH is an intracellular enzyme found in cells in almost all organ systems, which catalyzes the interconversion of pyruvate and lactate, with concomitant interconversion of NADH and NAD+.Lactate dehydrogenase (LDH) is one such biomarker of interest, especially since elevated LDH levels have been associated with worse outcomes in patients with other viral infections in the past. It is estimated that if there was a >6-fold increase in odds of severe disease and a >16-fold increase in odds of mortality in patients with elevated LDH.

3. What is the reason for switching from BiPAP to mechanical ventilation with intubation in this patient? What advantages did it provide?

BiPap may not be a good option if your breathing is very poor. It may also not be right for you if you have reduced consciousness or problems swallowing

Therefore patient might have got shifted to Mechanical ventilation

Advantages of Mechanical ventilation

  • The patient does not have to work as hard to breathe – their respiratory muscles rest.
  • The patient's as allowed time to recover in hopes that breathing becomes normal again.
  • Helps the patient get adequate oxygen and clears carbon dioxide.
  • Preserves a stable airway and preventing injury from aspiration.
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4) Covid 19 Mild 



Questions:
1. Is the elevated esr due to covid related inflammation? 

Erythrocyte sedimentation rate (ESR) is a blood test. It measures how quickly erythrocytes, or red blood cells, separate from a blood sample that has been treated so the blood will not clot.
The sustained high level of ESR possibly brings a negative effect on COVID-19 patients' prognosis
However the elevation in esr cannot be explained based on the present knowledge on Covid

2. What was the reason for this patient's admission with mild covid? What are the challenges in home isolation and harms of hospitalization? 

 After 14 days of isolation, the patient got tested again for COVID-19 which was positive . He then developed fever since 4 days, cough which was  productive since 4 days and shortness of breath grade 3 since 2 days. He also had fatigue.He lost the sense of taste and smell. Since the patient has SOB of grade 3. This poses a challenge for home isolation.

HARMS OF HOSPITALIZATION 

Patients with COVID-19 had almost 19 times the risk for acute respiratory distress syndrome (ARDS) than did patients with influenza, and more than twice the risk for myocarditis,deep vein thrombosis ,pulmonary embolism, intracranial hemorrhage, acute hepatitis/liver failure,  bacteremia,and pressure ulcers .

 The risks for exacerbations of asthma  and chronic obstructive pulmonary disease were lower among patients with COVID-19 than among those with influenza. 

The percentage of COVID-19 patients who died while hospitalized (21.0%) was more than five times that of influenza patients (3.8%), and the duration of hospitalization was almost three times longer for COVID-19 patients. 

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5) Covid 19 and comorbidity (Altered sensorium, azotemia, hypokalemia) 



Questions:

1) What was the reason for coma in this patient? 

The patient has an spo2 of 20%
This might be due low blood potassium as it can make you breathlessness, as it can cause the heart to beat abnormally. This means less blood is pumped from your heart to the rest of your body (even to brain).This might have lead to cerebral hypoxia and thus leading to coma

2) What were the competency gaps in hospital 1 Team to manage this intubated comatose patient that he had to be sent to hospital 2? Why and how did hospital 2 make a diagnosis of hypokalemic periodic paralysis? Was the coma related? 

Hospital 1 might not have correlated Severe weakness of 4 limbs with low values of potassium which hospital 2 has diagnosed.
Yes, coma is related to Hypokalemia periodic paralysis as it might have caused cerebral hypoxia.

3) How may covid 19 cause coma? 

Coma due to Covid might be due to any of the following causes:
1.After cessation of sedatives, the described cases all showed a prolonged comatose state. 

2.After prolonged periods of mechanical ventilation in the ICU.

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6) Severe Covid 19 with altered sensorium 



1. What was the cause of his altered sensorium?

Can be any of the following reasons
An altered state is any mental state, induced by various physiological( increased hospital stay) , psychological( mental depression due to isolation), or pharmacological maneuvers or agents( drugs of COVID)

2. What was the cause of death in this patient?

This patient is an elderly chronic alcoholic and smoker.
This might have delayed his healing process thus causing death
Also he had elevation LFT and RFT values
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7) Covid 19 Moderate with ICU psychosis 



Questions :

What is the grade of pneumonia in her?

Her grades was 12/25 according to her ct scan.(moderate)


What is the ideal day to start steroids in a patient with mild elevated serum markers for COVID ?


Ideal day for steroid administration is after the 8th day (early of pulmonary phase)of symptoms, when the virus is very low replecable and inflammatory response is about to settle down


What all could be the factors that led to psychosis in 

her ?

It can be due to any of the following reasons:

1.high dose corticosteroid use 

2.Prolonged hospital stay


In what ways shall the two drugs prescribed to her for psychosis help ?

1.Piracetam-
Improves the brain integrative activity, promotes memory consolidation and facilitates learning process. Changes the speed of spread of excitation in the brain, improves microcirculation, without causing vasodilatory effect, and suppresses the aggregation of activated platelets. 
2.Risperidone is an antipsychotic medicine that works by changing the effects of chemicals in the brain.
It is used to treat Schizophrenia, bipolar disorder and irritability

What all are the other means to manage such a case of psychosis?

1.Repeated reorientation of patients
2.Provisions of cognitively stimulating activities for the patients multiple times a day
3.A nonpharmacological sleep protocol
4.Early mobilization activities
5.Timely removal of catheters and physical restraints
6.Use of eye glasses and magnifying lenses, hearing aids and earwax disimpaction
7.Early correction of dehydration
8.Use of a scheduled pain management protocol
Minimization of unnecessary noise/stimuli

What all should the patient and their attendants be careful about ( w.r.t. COVID )after the patient is discharged ?

Recurrence of ICU psychosis 
Multi organ failure

What are the chances that this patient may go into long covid given that her "D Dimer" didn't come down during discharge? 

This patient is a known case of Hypothyroidism and Hypertension since 20 years. These might increase the severity of Covid and thus might cause long Covid 
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8) Covid 19 Moderate 


Questions:

1. Can psoriasis be a risk factor for severe form of COVID?

Elderly psoriasis patients and/or patients using conventional immunosuppressive regimens and biologic agents are at higher risk for infectious diseases. 
But the frequency of COVID-19 does not increase in patients using immunosuppressants, including those receiving biological therapy with a diagnosis of psoriasis

2. Can the increased use of immunomodulatory therapies cause further complications in the survivors?

According to the present knowledge on Covid,there is no indication that people taking immunomodulatory drugs for other diagnosed conditions should be concerned that their medication increases their risk for severe COVID-19,"

3. Is mechanical ventilation a risk factor for worsened fibroproliferative response in COVID survivors?

Patients of Covid with greater fibrotic changes required more prolonged mechanical ventilation, and this in turn was associated with an increased severity of systemic organ failure.
Hence Mechanical ventilation is risk factor 

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9) Covid with de novo Diabetes 


•What is the type of DM the patient has developed ?(is it the incidental finding of type 2 DM or virus induced type 1DM )?

It is most probably the type -1 diabetes ,developed due to viral infection and cytokine storm induced damage to pancreas might have caused the diabetes .!so it could be virus induced type -1 DM 

•Could it be steroid induced Diabetes in this patient?

There is a chance for steroid induced diabetes too but it doesn’t seem much significant when compared to virus induced diabetes .



10) Comparing two covid  patients  with variable recovery 


What are the known factors driving early recovery in covid?

These might be the factors responsible for early recovery of Covid:
1. Better immune response of the patient
2. Good food habits prior to And during the Covid period
3. Early detection of symptoms and thus using medication
4. Age related (Elderly have a slow recovery than young)
5. Maintaining hygiene even after Covid infection
6. Mental strength 
7. Health related (patient with Comorbidities have slow recovery)

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11) Covid moderate with first time detected diabetes:


Questions-

1) How is the diabetes related to the prognosis of COVID patients? What are the factors precipitating diabetes in a patient developing both covid as well as Diabetes for the first time? 



Patients of Covid with diabetes are at increased risk of severity of disease and thus have poor prognosis 
Factors precipitating diabetes can be:
1.Higher affinity cellular binding 
2.decreased viral clearance
3. Diminished T cell function 
4. Increased susceptibility to hyper inflammation to cytokine storm syndrome 

2) Why couldn't the treating team start her on oral hypoglycemics earlier? 

Since the patient’s blood glucose (per and post prandial) are very high. This can no longer be controlled with Oral hypoglycemics. Hence the patient might have been given Insulin as it is evenly distributed over 24 hours.
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12) Moderate to severe covid with prolonged hospital stay:


Questions :-
1) What are the potential bioclinical markers in this patient that may have predicted the prolonged course of her illness? 

The potential biochemical markers in this patient are
Elevated levels of
LFT- Total bilirubin : 1.24 mg/dl
         Direct bilirubin : 0.67 mg/dl
         SGOT : 73 units/ lit
         SGPT : 80 units/ lit
         ALP : 342 units/ lit
RFT Blood urea : 34 mg/dl
         Sodium : 150 meq/lit
         Potassium : 5.2 meq/lit

SERUM LDH 571 units/lit
FBS 332 mg /dl
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13) Severe covid with first diabetes 



1.What are the consequences of uncontrolled hyperglycemia in covid patients?

Severe inflammatory changes in lungs in case of covid pneumonia.

•Delayed recovery of the patient .

Since elevated blood sugar levels favors the virus growth and multiplication.


2.Does the significant rise in LDH suggests multiple organ failure?

High LDH levels

Extremely high levels of LDH could indicate severe disease or multiple organ failure. Because LDH is in so many tissues throughout the body, LDH levels alone won't be enough to determine the location and cause of tissue damage.


3.What is the cause of death in this case?

It May be due to 
Uncontrolled diabetes
Multi organ failure
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14) Long covid with sleep deprivation and  ICU psychosis 

Link to Case report log:


Questions:

1)Which subtype of ICU psychosis did the patient land into according to his symptoms?

The subtype of icu psychosis in this patient is of HYPERACTIVE 
It is characterized by agitation, restlessness, emotional lability, and positive psychotic features such as hallucinations, illusions that often interfere with the delivery of care. It should be remembered that new-onset psychotic symptoms in older adult patients are unlikely to be a primary mental illness, and search for a pharmacological or physiological cause should be carried out. 

2)What are the risk factors in the patient that has driven this case more towards ICU pyschosis?

There are more chances for a Covid patient to be landing into ICU psychosis if he has any of  these Major complications being 1) cardiovascular diseases 2) hypertension and 3) cerebrovascular diseases
Since this patient is a known case of htn since 2 years and had a cerebrovascular episode 2 years back 

3)The patient is sleep deprived during his hospital stay..Which do u think might be the most propable condition?
A) Sleep deprivation causing ICU pyschosis
B) ICU psychosis causing sleep deprivation 

The most probable condition in this case might be SLEEP DEPRIVATION CAUSING ICU PSYCHOSIS
 these might be have caused sleep disturbance and thus lead to icu pyschosis:
Environmental contributors include patient care, noise, light, and medications. 
Patient factors, including illness severity, SOB can also play important roles

4) What are the drivers toward current persistent hypoxia and long covid in this patient? 

The pneumonia that COVID-19 causes tends to take hold in both lungs. Air sacs in the lungs fill with fluid, limiting their ability to take in oxygen and causing shortness of breath, cough and other symptoms.While most people recover from pneumonia without any lasting lung damage, the pneumonia associated with COVID-19 can be severe. Even after the disease has passed, lung injury may result in breathing difficulties that might take months to improve.This might be the  cause for persistent hypoxia in this patient


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15) Moderate Covid with comorbidity (Trunkal obesity and recent hyperglycemia) 

Link to Case report Log:




QUESTIONS: 

1. As the patient is a non- diabetic, can the use of steroids cause transient rise in blood glucose?

Yes, Increase in the blood glucose might be due to the use of steroids, in this case Dexamethasone

2. If yes, can this transient rise lead to long term complication of New-onset diabetes mellitus?

 High blood glucose levels whilst taking steroids may subside after one stop taking steroids, however, some people may develop type 2 diabetes which will need to be managed for life.Type 2 diabetes is more likely to develop following longer term usage of steroids, such as usage of oral corticosteroids for longer than 3 months.

3. How can this adversely affect the prognosis of the patient?

 The reason for worse prognosis in people with diabetes is likely to be multifactorial, thus reflecting the syndromic nature of diabetes. Age, sex, ethnicity, comorbidities such as hypertension and cardiovascular disease, obesity, and a pro-inflammatory and pro-coagulative state all probably contribute to the risk of worse outcomes

4. How can this transient hyperglycemia be treated to avoid complications and bad prognosis?

1.At admission: pre-meal BG: 150 to 180 mg/dl and/or post-meal BG 200 to 250 mg/dl)If there is an anticipated delay in consulting endocrinologist/physician, initiate on Tab Metformin (either immediate or sustained release) 500 mg BD and a Gliptin (Tab Vildagliptin 50 mg BD or Tab Sitagliptin 100 mg OD or Tab Linagliptin 5 mg OD or Tab Teneligliptin 20 mg OD)

2.Indication: At admission: pre-meal BG: ≥180 mg/dl or post-meal BG ≥250 mg/dl

A. Total daily dose (TDD) = 0.4 units/kg/day (age > 65 yr, nephropathy or liver disease, use 0.2 units/kg/day)

B. Total daily dose is divided equally into 4 doses (25% each): 3 doses are for bolus insulin (Regular insulin 30 min before breakfast, before lunch and before dinner) and 1 dose for basal insulin (Inj. NPH insulin at bed time/ 2 hours after dinner).If pre-meal BG value is 140 to 180 mg/dl and/or post-meal BG value is 180 to 250 mg/dl → consult endocrinologist/physician for OAD optimization

5. What is thrombophlebitis fever? Thrombophlebitis is when a blood clot Any veins and slows the blood flow in the vein. It may be due prolonged use of IV cannula. Due to inflammatory reaction, fever occurs.

6. Should the infusion be stopped inorder to control the infusion thrombophlebitis? What are the alternatives?

There is no need to stop infusion to control Theombophlebitis. Instead change the IV cannula to opposite or another site. If there is pain at that site use aspirin or ibuprofen 

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16) Mild to moderate covid with hyperglycemia 



QUESTIONS: 

1. What could be the possible factors implicated in elevated glycated HB ( HBA1c ) levels in a previously Non-Diabetic covid patient?

The elevation in the Glycated Hb is probably due to steroid induced Diabetes. In this case the patient has used Dexamethosone for 7 days.

2. What is the frequency of this phenomenon of New Onset Diabetes in Covid Patients and is it classical type 1 or type 2 or a new type?

In the hospital setting, there is evidence that more than half of the patients receiving high-dose steroids develop hyperglycemia, with an incidence of 86% of at least one episode of hyperglycemia and 48% of patients presenting a mean blood glucose ≥ 140 mg/dL
The mechanism responsible for glucose intolerance after GC administration is similar to that of type 2 DM since steroids increase insulin resistance, which can be up to 60%-80% depending on the dose and type used

3. How is the prognosis in such patients? 

The reason for worse prognosis in people with diabetes is likely to be multifactorial, thus reflecting the syndromic nature of diabetes. Age, sex, ethnicity, comorbidities such as hypertension and cardiovascular disease, obesity, and a pro-inflammatory and pro-coagulative state all probably contribute to the risk of worse outcomes

4. Do the alterations in glucose metabolism that occur with a sudden onset in severe Covid-19 persist or remit when the infection resolves?

High blood glucose levels whilst taking steroids may subside after one stop taking steroids, however, some people may develop type 2 diabetes which will need to be managed for life.Type 2 diabetes is more likely to develop following longer term usage of steroids, such as usage of oral corticosteroids for longer than 3 months.

5) Why didn't we start him on Oral hypoglycemic agents earlier? 

As it is said, not all the patients who are given steroids might land up into Steroid induced Diabetes. Hence Oral hypoglycaemics might not have been prescribed

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17) Covid 19 with hypertension comorbidity 



1)Does hypertension have any effect to do with the severity of the covid infection.If it is, Then how?

It would be plausible to interpret that the high prevalence of hypertension among patients with severe and fatal COVID-19 may be attributed to the vulnerability of older individuals to SARS-CoV-2 infection. At present, there is no clear epidemiological evidence supporting that hypertension itself is an independent risk factor for developing severe disease in patients with COVID-19. 

2)what is the cause for pleural effusion to occur??

The exact pathogenesis of pleural effusion due to SARS-CoV-2 pneumonia is not known. However, patients have significantly increased inflammatory markers, which may signify an increase in capillary and endothelial dysfunction leading to exudation of fluid into the pleural space. Only 40% of pleural effusions were lymphocytic predominant (lymphocytes >50% of nucleated cells), lower than seen in other viral infection-related pleural effusions such as avian influenza.This finding can be explained by relative lymphopenia seen in patients with SARS-CoV-2 infection. Majority (3/5,60%) of effusions were hemorrhagic (RBC >100,000 per mm3) ,While it is possible that intrapleural bleeding could reflect a procedural complication in patients receiving systemic anticoagulation, anticoagulants were held prior to drainage. Moreover, most of these patients were on steroids, which can explain low eosinophils in the pleural space.

It can also be hypothesized that sanguineous pleural effusion in SARS- CoV-2 may be the result of endothelial dysfunction-related microthrombi from underlying inflammation that causes foci of hemorrhage in the lung parenchyma extending into the pleura.

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18) Covid 19 with mild hypoalbuminemia 




QUESTIONS: 

1. What is the reason for  hypoalbuminemia in the patient?

Significantly decreased albumin level is common in severe COVID‐19, but the change in albumin does not parallel the severity of hepatocellular injury in COVID‐19.This suggests that there may be mechanisms other than a hepatocellular injury that explains the profound hypoalbuminemia seen in COVID‐19. One of the possible mechanisms is the intense systemic inflammation being reported in severe COVID‐19. Hypoalbuminemia is common in many inflammatory diseases because increased capillary permeability can result in the escape of albumin to the interstitial space.

2. What could be the reason for exanthem on arms? Could it be due to covid-19 infection ?

In coronavirus 2 (SARS-CoV-2) infection, or coronavirus disease 2019 (COVID-19), describing “erythematous rash,” “widespread urticaria,” and “chickenpox-like vesicles.” 
Whether these manifestations are directly related to COVID-19 remains unclear, since both viral infections and adverse drug reactions are frequent causes of exanthems. An important clue to distinguish between both entities is the presence of enanthem (oral cavity lesions).However, owing to safety concerns, many patients with suspected or confirmed COVID-19 do not have their oral cavity examined.
Only 9% of patients with enanthem had a drug reaction, whereas 88% had an infectious etiology, most frequently viral

3. What is the reason for Cardiomegaly?

Since there is downregulation of ACE2 receptors in Covid, angiotensin 2 causes cardiac thickening by fibrosis thus leading to Cardiomegaly

4. What other differential diagnoses could be drawn if the patient tested negative for covid infection?

1.Influenza 
2.parainfluenza 
3.mycoplasma pneumoniae
4.Streptococcus pneumonia
5. Any other bacterial pneumonia
6. Respiratory syncytial virus

5. Why is there elevated D-Dimer in covid infection? What other conditions show D-dimer elevation?

D-dimer (or D dimer) is a fibrin degradation product (or FDP), a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis.

1.venous thromboembolism (VTE), which can present as either deep vein thrombosis (DVT) or pulmonary embolism (PE). 2. pro-coagulant state

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20) Covid 19 with first time diabetes 


Questions:

1)Can usage of steroids in diabetic Covid patients increases death rate because of the adverse effects of steroids???

Corticosteroids are generally contraindicated in diabetic patients due to the risk of disrupting glucose control leading to acute decompensation. In some cases however, corticosteroid therapy can be beneficial if given early with a well-controlled regimen.
Therefore there might be any increase in death rates due to steroids in diabetics

2)Why many COVID patients are dying because of stroke though blood thinners are given prophylactically???

With the present knowledge on Covid there is no evidence stating that using Anticoagulants would decrease clot formation and thus reduce stroke.
Hence it can be said that they are given as a preventive measure

3)Does chronic alcoholism  have effect on the out come of Covid infection????
If yes,how??

Consuming excessive amounts of alcohol could cause damage to immune cells in the lungs and upper respiratory system which in turn can increase the risk of developing diseases such as tuberculosis, pneumonia ,respiratory distress syndrome  and make the lung more susceptible to virus entry 

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21) Severe Covid with Diabetes 



Questions-

1. What can be the causes of early progression and aggressive disease(Covid) among diabetics when compared to non diabetics?

Diabetes and related traits may increase ACE2 expression, which may influence susceptibility to infection (or more severe infection
Thus it leads to early progression and thereby leading to an aggressive disease

2. In a patient with diabetes and steroid use what treatment regimen would improve the chances of recovery?

A. To continue existing OAD if all of the below mentioned criteria are fulfilled:
i. BG levels are controlled (Pre-meal <140 mg/dl and post-meal <180 mg/dl)
ii. Patient is conscious, oriented and has good oral acceptance
iii. COVID symptoms are mild
iv. KFT and LFT are normal
B. If patient does not fulfil all of the above criteria, consult endocrinologist/physician [to start on basal-bolus insulin regimen (also called as multiple subcutaneous insulin injections or MSII regimen) or intravenous (IV) insulin infusion, depending on BG levels 
3B: If patient is on OAD and blood glucose levels are uncontrolled (Pre-meal BG ≥140 mg/dl or post-meal BG ≥180 mg/dl)
A. If pre-meal BG value is 140 to 180 mg/dl and/or post-meal BG value is 180 to 250 mg/dl → consult endocrinologist/physician for OAD optimization
B. If pre-meal BG value ≥180 mg/dl and/or post-meal BG value ≥250 mg/dl despite being on OAD → start basal-bolus insulin regimen using calculation mentioned in section 3A (Kindly note that in this particular scenario, OADs apart from Metformin and Gliptins need to be stopped). Consult endocrinologist/physician for optimization.
Caveat: Bolus insulin (Inj. Regular insulin) may not always be needed for all the three meals and can only be added to individual meals requiring prandial coverage (i.e., for meals with pre-meal to post-meal BG increment of >40 mg/dl on a given day, regular insulin should be added before these meals on the next day). For example, on a given day BG levels increased from 112 mg/dl (BL) to 204 mg/dl (2h AL). Since increment is >40 mg/dl (92 mg/dl), Inj. Regular insulin should added before lunch on the next day.
 C. If FPG is ≥140mg/dl and post-meal increment in BG level is normal (<40 mg/dl), then one can just add basal insulin (Inj. NPH insulin bedtime/ 2 hours after dinner)
3D: To switch to basal-bolus insulin regimen from insulin infusion
A. Consult endocrinologist/ physician to switch to basal-bolus insulin regimen
B. If there is an anticipated delay in consulting the endocrinologist/physician, follow the steps mentioned below to switch to basal bolus regimen:
i. Calculate the total daily dose (TDD) based on insulin infusion requirements for the last 24 hours: TDD = 80% of the total daily insulin requirement on IV infusion in the last 24 hours.

3. What effect does a history of CVA have on COVID prognosis?

COVID-19 associated ischemic strokes are more severe with worse functional outcome and higher mortality than non-COVID-19 ischemic strokes.

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23) Covid 19 with multiple comorbidities:


1) What do you think are the factors in this patient that are contributing to his increased severity of symptoms and infection? 

Chronic NSAID use since 1991
DM 2 since 7 years 
Bronchial asthma since 7 years
CKD since2 years
Dyspnoea of grade 4

2) Can you explain why the D dimer levels are increasing in this patient? 

This patient has many comorbidities over a long time.
1. Diabetes mellitus since 7 years
2. Pulmonary kochs since 7 years
3. Bronchial asthma since 7 years
4. Chronic kidney disease since 2 years 
 All these comorbities increase the risk of COVID and also its severity.
Also all these comorbities increase the values of d dimer.
This might be the reason for his sudden increase of d dimer 

3) What were the treatment options taken up with falling oxygen saturation? 

initially he was given 15 L O2 but as his spo2 continued to fall, he was put on cpap and eventually intubated

4) Can you think of an appropriate explanation as to why the patient has developed CKD, 2 years ago? 

(Note: Despite being on anti diabetic medication, there was no regular monitoring of blood sugar levels and hence no way to know for sure if it was being controlled or not)

The patient is a Diabetic since 7 years .As a result High blood glucose can damage the blood vessels in your kidneys. When the blood vessels are damaged, as a result the waste products start accumulating. Thus causing Chronic kidney disease/ Diabetic kidney disease

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