Case presentation

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬
‫اشراف‬ ‫تحت‬
:
‫أد‬
/
‫زين‬ ‫محمد‬
.
‫باسيوط‬ ‫الصحة‬ ‫وزارة‬ ‫وكيل‬
‫د‬
/
‫جمال‬ ‫محمد‬
.
‫باسيوط‬ ‫العام‬ ‫يمان‬ ‫اال‬ ‫مستشفي‬ ‫مدير‬
.
‫لسيادتكم‬ ‫مقدمة‬
:
‫د‬
/
‫مكرم‬ ‫بيشوي‬
.
‫المركزة‬ ‫الرعاية‬ ‫نائب‬
.
‫االيمان‬ ‫مستشفى‬
.

2. Covid case

Clinical Approach and Management

3. Patient Presentation

Female patient 43 years old admitted emergency department on 26/9/20210 .

Past history : pt known to be DM type 1 on insulin , not HTN .

Clinical presentation :

Pt was dysnea , tachypnea , cough of 3 dasys .

Fever of 3 days , general fatigue .

Pt was conscious alert , GCS : 15/15

4. Vital signs

Blood pressure : 120/ 80

Pulse : 95 / min

temp : 38

R R : 24 /min

RBS : 300 mg / dl

Oxygen saturation : 82 % on room air

5. Investigtion
Imaging

CT chest :

Bil lung infeltrations , Ground Glass Opocities , Corad 4 .

EKG : normal sinus rhythm.

Abd U/ S : normal , fatty liver .

6. Labs

CBC:
HB : 9mg / dl , TLC : 2.8 , Lymph : 1.1 , PLT : 75
S Creatinine : 0.9 , S Urea : 32
ALT : 21 , AST : 19
T protein : 7 Albumin : 3.2
T bilirubin : 0.4 , D bilirubin : 0.1 INR : 1
D Dimer : 1.4 , S Ferritin : 1000
Na : 138 , K : 3.9 , Ionized Ca : 0.9
CRP : 77 , HBA1C : 7.5
ABG : PH : 7.38 , Pco2 : 40 , PO2 : 55 , HCO3 : 22
PCR was done on admission and was positive later

7. Management

Oxygen therapy :

Pt was put on NR mask of 10 l oxygen , the saturation was 97 %

Prone Position :

Pt was on prone positin for 4 to 6 hours daily

Feeding protocol:

Low carb, low sugar diet , good hydration , high protein .

8. Treatment

Antibiotics :

Ceftriaxone : 2gm IV / 24 h

Xithrone 500 mg : 1 tab /24 orally .

Rrmedisvir : 200 mg IV loading then 100 mg daily for 5 days .

Anticoagulant : LMWH , prophylactic dose .

Steriods : Dexamethasone : 6 mg IV /24 h

Paracetamol : 500 mg orally / 8 h

Antitussive syrup / 8 h

Vitamins : zinc , cit c

Regular insulin / 6 h + lantus before sleeping

Vit B12 every other day IV

9. Consultations

Hematological consultations :

Pt show normochromic normocytic anemia with thrombocytopenia , for follow up ,
mostly related to Covid infection .

Pt received 2 units of P RBCs and 2 units of Plasma .

For reconsult after 3 days .

Internal medicine :

For control of Diabetes Melitus

10. Progression 1

On 2nd day of admission :

Pt was on NR mask of 10 l oxygen , saturation was 97 % , less tachypnea and
dysnea .

Vital signs : BP : 120/70 , Pulse :85 , Temp : 37.8 , RR : 22

ABG : PH : 7.39 , PCO2: 40 , PO2 : 60 , HCo3 : 22

Investigations : HB : 9.5 , PLT : 88 . TLC : 4.3

RBS : controlled

Others are withen normal .

11. Progression 2

On 3rd day of admission :

Pt was put on ventury 50 , 10 l , oxygen saturation was 94 % , less dysnea and
tachypnea .

Still in prone position .

Vital signs : BP : 120/75 , Pulse : 80/ min , RR : 20 , Temp : 37 .3

CBC : HB : 9.7 , PLT : 66 , TLc: 7.2

Creatine : 0.7 , Urea :22, INR : 1 , D Dimer : 1.2 S Ferritin : 774

RBS : between 140 and 200 during the day

12. Progression 3

On 5th day of admission :

Pt was put on ventury 40 , oxygen saturation was 94 %

Vital signs : BP : 120 / 80 , Pulse : 80/min , Temp : 37 , RR : 21

ABG : PH :7.4 , Pco2: 42 , PO2 : 63 , Hco3 : 23

CBC : HG : 9.5 , PLT 55 , TLC : 7.3

Other investigations are accepted

We start chest physiotherapy

Treatment : xithrone , remedisvir were stopped , steroid descalating to ½ amp / 24
h .

Contol of DM , Good diet and hydration .

13. Progresssion 4

On 7th day of admission:

We descalating oxygen requirement to ventury 31 , the oxygen saturation was 95 %
, less dysnea and tachypnea .

Vital signs : BP : 120 /75 , Temp : 37 .1 , RR : 18 , Pulse : 76/ min

ABG : PH : 7.4, Pco2 : 42 , PO2 : 65 , Hco3 : 22

CBC : HB : 9.3 , TLC 8 , PLT : 80 , Lymph : 2.3

UREA : 44, Creatine : 0.7 , NA : 134 , K : 3.7 , CRP : 24

D Dimer : 0.8 , S ferritin : 330 INR : 1.1

CT chest was done : improved

RBS : controlled , diet control , chest physiotherapy .

14. Progression 5

On 9th day of admission :

Oxygen requirement descend to simple mask of 8 l , oxygen saturation was 96 % .

Vital signs : BP : 120/80 , Pulse : 75 / min , Temp : 37 , RR: 18

ABG : PH: 7.4 , PCo2 : 39 , PO2 : 70 , HCo3 : 24

CBC : HB : 9.5 , TLC : 66 , TLC 7.5

Other investigations were normal

Treatment : stop ceftriaxone , change steroid to oral dose and start to descalating ,
continue antitussive and vit and insulin .

For follow up with heamatologist

Pt was discharged to ward on simple mask and discharged home after 5 dasys