Detail explanation of COVID 19 pneumonia, with a clinical case discussion on it. moreover, SOAP format of the case presentation also available. just to improve knowledge not for clinical use.

1. CASE ON COVID-19
PNEUMONIA

2. INTRODUCTION
PNEUMONIA: It is an infection the inflames the air sacs(alveoli) in one or both lungs. the air sacs
may fill with fluid or pus, causing cough with phlegm or pus, fever, chills, SOB.
CAUSES: bacteria, virus and fungi.
COVID-19 PNEUMONIA: Pneumonia that is caused by corona virus (SARS-COV2 VIRUS)
Signs and symptoms:
Fever, dry cough(may be productive), SOB, fatigue are common early signs of COVID 19
Others are; chills, Nausea, vomiting diarrhoea, belly pain, muscle/body ache, loss of smell or taste,
sorethroat, congestion/runny nose, pinkeyes, skin rashes.
Early signs that covid-19 causing pneumonia are- Rapid heart rate, Rapid respiratory rate,
SOB, breathlessness ,dizziness, heavy sweating

3. PATHOPHYSIOLOGY:
entry into host cells is the first step of viral infection.
where the spike glycoprotein of the virus binds to ACE2 receptors which are mainly expressed on type ii alveolar
epithelial cells of lungs(weakly expressed on the surface of epithelial cells in the oral and nasal mucosa and
nasopharynx), indicating that the lungs are the primary target of SARS-COV 2.
membrane fusion of the virus and the host cell is activated after binding, and viral rna is subsequently released
into the cytoplasm, establishing infection.
The infected cells and inflammatory cells stimulated by viral antigens can produce pro-inflammatory cytokines
(PICS) and chemokines to activate immunological reactions and inflammatory responses to combat the viruses.
cell-free and macrophage-phagocytosed viruses in the blood can be transmitted to other organs and infect ACE
2-expressing cells at local sites(highly expressed on myocardial cells, proximal tubule cells of the kidney, and
bladder urothelial cells, and is abundantly expressed on the enterocytes of the small intestine, especially in the
ileum).
Moreover, high Ang-ii levels in the lungs can increase vascular permeability and cause pulmonary edema.

5. DIAGNOSIS:
IMAGING- CHEST X-RAY, CT SCAN.
RT-PCR TEST, COVID-19 ANTIGEN TEST, COVID-19 ANTIBODY TEST.
CBC(NEUTROPHILIA AND LYMPHOPENIA), D DIMER ( HIGH)

9. DAY WISE INFORMATION
DAY 1: C/O SOB
COUGH WITH SPUTUM SINCE 2 DAYS.
O/E, PATIENT C/C
B.P- 130/90 MMHG
PR- 100 BPM
RR- 22/MIN
SPO2- 99% ON 4LO2
TEMP- 99F
CVS- S1S2 +
RS- BAE +
CNS- NO FND
P/A-SOFT
ADVICE:
MONITOR VITALS
SEND INVESTIGATIONS
FOLLOW DRUG CHART
INFORM SOS
DAY 2: NO C/O
TEMP- AFEBRILE
B.P- 130/90 MMHG
PR- 100 BPM
RR- 24/MIN
SPO2- 93% ON RA
CVS- S1S2 +
RS- BAE + , CNS- NO FND, P/A-SOFT
ADVICE:
COLLECT ALL REPORTS, FOLLOW DRUG CHART
MONITOR VITALS, INFORM SOS
DRUG CHART: SAME AS DAY1, EXCLUDE INJ.DECARDON
ADD: CHANGE DOSE AND FREQUENCY OF
INJ.REMEDESVIR 100MG IV OD
INJ.METHYL PREDNISOLONE 40MG IV BID
T.MONTEK FX 60MG PO BID.

10. DRUG CHART DAY 1:
BRAND NAME GENERIC NAME CATEGORY DOSE ROUTE FREQ
INJ.REMEDESVI
R
remedesvir antiviral 200mg IV stat
INJ.AUGMENTI
N
Amoxicillin+clavulanat
e
antibiotic 1.25g IV TID
INJ.DECARDON dexamethasone corticosteroid 6mg IV OD
INJ.PAN pantoprazole PPI 40mg IV OD
INJ.CLEXANE enoxaparin anticoagulant 10mg SC OD
T.ZINCOVIT multivitamin multivitamin 1tab PO OD
T.LIMCEE Vitamin c Vitamin 1tab PO TID
T.CALCIQUI
CKD3
Calcium + VitD3 vitamin 1tab PO Once
weekly
INJ.OPTINEURO
N
Vit B6+B12+B2+D
panthenol
vitamin 1amp IV OD
T.BILASURE M Bilastine+montelukast Antihistamine+
Leukotriene
antagonist
1tab PO BID
SYP.RESWAS Chlorpheniramine maleate and
levodropropazine
Antihistamine+
antitussive
15ml PO TID

11. LABORATORY DATA:
OTHER DIAGNOSTIC TEST: RAPID ANTIBODY POSITIVE(COVID-19),
CTSS-11/25, CORADS-5.
Day 1 Day
2
Day 4 Normal range
Hb 16.4 15.7 15.7 13.5 -17.5g/dl
pcv 46 46.4 46.9 40-52%
TC 7560 7570 5920 4500-
1100cells/mcL
N 83 83 81 55-70%
L 14 11 13 20-40%
E 1 0 0 1-4%
PLT 1.76L 1.62
L
1.62L 1.5-4.4L/mcL
Sr.C
r
1.2 1.1 1.0 0.6-1.5mg/dl
Na 138 138 141 136-150meq/L
K 4.2 4.2 4.2 3.5-5.5meq/L
Ca 9.4 9.4 9.5 8.5-11
DAY
1
Normal range
SGOT 50 8-45IU/L
SGPT 40 7-56IU/L
ALP 111 50-100
bilirubi
n
1.0 0.3-1.0mg/dl
T.pr 6.8 5.7-8.2gm/dl
albumi
n
4.2 3.2-4.8gm/dl
globuli
n
2.6 2.5-3.4gm/dl
A/G 1.6 1.2-1.5
DAY 1:
PT TEST- 13 (normal range- 11-
13.5 sec)
INR- 1 (normal range- 0.8 to 1.1)
D-DIMER- 605ng/ml (<500ng/ml )

12. DAY 3: NO SOB
O/E, PATIENT C/C
B.P- 140/80 MMHG
PR- 80BPM
RR- 16/MIN
SPO2- 92% ON RA
TEMP- AFEBRILE
CVS- S1S2 +
RS- BAE +
CNS- NO FND
P/A-SOFT
ADVICE:
MONITOR VITALS, FOLLOW DRUG
CHART
INFORM SOS
DRUG CHART: SAME AS DAY2
DAY 4 : NO FRESH C/O
TEMP- AFEBRILE
B.P- 130/80 MMHG
PR- 78 BPM
RR- 20/MIN
SPO2- 98% ON RA
CVS- S1S2 +
RS- BAE +
ADVICE:
SPIROMETRY
FOLLOW DRUG CHART
MONITOR VITALS
INFORM SOS
COLLECT REPORTS
DRUG CHART: SAME AS DAY2

13. ADVICE AT DISCHARGE:
TAB.MOX-CV 625MG TWICE DAILY AT 9AM AND 9PM FOR 7DAYS.
TAB.PANTOCID 40MG ONCE DAILY BEFORE BREAK FAST FOR 15 DAYS.
TAB.ZINCOVIT ONCE DIALY AT 2PM FOR 15DAYS.
TAB.LIMCEE 500MG TWICE DAILY FOR 15 DAYS.
TAB.LUMIA 60K ONCE WEEKLY FOR 8 WEEKS
TAB.MONTEK FX 60MG AT 10PM AT BEFORE BED TIME FOR 5DAYS.
TAB.IFAXA(RIVOXABAN) 10MG ONCE DAILY FOR 10 DAYS.
FORACORT( FORMETEROL+BUDESONIDE) INHALER 200MCG 2PUFFS WITH SPACER TWICE DAILY FOR
30 DAYS.
INCENTIVE SPIROMETRY.
HOME PULSE OXIMETRY AND HOME SPO2 MONITORING.
HOME VENTILATION.
PROHANCE HP PROTEIN POWDER 2 SCOOPS TWICE DAILY 15 DAYS.
REFER AFTER 7 DAYS WITH CBT, RFT, SR.ELECTROLYTE, CRP, DIMER, FBS, PLBS.

15. SOAP
 SUBJECTIVE EVIDENCE:
shortness of breath, cough with sputum, generalized weakness,
burning sensation in abdomen since today morning.
(FEVER WITH CHILLS AND GENERALIZED BODY PAINS 10 DAYS BACK, TREATED AS VIRAL FEVER AND GOT DISCHARGED 2DAYS BACK)
 OBJECTIVE EVIDENCE:
RAPID ANTIBODY POSITIVE(COVID-19)
neutrophilia and lymphopenia. D DIMER - HIGH
CTSS-11/25, CORADS-5.
 FINAL DIAGNOSIS (ASSESSMENT):
Based on subjective and objective evidence, the patient is diagnosed with COVID-19 PNEUMONIA

16.  PLAN:
 GOALS OF THERAPY:
To relieve symptoms(shortness of breath, cough with sputum, generalized weakness,
burning sensation in abdomen )
To decreases the further progression of diseases.
 GOALS ACHIEVED:
The symptoms are relieved.
 MONITORING PARAMETERS:
Disease specific: monitor SPO2, monitor signs of SOB.
Drug specific: NIL
 PROBLEMS IDENTIFIED:
SYP. RESWAS is prescribed which is for dry cough, but the patient had C/O cough with sputum
(they would have prescribed SYP.RESWAS LS)

17. THERAPEUTIC MANAGEMENT OF HOSPITALIZED ADULTS WITH COVID-19: ( GENERAL TREATMENT )
If dexamethasone is not available, an alternative corticosteroid such as prednisone, methylprednisolone, or hydrocortisone can be used.
Disease severity Treatment recommendation
Hospitalized but does not
require supplement oxygen
Symptomatic treatment is done
Hospitalized and require
supplemental oxygen
Use one of the following option:
1. Remdesivir(200 mg IV once, then remdesivir 100 mg IV once daily for 4
days or until hospital discharge).
2. Dexamethasone( 6 mg IV or PO once daily for up to 10 days or until
hospital discharge) plus remdesivir( for patient who require increasing
amounts of supplemental oxygen).
3. Dexamethasone( when combination with remdesivir cannot be used or
not available).
Hospitalized and requires
oxygen delivery through a
high- flow device or
noninvasive ventilation
Use one of the following option:
1. Dexamethasone
2. Dexamethasone plus remdesivir
3. For patients with rapidly increasing oxygen needs and systemic
inflammation:
Add either barictinib/tofacitinibe or IV tocilizumab/sarilumab
Hospitalized and require
IMV Or ECOM
1. Dexamethasone
2. For patient who are within 24hrs of admission to ICU:
DexamethasonePlus IV tocilizumab/ IV sarilumab

18. • For patients with high thrombotic risk ( those with dyspnea, RR->24, spo2-<90%, rising d-dimer
level, elevated CRP. Use of anticoagulant therapy with parentral heparin( in ICU), enoxaparin
SC 1mg/kg twice daily( non ICU) or other anticoagulant drugs.
• ANTIBIOTICS ( A small number of viral pneumonias can also develop a bacterial infection within
the lung)
penicillins (ampicillin plus sulbactam), (amoxicillin plus clavulanate)
piperacillin plus tazobactam
cephalosporins (ceftriaxone, Cefepime)
aminoglycosides (tobramycin),glycopeptides (vancomycin )
• VITAMIN SUPPLEMENTS to boost immunity.
• Other Symptomatic treatment in done.

19. SPECIFIC TREATMENT:
INJ. REMDESIVIR(200 MG IV ONCE 1ST DAY, THEN REMDESIVIR 100 MG IV ONCE DAILY FOR 4 DAYS OR UNTIL
HOSPITAL DISCHARGE).
DEXAMETHASONE( 6 MG IV OR PO ONCE DAILY FOR UP TO 10 DAYS OR UNTIL HOSPITAL DISCHARGE)
TAB.MOX-CV 625MG TWICE DAILY.
TAB.PANTOCID 40MG ONCE DAILY.
TAB.IFAXA10MG ONCE DAILY.
FORACORT INHALER 200MCG.
TAB.ZINCOVIT ONCE DIALY.
TAB.LIMCEE 500MG TWICE DAILY.
TAB.LUMIA 60K ONCE WEEKLY FOR 8 WEEKS.
TAB.MONTEK FX AT 10PM AT BEFORE BED TIME.
FORACORT INHALER 200MCG 2PUFFS WITH SPACER TWICE DAILY.
SPECIFIC TREATMENT:
 INJ. REMDESIVIR(200 MG IV ONCE 1ST DAY, THEN REMDESIVIR 100 MG IV ONCE DAILY FOR 4 DAYS OR UNTIL HOSPITAL
DISCHARGE).
 DEXAMETHASONE( 6 MG IV OR PO ONCE DAILY FOR UP TO 10 DAYS OR UNTIL HOSPITAL DISCHARGE)
 TAB.MOX-CV 625MG TWICE DAILY.
 TAB.PANTOCID 40MG ONCE DAILY.
 TAB.IFAXA10MG ONCE DAILY.
 FORACORT INHALER 200MCG.
 TAB.ZINCOVIT ONCE DIALY.
 TAB.LIMCEE 500MG TWICE DAILY.
 TAB.LUMIA 60K ONCE WEEKLY FOR 8 WEEKS.
 TAB.MONTEK FX 60MG AT 10PM AT BEFORE BED TIME.
 FORACORT INHALER 200MCG 2PUFFS WITH SPACER TWICE DAILY.
 SYP.RESWAS LS 10ML THRICE DAILY.
 SYP. APTIVATE 15ML THRICE DAILY.
 OXYGEN THERAPY IF SPO2 IS <90%.

20. PATIENTCOUNSELLING:
Eat balanced nutritious diet(protein rich diet foods like boiled egg, meat, nuts). Fresh vegetables
and fruits.
Stay hydrated ( drink at least 8-10 cups of water(2-3lits))
Avoid smoking and consumption of alcohol. Avoid eating outside food.
Have adequate sleep(6-8hrs) and rest. Avoid physical exhausting activity take break from normal
routine to give body the rest it need to recover.
Self monitoring at home- temperature, SpO2 level with help of pulse oximeter.
Breathing exercise- using incentive spirometer.
Take regular medications as advised.
Home isolation to avoid the spread of disease.
Inform the doctor immediately if you are feeling feverish, increased breathlessness, dizzy, hot
and cold flashes, SpO2 level less than 90(can use home ventilation).