CME INDIA Presentation by Dr Basab Ghosh, Internist, Agartala.

First see a scenario of real life (Discussed in CME INDIA Group)

Dr Sheel Goyal, DNB GEN MED., JAIPUR: As cases are increasing exponentially, if many of the same family members develop symptoms of URI one by one within 3-4 days period, vital parameters and routine CBC being normal, all afebrile, should go for RTPCR for COVID 19?

Dr Kalavathy Elango, TN, Hosur: Yes

Dr Rahul Kapoor, Kanpur: Isolate for 10 days. If all well then what is the need for COVID test, as all are involved.

Dr Pavan Raj: Strict isolation, Watch the symptoms, if increasing then consider for RT PCR

Dr Basab Ghosh, Agartala: Better to go for COVID screening. If, had to go for testing after few days, these days of symptoms will not be counted. Quarantine will be counted from date of testing. So, administrative problems will increase in the house.

Dr Bhanu Pratap Singh, Physician, Siwan, Bihar: If there is associated loss of taste /appetite, cramps in thigh or legs, myalgia and fatigability, definitely go for COVID test. We are getting cases even without ILI with only cramps and fatigability. And I have come across 4-5 cases who have only myalgia and cramps in thigh and calves with fatigability. Interestingly, these pts have HRCT thorax findings even with mild cough as a symptom.

Dr N K Singh: It is now almost clear that up to 32% present with Anosmia and loss of taste. It has been found as reliable as a test. In the UK and the USA, if such symptoms coming, family does not go for test. In all places, now people have developed a tendency to avoid tests.

Dr Anu Jain, Ambala Can’t: But they should isolate for at least 10 days, so as not to spread it to others.

Dr Raju Sharma, Physician, Jamshedpur: I feel, all fevers in this period should undergo testing. I have followed that and nearly all have returned positive while they were treated as “just a fever” by others. It makes the patient aware and prevents further spread and when they develop cough or hypoxia then you are better prepared

Dr Vipul Rastogi, Delhi: Should definitely go for testing. A vast majority have similar history…don’t get tested at all and most of them recover… Some present after 10 to 15 days with SOB and bilateral pneumonitis. So, in these testing times its better that RTPCR be done with CXR CBC and CRP to reduce doubt.

Take-Home Point is that life will now go on with Mask and other measures. People will keep getting infected. No hope in near future. So as physicians, we must be aware about science and art of Home Quarantine. This article is for propagating the means and ways to public.

Dr Basab Ghosh Explores:

(Intention of this post is neither to gain any personal benefit or to hurt any individual, institution, office, department, state, etc; rather intention is if anyhow some support could be extended to the sufferings!)

1) Home management:

• Once positive totally quarantine in the house, preferably in a separate room with separate toilet. Number of persons positive and in the same house how many are negative, this is immaterial. I suggest treat everyone in the house as positive.
• Corona virus is discharged in the stool and possibly those viruses might infect others if sharing the toilet, so always use mask in the toilet. If western toilet, then always keep the lid covered before flush.
• Keep the room as well as house clean. It will be very tuff, but try to clean the floor and other surfaces clean with soap water; if you allow to dry the floor, soap will be dried up and will not cause accident.
• Keep the bed clean. Remember Corona is destroyed in soap water, so clean anything with normal soap water and it’s enough.

2) Diet:

• Healthy diet with normal fruits, vegetables including green leafy vegetables, egg, fish, meat, milk, curds, etc. Healthy diet will increase power (immunity) of the body to fight COVID-19 out of your life!

3) Hygiene:

• Maintain dignity in garbage disposal as per your availability, don’t throw in the roadside. Always arrange disposal to the Municipality garbage container or in multiple packets keep inside your house, it’s a matter of just 14 days!
• Maintain spitting and cough hygiene inside room and in the house. Use facemask as much as possible when coming in two-meter contacts of any positive or negative family members. This will minimize viral numbers (load) in all family members.
• Take daily bath preferably with warm water to avoid cold and cough, because that may disturb in clinical assessment.

4) Awareness:

• Remember at home further assessment is totally symptom wise; your explaining of symptoms, Thermometer and Pulse-oximeter are the maximum helping tools for tele consultations!
• Neither neglect nor overreact, late reporting to symptoms might cause dangerous consequences!

5) Prescription:

[Not to be followed without local physician advice at any cost]

(Those medicines, as Sl. No A to I, as cocktail tried by several experts and according to them it should be helpful.)

A) Tablet Ivermectin 12mg, 1 tad daily for 3 consecutive days. For all family members above 2 yr. age.

(As per Govt of UP circular)

B) Cap Doxycycline 100mg, 1 cap 12 hourly after meal for 5 days, for person having fever, cough or both.

C) Cap or sachet of Vit D 60000 IU in 3 consecutive days as loading dose to boost immediate immunity as most of the Indian population is having Vit D deficiency, thereafter 1 cap or sachet weekly once continue for 8 weeks for all family members.

D) Tablet Vit C 500mg 2 times daily for 10 days, thereafter 1 tab daily continue for 2 months, for all family members.

E) Tab with 50mg elemental Zn preparation is ideal. (As per ICMR, for positive cases 50mg and for prevention 25mg elemental zinc is required.)

F) Xylometazoline containing preparation Nasal drops, 2 drops 3 times, (if nose is blocked as can be checked by pressing the other nose and try to breathe with the another one).

G) Steroid Nasal Spray, 1 spray in each nostril, 2 times in a day. (Steroid Nasal spray is very helpful to reduce local inflammation and prevents entry of Corona virus to the system according to many experts.)

H) Tablet Montelukast 10mg containing preparation, 1 tablet daily once. (According to experts it suppresses the entry of Corona virus in the system.)

I) Steroid Nebulization with Beclomethasone or Budesonide. Some experts addressed it very useful both for prevention and treatment of positive cases. Now, in any COVID treatment centre it is started immediately for complain of cough, sore throat, respiratory troubles, etc.

• The nebulizer machine in BPL costs around Rs 2500 and different companies are also available in the medical instrument shops.
• Dose: each ample of solution 2 times daily. It’s very soothing in my personal experience.
• Cleaning: clean after use in a bucket with soap and water, but don’t clean the connection pipe. With one unit and one mask several people can use after proper cleaning after every use.

[As per expert opinions]

J) Tab Paracetamol 650mg, 3 to 4 tablets daily at 6 to 8 hr interval after some food to keep the fever under control. It also reduces body pain and helps to feel good.

K) Tab Rosuvastatin 10mg, one tablet daily at bed time can be taken irrespective of blood cholesterol levels for better pleotropic benefits by anyone above 30-year age for next 2 months.

L) Dexamethasone or Methyl prednisolone –Not to be started without physician’s assessment. If fever is uncontrolled, cough is increasing, sore throat is disturbing even after regular gargling, some sort of breathing difficulty is felt, you feel that hospitalization is next step, talk to your physician immediately.

M) Injection Low Molecular Weight Heparin (LMWH), for example Enoxaparin can be taken by anyone very easily at home as sub cutaneous infection. Procedure is same like insulin and insulin is always taken by the patient’s own self. This is for just awareness, to be started only after your physician advice. If fever is uncontrolled, cough is increasing, sore throat is disturbing even after regular gargling, some sort of breathing difficulty is felt, you feel that hospitalization is next step, please discuss it to physician.

N) Oxygen supply:

• If Oxygen is required from outside, this part is critical. It may last for several days and expert monitoring is must, so please get hospital admission. Oxygen supply from oxygen filled cylinders or containers requires constant supply from outside, which may not be very easy for a quarantine family. Any drop in required oxygen supply is injurious.
• Best way of Oxygen supply is by Oxygen Concentrator machines. They are costly, around 45000 to 55000 in present Agartala market, though availability is on demand and inconsistent. But very easy to use. It will concentrate Oxygen from room air, so headache of supply from outside is not there, but in any case, it will not work without electricity, so backup cylinders at home is advisable. I came to know many patients are under oxygen support at home, so this ‘para N’ I included, otherwise personally I request immediate hospitalization.

O) Pulse Oximeter:

• It is a simple instrument to measure blood oxygen concentration, costing Rs 1500 to 5000, available. In case of Oxygen Concentrators, Pulse oximeter is attached to that.
• Normal physiological oxygen levels are 96% or above for below 70-year age. For Chronic Asymptomatic and certain other medical conditions and age above 70-year, normal physiological oxygen levels are 94% or above.
• Make measurements indoors, at rest, and during quiet breathing
• Use the index or middle finger; avoid the toes or ear lobes
• Only accept values associated with a strong pulse signal Observe readings for 30–60s to identify the most common value
• Measure and record values two to three times per day
• Remove nail polish from the finger on which measurements are made
• Warm cold extremities prior to measurement.
• Do not panic if suddenly Pulse oximeter shows abnormal values. Many cheap Chinese brands have created unwanted emergencies, unavoidable admissions by giving false readings. Do opt for a good brand.
• Six-minute walking test: very good indicator for home quarantine patients to assess the lung function, because X-ray chest to CT scan of chest is impossible for all. Check oxygen saturation after 3 minute and 6 min normal walking even inside room, if saturation falls by 4% at 6 min walking, very soon oxygen supply is needed. If saturation falls by 4% at 3 min walking, condition might require oxygen supply any point of time.

CME INDIA Take Home Messages:

(I request, this social media post is only as services to humanity, not for any medico legal purpose!)

ICMR UPDATED CRITERIA dated 2nd July for Home Isolation

• The person should be clinically assigned as a very mild/pre-symptomatic/asymptomatic case by the treating medical officer.
• Such cases should have the requisite facility at their residence for self-isolation and also for quarantining the family contacts.
• Patients suffering from immune compromised status (HIV, Transplant recipients, Cancer therapy etc.) are not eligible for home isolation.
• Elderly patients aged more than 60 years and those with co-morbid conditions such as Hypertension, Diabetes, Heart disease, Chronic lung/liver/ kidney disease, Cerebro-vascular disease etc. shall only be allowed home isolation after proper evaluation by the treating medical officer.
• A care giver should be available to provide care on 24 x7 basis. A communication link between the caregiver and hospital is a prerequisite for the entire duration of home isolation.
• The care giver and all close contacts of such cases should take Hydroxychloroquine prophylaxis as per protocol and as prescribed by the treating medical officer.

When to seek medical attention Patient / Care giver will keep monitoring their health. Immediate medical attention must be sought if serious signs or symptoms develop. These could include:

• Difficulty in breathing.
• Dip in oxygen saturation (SpO2 < 95%).
• Persistent pain/pressure in the chest.
• Mental confusion or inability to arouse.
• Slurred speech/seizures.
• Weakness or numbness in any limb or face.
• Developing bluish discolorations of lips/face.

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