 Good afternoon. I am Dr. Basavaraj Kuntuji working as a consultant physician and intensive studies at Manipal Hospital in Malaysia. For the next 15 or 20 minutes, I would like to speak to you about outpatient basis management of COVID infection and thereby we will also see whether we can reduce the number of admissions as much as possible. I will be talking to you about the introduction to understand the OPD basis management when to suspect COVID for the first time and when to send for RTPCR when we should get a chest x-ray HRCT chest depending on the timeline basis. We know if ABO are inconclusive what we should do the next and once these are conclusive what we can do the management as an outpatient basis or a home care treatment wise. I will also go through the various medications that what we can use and its adverse effects and we all know how often we need to see the patient as an OPD basis or a tele-OPD basis and when and how to suspect that this patient needs an admission and not to forget a non-COVID diseases during this pandemic also. The whole topic depends on a fact that the COVID-19 infection 80% of such patients can be treated as an outpatient basis treatment that means 80% of COVID infected patients we can manage them as a home care based treatment but however 15 to 20% of the patients requires admission and 5% of these patients require an ICU admission also. So hence here I would like to highlight when we are taking care of the patients at home how we can prevent them getting admission but however in spite of this some patients do need admission and as well as an ICU care and this is what I'm going to speak to you based on the OPD patients that I have seen since last three months maybe around 3000 patients that I have seen over a period of last three months period wherein we have I mean I have tried to manage them at home based treatment or an OPD based treatment and also trying to detect early that when they can require an admission. The foremost important thing that what we need to understand is what is an incubation period in COVID-19. An incubation period is the time between when you contract a virus and when your symptoms start. We all know generally it is 2 to 14 days after the exposure and the average incubation period seems to be around 5 days sometimes it can be 7 days and sometimes as informed as late as 11 day, 12 day also patients have become symptomatic. Why this incubation period is important is the many patients will ask you I had been in contact with the so and so person four days or five days back and they will do the RTPCR immediately within two days and they say they are negative and they seem they feel that we are out of COVID and hence they get relaxed. Hence this incubation period is important to know when to test the patient and when they may become symptomatic. This is what is very important for high risk contacts. High risk contacts we know that patients who have been with the COVID positive patients in the past without wearing a mask spending more than 5 or 15 minutes. So these high risk contacts we need to know that incubation period ranges from 2 to 14 days and hence we need to test them after 7 days of the last exposure. Going to a pathophysiology yes after the incubation period gets over then the virus in that particular person starts multiplying in the cells of the body and these virus will multiply and they will start causing a viremia and this viremia only will lead on to the fever, body pain, headache, myalgia most commonly in the initial 3 to 5 days period of time and we have we have got several patients who have got these symptoms only for one day or two day or three day and then they subside and they feel that they are they are they are out of COVID infection because they are feeling better. But most importantly what we need to understand is from this time onwards there are around 30 to 40% of the patients who will continue to remain asymptomatic even at the end of 10 days and 12 days and they will they and they will for them we can say that yes they are out of COVID complications. But however after these 3 to 4 days of illness when it starts subsiding few of the patients will land up into the second week or what I call between the 5 to 10 days period during this time they may again start having the fever cough breathlessness. So this is what we call host inflammatory response phase wherein the host will start having hyper inflammatory response or there may be a thrombotic response. So this period is the most important for a clinicians like us to detect as well as treat them as well as decide when they need an admission. So this is what is the second phase what we call host inflammatory hyper response or a thrombotic phase and and as I as I mentioned these in during this period we need to find out and treat appropriately and see and prevent whether they can go into the moderate or severe infection and thereby prevent the hospital admission. As I told you incubation period on an average is 5 days. Example a person has met his friend on April 25th. So from April 25th he has met a friend who was COVID positive and now the person X who has met Y, Y was a COVID positive patient and the person X isolates himself for 5 days or 6 days and during this period he remains asymptomatic. But after 5 days of the incubation period he may develop signs and symptoms. So that means approximately on 1st of May he may develop signs and symptoms like fever, body pain, myalgia and all. So I divide them into mainly the two phase that is the initial viremia phase that is first 5 to 7 days which is a viremia phase and most of the symptoms in most of the individuals will subside. But however after 5 to 7 days I mean during this 5 to 7 days very few patients may continue to have fever persisting beyond 5 to 7 days also. But after 5 to 7 days for the patients where the fever is subsided or for the patients where the fever is continuing in them the post inflammatory response will happen and then they start manifesting with cough, fever, breathlessness, chest tightness and all. So during this phase is the most important and crucial phase for all of us to recognize these symptoms and start treatment appropriately as early as possible as well as find out when they require an admission. The alert sign for the home care or as an outpatient department treatment is if they start saying that they are having breathlessness after going to the wash room. Some patients will say that they have a chest tightness or a chest compression. Sometimes they may not be exactly able to express these words but we need to ask leading questions like do you have a chest compression? Do you have a chest tightness? Are you feeling breathlessness? Then they may come out and say yes they are having these symptoms. And an extreme fatigue that means that they are unable to sit, stand, walk and most of the time they are sleepy and especially in elderly this is the most common symptom that what we see. They may not be having fever, they may not be expressing you a breathlessness but they say they are completely fatigue, they are not eating anything and the loss of appetite, feeling very fatigue. Most of the times they are sleepy and when you check their saturation, saturation may be less than 94-92. Some of the in patients will have a continuous excess cough. The cats is also cough, they are not able to speak also and during the each sentence also they will express, they will having a deep cough. When these symptoms are present, this is the period where we say the viremia phase is over but they are in a hyperimmune response phase and we need to treat these patients appropriately at this point of time. Oxonation is been given a very high importance for that mission but however as we all know that we have got two lungs and we also know that even if the one lung is not maintaining only if the other lung can function and the saturation can be 98 even with one lung. So what we need to understand is that for the saturation to become less than 94% there has to be at least 25% to 50% of the total lung capacity might be going low only then the saturation drops. So hence we cannot or we should not depend only on the oxygen level going less than 94% and only then we have to ask them to get admitted but however as I said we need to take this also in talk on apart from their breathlessness, chest tightness, chest compression and extreme fatigue especially more so in elderly individuals. The other important point is if a person is having a high grade fever beyond seven days so these are the patients where again we need to be cautious and treat them apart appropriately. A lot of patients come back to us saying that their HRCT CT scoring is so and so hence what needs to be done. HRCT will not give us any importance if we are doing within five days of their symptom onset. So hence we should decide that if they require HRCT we should advise them to do after five days preferably on sixth or seventh day of their illness that will give us actual importance of the lung involvement. If we do within five days of the symptom onset HRCT may show it is normal and it will give the wrong wrong importance also. HRCT may not be required if the patients are symptomatically doing well at home. So hence if they have got these symptoms if sometimes if the RTP is negative then we can think of getting the HRCT to diagnose the COVID infection. And other important point is when we call with respect to oxygenation we call it as mild if the saturation is less than 94% whereas in HRCT we call it as mild when the score is less than 9 out of 25 or less than 11 out of 40 but both may not correlate. We have seen patients where the score is 18 or 20 or even 22 out of 40 but their oxygen level is more than 94%. So hence do not depend only on the HRCT scoring and then admit depend on all other above mentioned signs and then decide whether we can continue treating them at home or whether such patients requires an admission. Only other thing what we can mention is as we all know the other viral infection is dengue fever. So we all know dengue fever used to I mean we all have treated dengue fever enough number of patients every year. What we know from dengue fever is these patients of dengue fever will have a fever of two days, three days, four days period and as the fever subsides they will land up with complications like thrombocytopenia, dengue hemorrhagic fever, polysericitis only. So exactly the same thing will happen also hence in COVID infection once the fever myalgia subsides do not think that they're totally all right but we need to keep a close watch on them especially between 5 to 10 days or between 7 to 12 days after symptom onset is what I wanted to highlight here. When to suspect or send the further infection RTPCR test especially has to be done in a high risk contacts as I mentioned on beyond 7th day or 10th day of the previous contact. Even if they have got mild symptoms of throat pain or the fever body pain they need to be tested for RTPCR. There are few patients wherein we have seen they may not express appropriate symptoms and they attribute their symptoms for allergy or the dust or the previous illness of their experience hence we need to speak to them in person to the patient or even if they're literally individual and we need to advise them yes you need to get the RTPCR test. The high risk contacts which I mentioned that in these individuals preferably the advice of COVID RTPCR has to be done on 7th or 8th day or if they develop symptoms earlier then also the test has to be done. There is also a question if person develops symptoms whether we should send on the same day or the previous day or the next day it is advisable that if a person develops the fever cough or breathlessness or a body pain either one day prior or one day prior on the same day of the illness or maybe the next day itself the COVID RTPCR can pick up if they have COVID positive so hence do not delay getting the RTPCR test done thinking that it may it may come negative when they are already having a fever cough or breathlessness and we have seen several patients the RTPCR comes negative but patient continues to have symptoms so what what we can do the next. So as I mentioned if the patient is having symptoms of viral infection and if the RTPCR comes negative so do not think that it is negative so hence how we can diagnose that they are having COVID infection what is the next modality is if the RTPCR is negative if they continue to have symptoms we can also ask them to do an HRCT test beyond five days or six days remember if you do within five days of symptoms again the HRCT may not pick up or if they are hypoxic you can do the same day and say that CT scan also will will pick up the COVID infection very rarely we have also seen the patients had symptoms almost 10 days or 14 days back and they are totally cured of infection some of the other family members started having a fever in them we can also do a COVID antibody we know that COVID antibody generally starts appearing after 15 days but with our experience in the patients who are admitted these COVID antibody can present as early as seven days or eight days itself so hence wherever the RTPCR has come negative and if the HRCT also has not picked up sometimes we can ask the COVID antibody and we may feel I mean we may we may not be surprised that COVID antibody may come post you so hence any one of these things are present we should be able to read them I'm talking about the COVID antibody during the illness within 10 days 12 days period the antibody when we do beyond 14 days that is different this is when the acute viral or the hyperimmune response is happening how to diagnose we can use this COVID antibody test also and meantime whether these reports comes positive or negative continue treating patients according to the symptoms and signs hence do not wait for any of these reports to come either positive or negative and what one need to remember also at the end of all these things we need to keep a close watch also on the non-COVID disease because we're seeing a patient who is having the fever of 15 days or three weeks or four or a month duration when we have done a CT test we have found that patient might have turned into a tuberculosis disease patient might have turned into other chest infection also so hence all hence also keep in mind there are non-COVID disease which can exist also during the pandemic situation also okay so we have confirmed the COVID infection with various parameters then what are the outpatient outpatient basis or home care basis treatment that are available and the other question also comes when we should do the viral markers so I would suggest the viral markers can be sent on either on third or fifth day of the symptom and if they are abnormal and if a patient continues to have symptoms we may repeat again after third day if a patient is getting better at home if the patient is improving in them there is no need to do the blood test or the viral markers or even the HRCT test also how often we need to see the patient yes generally we advise for the first time when we consulted if they're not getting better you please again get back to me either tomorrow or or within two three days wherever you have found or you are having some doubts that this patient is a high-risk individual who may require admission or who may require close contacts you please ask them that whether you can look after them either twice daily even at the home care basis or as an outpatient basis or at least the next day you can do a follow so what are the various medications we have and its adverse effects so we have the hydroxychloroquine ivernutin, favipiravir and the monoclonal antibody and colgicin which can be used as an outpatient basis management. Apart from this we also have symptomatic treatment which we can use paracetamol or we can use anti-stimines and the antibiotics also can be used and the specific treatment even in these individual visuals i will say the steroids may benefit in a selected individuals. Coming back to the hydroxychloroquine what we used in the last year that hydroxychloroquine we use it as a prophylaxis we use it at treatment also but in this pandemic yes hydroxychloroquine still may have a role in pregnancy because this is the only safest drug that what we can use in the pregnancy but however it is not for all COVID post-tubations in the pregnancy in the selected individuals who can still choose the hydroxychloroquine because the other drugs like ivernutin and the favipiravir are not to be used in pregnancy. Coming to the ivernutin there are various trials including ivern cork COVID-19 studies same trials are still ongoing but with the available data ivernutin can be used as prophylactic medication as well as it can be used as therapeutic medication also. The dose is also a controversial but to make it very simple you can use the ivernutin 12 mg once daily for three days or as a therapeutic also 12 mg once daily for three days to a maximum five days one can use but however one need to be cautious that ivernutin whenever we use also can cause the arthralgia and diarrhea so some of the patients when they come with arthralgia we need to also check whether they are on these medications and many of the times the medication itself may be causing more symptoms and signs than the disease itself. Coming to the favipiravir yes i am not discussing about its dose at all I am mainly highlighting it also can lead on to the adverse effects like GI symptoms like vomiting and loose motion some patients have got a cns abnormality feeling very very fatigue sometimes even the altered sensorium also perfuming some abnormal behavior it also has got adverse effects on the liver also hence we need to be careful on these adverse effects also. Coming to the anti-stimines yes anti-stimines has to be used if they are having a running nose or nasal block during the early stage but many of the patients may come back saying that they are having a drowsiness or many of the patients also will have a dryness of the mouth so if they are having a dryness of the mouth we need to be cautious whether we should ask them to continue these anti-stimines or not the dyslorety also can cause diarrhea and dryness of the mouth and vomiting so hence in such situation I would advise to stop the medications and give symptomatic treatment for the vomiting and diarrhea and many of the patients improve without these medications. Coming to the most important thing is about the steroids the first point is about the equivalent dose of the steroids the hydro cortisone of 160 mg is equivalent to the prednisolone of 40 mg the prednisolone of 40 mg and it is equivalent to methyl prednisolone of 32 mg and dexelone of 60 mg we have got hydro cortisone available in the IV form as well as a oral form prednisolone is available again as a oral methyl prednisolone again as IV and oral dexelone also is IV and oral some of the patients that I've seen dexelone since the tablet is available as 0.54 and 6 mg some of the patients have taken only 0.5 mg thinking that it will give them a good relief so hence this is hence I have written the what is the equivalent dose that one if we are using what is the dose has to be used there are various trials have been done on steroids mainly the recovery trial codex trial k-covid trial meta-analysis of the steroid trial all these trials have shown that patients who are moderate and severely ill-covid infection steroid has got a definite role and it prevents the mortality also so can we can we utilize these for our patients who are on outpatient basis who are on home care treatment when to use steroids is very very is very important so as I told once the viremia phase gets over suppose the patient has had fever for one or two days and his next two three days he's a asymptomatic and after six or seven the day he starts having a cough so this is a way this is where I feel that he has completed his viremia phase and he's into the hyper immune or thrombotic phase these are the this is the period where if the patient continues to be symptomatic which I told you previously if they have breathlessness chest tightness if the complaints of extreme fatigue still steroid has got a role in these patients sometimes I feel the guideline says that if you have to use steroids if the saturation is less than 94 percent and as I mentioned for the saturation to become less than 94 percent almost half of the lung or 40 or 50 percent the patient's lung has to be affected only when the saturation becomes less and by the time we might have missed the bus so hence we can use this during when the viremia phase gets over if they start having these symptoms we we we can use the steroids but we should also be knowing when not to use steroids if a patient is having diabetic ketosis of course the sugars are high so hence in these individuals a shoe steroids steroid should not be used however as soon as you control the sugar as soon as you control the ketosis if the patients continues to be symptomatic if they require oxygen oxygen therapy and if they are still in a hyper immune phase we can restart the steroids also the other thing that what we need to remember is about the mucar mycosis if a person who is having a unilateral headache face ill pain blurring of vision in them we need to suspect check our opd treatment chart if they're on steroids we need to stop steroids also in such individuals what to monitor yes whenever we prescribe steroids we need to inform the inform the patient or the family that we need to check their sugar level sugar level of more than 300 400 continue them with the steroids again it is not going to help them during this hyper the during this once the viremia phase gets over during this between 5 to 7 days up to 10 or 12 days of management at home they may management at home when they develop these alert signs and symptoms we can start the steroids the dosage also is important it all depends on how the patient is how severe the symptoms are there what I personally use is use a methyl pregnancy alone which I mentioned per day dose of 32 mg for initial one day or two day and later on you can taper suppose this patients who are hypoxic if they're getting admitted we know that we use the methyl pregnancy alone as high as 40 mg twice daily that means 80 mg twice daily so depending on each patient's symptoms we can tend to use the higher dose of steroids but depending on the patient's symptoms we can use the lesser dose of oral steroids in a selected group of individuals and we should not assume that yes we have started steroids on a home care basis and these patients will become better no as far as my experience goes treating as I mentioned various patients out of 10 of these selected group of patients 7 to 8 patients will definitely respond well to the steroids but another 2 or 3 patients may not respond to the steroids either in them we need to use the higher dose of steroids or such patients needs early admission to the hospital and then they may require various modality of hospital based treatment and steroids also have got adverse events and if we think that yes steroids has helped and patient is getting better and maybe after 4 days or 5 days if their symptoms recur if they again start having fever if they become hypoxic if they start having cough we need to suspect there may be an additional bacterial or a possible fungal infection also we need to suspect we need to ask a very leading question like do you have a burning sensation in the mouth examine the mouth for oral candidiasis you ask specific question in genitalia do you have a white discharge or the white discharge in the penile area and then they may come out yes they want these symptoms and hence watch for adverse effects and we need to we need to detect them early and as well as treat them early also this is what I was trying to say the first week within the 5 to 7 days is the viral stage and the second week is the cytokine storm or the hyperimmune response wherein few of the patients may have got tiredness body ache old cough fever which may be persisting or it might have gone and in a selected group of individuals what I said is whether we can use the steroid at these selected group of individuals but do not use during the viral phase but what the guidelines are recommended is use it beyond when they become hypoxic when they get admitted to the hospital but I feel by this time we might have missed the bus and hence if we treat them for these alert signs and symptoms and if we can also know the adverse effects steroids we can use it earlier also in a selected group of patients and thereby prevent their admission but at the same time do not think that yes we have started steroids hence everything will be taken care by them we need to keep a close watch few of the patients still require an admission for the further care as well as management we have seen a patients who saturation was around 8990 and their blood less their hypoxic and they are unable to get the bed so in them yes the oral steroids depending on the symptoms as I mentioned either the methylprednisolone of 16 mg per day as high as 32 mg per day in a very rare cases still higher dose per day has definitely helped them and the next day they when they come for follow up they are told yes they are symptomatically they are symptomatically better their oxygenation also has improved but along with this we also should advise doing the incentive spirometry so that their breathing capacity improves and a deep breathing exercise whatever they know and also the prone position at their home also will definitely help to improve the oxygen we all know if such patients are admitted to the hospital obviously we will advise them for this prone position deep breathing exercise and incentive spirometry also coming to the steroid inhaler most of the patient who have got the symptomatic cough or extreme cough the steroid inhaler definitely has helped them we need we can use the bidocard inhaler 800 mice or up to 1200 mice per day so we should be knowing when we prescribe inhaler the put in the side inhaler comes as 100 or 200 mice so we need to decide about 800 mice per day that what we can use similarly the rotailer also comes as 100 or 200 similarly nebulization also comes around 500 mice in each respite so we need to advise the steroid inhaler definitely the cough will get much better with the steroid inhaler and the studies also have proven especially for home care basis the steroid inhaler will help for the symptomatic cough relief but the word of advice again here after take after they take either inhaler, rotail or nebulization they need to clean their mouth as well as the throat with by gorgling so that the steroid doesn't remain there and it should not lead on to the further adverse effects such as infection so with this I would like also to highlight about outpatient basis management of the patients who were admitted to the hospital who have recovered and who have discharged back to home in them also we get teleopathy as well as they also come back saying that they have got an extreme weakness and what to what to treat most of the patients yes when they continue a good food home food as well as when you give a vitamin B to all supplementation if required the vitamin D supplementation they do improve but however we should not chase the weakness we need to ask specific question is the weakness is getting better every day or the is the weakness is getting worsen if the weakness is getting worsen in such patients or if they want to fever again we need to suspect that they may be having a secondary bacterial or fungal infection and hence we should not chase only about the COVID infection at this point of time hence in these individuals we may have to send a repeat blood test blood culture urine culture and we may have to start the antibiotics and if required the antifungals also and most of them do and most of them do well also so with this with this I would like to thank you hope this has helped you to manage the alert symptoms and science as well as how we can treat them as an OPD basis management but wherever it is required we need to inform them earlier yes this patient needs an admission hence these patients has to be referred for an admission to the hospital also thank you yeah good afternoon sir yes yeah I have a question for you yes yeah actually you're talking about some non COVID related diseases which we need to be careful while treating the cases nowadays and actually to be frank we are getting so many cases with fever and sometimes even with the cold cough also and sometimes with only fever and body pain and sometimes with fever with like some gastro-related symptoms so all these like we can't ask the patient to go for RTPs here for everyone so now my question is how to differentiate those these cases and how to deal with these cases if at all if any of the cases have turned to the COVID so how can we differentiate between those parameters which are nowadays we are checking in the COVID cases like antipythia CRP levels D-drymer all these things so is there any conditions where these also can be like elevated apart from COVID so these are two questions of mine basically to you okay understood well because I was not able to hear you the question one is about how to keep a watch on a non-COVID disease during the pandemic yes the first differential diagnosis has to be COVID we need to see that we do them the COVID test and also continue monitoring the symptoms and if you are unable to do if the COVID RTPs are as negative as I mentioned beyond six or seven days yes we should do the CT test also and if these all comes negative and if you think that yes there is something different than what we commonly see in COVID patients we need to keep a watch on non-COVID disease especially after getting a CT scan few very few patients have also turned into be a tuberculosis and we are sent a sputum AFB and that has turned out to be a positive and such patients have been running around various hospitals getting RTPs here again and again and they were unable to diagnose but since the CTs been much earlier we are able to detect these non-COVID issues especially by doing a CT scan but yes there are patients even at the end of 15 days or 10 days of therapy thinking of the COVID it is the COVID but we need to keep a close watch that whether the non-COVID disease also is possible so what I mean is during the pandemic yes COVID does exist but we need to think of non-COVID disease also depending on their various symptoms and signs okay there is a question from Dr. Nareesh when we use steroids on open basis which is better is it the five days course or paper or 15 days I have mentioned the alert signs and symptoms especially after the viremia gets over the steroids has to be steroids can be used which is better but yes either we can use hydro cortisone which has got glucocorticoid action one is to one or we can use redness alone which has got a four glucocorticoid action and one mineralocorticoid action and when we come to methyl redness alone it has got five is to one but dexona is the only drug which has got the highest glucocorticoid anti-inflammatory action so that is 20 is to one so when you want the highest anti-inflammatory dose then dexona tablet can be used but however the getting a dexona tablet of 4 mg 6 mg is rare so hence sometimes the 0.5 mg only is given and they have been asked to take twice daily there are some prescription where it is written dexona 0.5 mg take twice daily it is not going to help so hence either you use a dexona tablet 6 mg per day or a methyl predisolone which I mentioned ranging from 8 mg to 32 mg very rarely higher dose than this or the hydro cortisone dose which I mentioned the equivalent dose so these are can be used yes initially for two days three days three days they may require the highest dose but as early as possible you try to taper over a period of seven days or maybe up to nine days because we know that moderate to severe cases 10 days steroid is what been advised and then either taper and stop similarly the same thing we can use it here but again what I mentioned is these has to be only after the vitamin phase gets over in a selected group of patients with the particular symptoms and signs these can be used is what I feel the next question is from Sushma sir the D-dimer test done after a COVID recovery is about 2000 and it is not coming down yes so whenever the patient gets discharged we do ask them to come back after one week with a repeat D-dimer or and along with a sugar test done because we know that sugar can vary we need to know whether it is under control or not with respect to specifically the D-dimer yes there are patients where the D-dimer remains high if the patient is getting symptomatically better we can counsel that yes not to worry about this but however the oral anticoagulants can be given at home and you again repeat a D-dimer after seven days oral oral anticoagulants may be like epixima map or or the any other oral anticoagulant you can use it and appropriate those and most of them the D-dimer when you repeat after seven days it will come back to normal and you should be able to manage them as an outpatient basis only the next question is ideal time to send lab investigation whether we need all viral markers or basic gut investigations enough is initial so what i advise is when we treat them as an outpatient basis or a home care basis look at the symptoms and signs if the symptoms or signs are getting better at their home such patients there is no need of doing any blood test for them if beyond third day if they continue to have symptoms we should not be missing the severity of illness also so hence i would advise if they continue to have symptoms beyond third day or if the symptoms are increasing beyond third day or fifth day yes we can have blood investigation as a basic parameters out of which may out of which the CPC in which the total count as well as neutrophil lymphocyte ratio D-dimer and CRP may help at this point of time when they are at home based treatment is what i would advise they need not be on all the blood tests can be done and if they are getting better there is no need to repeat the test and if they're worsening we can do the test again after two days only for the comparison but i would believe in patients symptoms and signs rather than these viral markers because we have seen patients CRP of 256 and IL-6 of 200 but the patients are doing very well whereas the IL-6 is only 5 and the CRP levels are also very low and the patients are not doing hence correlate the symptoms with the investigations and then decide what needs to be done but sometimes if we go on a reverse way like CRP is high and the value markers are high but the patient is doing well in such situations we can wait for further escalation of the treatment the next question is Lina Mukun what kind of pharyngeitis is seen in COVID to be frank generally we tend to avoid examining the oral cavity or the throat but yes if we are doing a tele-OPD consultation we we can see their throat also but in in patients also yes we have seen their throat i'm not sure what kind of pharyngeitis but this pharyngeitis also do very well respond when we start them on steroids if they are beyond the viremia phase also and if required we need to take a ENT consultation also some patients do have lymphaticitis and we need to decide is it a disease or is it an adverse effect of any of the drugs which is causing other issues also we need to keep in mind the Sayyad Sayyad has asked whether aspirin can be used uh yes when the anti-coagulation is required whenever you suspect somebody's D-dimer is high and if there are risk individuals to develop into the arterial thrombus like MI like lower limb arterial ischemia like stroke in such individuals aspirin can be used along with the oral anti-coagulants also but however we need to see that the aspirin alone itself can cause the adverse effects so whenever we are prescribing ask specific questions whether they can tolerate or is there is there any severe gastritis or is there any blood loss that also has to be asked yes we can use aspirin maybe along with the and oral anti-coagulants uh when the D-dimer levels are high the next question is how to treat for increased ferritin and LDH yes as I mentioned earlier correlate the symptoms and signs along with the ferrit along with the blood reports if the patient is doing well do not worry of do not worry about the ferritin and LDH levels if the patient is having more symptoms and signs in them if the ferritin and LDH levels are also high in them yes the steroids will definitely help them but however again do not think that steroids will take care of everything you please keep a close watch and decide when to admit for the next therapy that is required so have a clinical assessment of the overall patients and treat the patients and you may use the viral markers uh in a particular individuals to see that these markers are improving are getting better but however I personally feel the symptoms and signs are the main important things rather than these numbers that what we get the next question again is about the same sir how to manage high ferritin levels lot of importance is being given about these markers including the ferritin there are patients who have recovered and who have got discharge but when you check the ferritin levels are high like 1500-2000 and all if the patients are doing well so not to not to not to worry among these patients and these ferritin levels and the CRP levels will will come down if the patients are having symptoms yes we need to escalate the treatment so hence correlate their reports only with the symptoms and signs but just do not read only these numbers the next question is one patient after discharging was sent on anticoagulant for 15 days he was fine until then overall anticoagulant at the time of discharge may not be required for all the patients and as I mentioned if they have got a high risk of having possible thrombus burden and if the D-diamers levels are high two times or three times yes in them we can use the oral anticoagulants because when you start working in a ccu or in neurosurgery boards or the ICU there are several patients post-covid they have landed with an MI they have landed with a stroke and they have landed with a non-stylation MI so hence we are not sure the evidence is not sure but however we can use them the oral anticoagulants if these symptoms if the D-diamers levels are high in at the time of discharge the next question is when to start CLEXAIN as I am discussing here about the home care management as well as the OPD basis management I feel there is no there is no role of giving a CLEXAIN as an home home home based management there is no need to give any oral anticoagulants what we're trying to see is an outpatient management starting from the symptom onset up to seven days or up to 10 days and with after viremia phase goes of after five to seven days we need to keep a close watch on them that are they symptoms are getting better or getting worse and if they're worse than yes as an inpatient if they require an inpatient definitely we need to use the CLEXAIN after they get admitted either either either once daily or in a given situation twice daily but however the evidence is still not clear so hence when we are treating them as a outpatient basis management that there is no need of giving them a CLEXAIN at their home is what I feel next question is by Dr. Sanjit his follow up D-dimer also was normal from next day patient started developing restlessness and sleeplessness after one week of D-dimer levels were 1300 are the symptoms related to D-dimer level it is very unlikely that D-dimer level itself will cause the symptoms D-diver level is a marker that whether the patient can land up with can land up with a venous or thrombosis or an arterial thrombosis so hence we need to decide that whether the patient is having a stroke or a venous or a cerebral venous thrombosis and hence whether he's in a altered sensorium but however we need to also look at other parameters and rule out are there any other causes for restlessness or sleeplessness and most of the times we need to get and check their drug list what they are taking and some and sometimes the medications itself may be causing and in spite of stopping that if they continue to have a sleeplessness or a restlessness we need to evaluate further further but D-dimer level alone may not cause the restlessness or sleeplessness unless the patient has landed with the complications the next question is by Dr. Vikram we keep seeing GP starting on antiflu or phabiflu as soon as the rat is positive or even mild symptoms is this advisable in my opinion the previous guideline we started I mean last year we started having a guideline saying that it can be H1N1 so hence you start adding phabiflu before the report comes but we know that this is a pandemic of covid we have not seen any H1N1 infection and we know that starting the acetyl tomovir is not going to is not going to help so hence definitely acetyl tomovir if you are talking about the fluvir treatment is there is no role in treating covid infection the second one I think if you are asking about phabiflu I think I will read the question again phabiflu as soon as the rat is positive or even the mild symptoms is this advisable as I mentioned the antivirals what we can use is as an ornament as we use either the hydroxychloroquine or the ibermatine or the phabipiravir in my understanding we are not sure how much any one of these is going to help yes if you believe that phabipiravir helps yes you can use it once the patient is having symptoms as well as once it is turned over here turn out to be a covid positive but however we need to know that phabipiravir can also cause the adverse effect and if we look at the total cost of the the phabipiravir treatment will come up to 30,000 or 40,000 rupees for entire 10 days period yes if you believe that phabipiravir helps you can prescribe phabipiravir as soon as he's been diagnosed as covid-19 or positive along with the symptoms and signs medications which can be used for OPD management of covid in pregnancy yes as I mentioned we avoid using the ibermatine we avoid using the phabipiravir also the only drug which can be used is the hydroxychloroquine which is safe during the pregnancy but however in them also try to manage the patients symptomatically but but if they continue to have symptoms and if they do not have the alert signs and symptoms we can try hydroxychloroquine in them also the evidence again is not clear even in non-pregnant individuals also but since we do not have any other options if they continue to have symptoms and signs beyond the symptomatic the supportive care one can also choose to use hydroxychloroquine in pregnant individuals so hope this has okay there is a last question medications which can be used for OPD management of covid-19 pregnancy that are answered next is so what should be the target blood sugar levels when treating with oral steroids in uncontrolled patients as I told steroids are not for all OPD basis treatment steroids as again and again mentioned it has to be after the viral viremia phase gets over in a selected group of individuals where I mentioned alert signs and symptoms and especially more so if their diabetic and uncontrolled sugar yes if they're having symptoms and signs you can start even in them steroids but however we need to give them medications to aggressively control their blood sugar whenever they're on steroids ideal goal is whether we can continue we can control the sugar as less as below 180 what the evidence shows but however if they have a sugar level beyond 250 300 400 all we need to decide should we continue steroids or should we aggressively control the sugar either with the oral hypochlorous implications or definitely it helps by adding the insulin especially once a day Lantas insulin or you can add the appropriate insulin if they are able to take the medications at home or else we need to monitor or keep asking them every day what are their sugar levels because many of the patients of covid patients are having lots of symptoms and weakness only because their sugars are high and when we have control their sugars within next 24 hours they feel much better even without any specific treatment of the covid infection so hence hence please see that sugars are well controlled more so if you are started on steroids give them an advice give them advise that they need to monitor their sugar and you need to be available to them to advise what medications they can take recently in news few patients died after few days of discharge from hospital any cause attributed I'm not sure patients who have died and we are not come across so that immediately after going home they have died it is very vague that what may be the various causes it may be the same cause that any other illness may be having I'm not sure whether the covid specific itself might have caused but however out of this if they are thrombotic if their D-diamers levels are high maybe an MI may be a pulmonary embolism what we do not know maybe whether the need of oxygen itself might have caused may cause the the sudden death but it is difficult to answer because I feel once the covid infection gets over and they have been discharged they have the same same concerns issues as well as the complications than any other any other patients is what I feel but however they may be having more of possible thrombotic episodes either venous or arterial thrombosis which could be MI which could be a stroke which could be a cerebral venous thrombosis or which could be a ischemia of the intestine which could be it ischemia of the limbs so these needs to be closed watch hence frequent speaking to them and frequent outpatient basis management heliopathy will help to detect such events earlier and we can prevent is what I feel okay with this I would like to conclude and you can still be in touch with me if you have any if you have any queries and you can leave a message especially if you are a medical person so that we can keep interacting and we can keep learning from each other thank you very much thank you one and all thank you