COVID-19 Clinical Course and Guide to Management

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COVID-19 Clinical Course and 
Guide to Management
Patients whose symptoms are improved and who
had no fever for three days can leave isolation
The subtle sign of falling oxygen is that the patient’s
may start talking short, fast breaths to compensate
Prof. Emeritus Lt. Gen. Mahmud Ahmad Akhtar
Former Surgeon General/DG Pak Armed Forces

COVID19 is a new disease due to mutation of the corona virus. As it is a new disease all aspect of this infection are being studied. The studies have shown- its onset and the range of early symptoms are unpredictable but when it turns serious it often follows a consistent pattern. While most patients recover in about a week, a significant minority of patients enter a very nasty second wave of symptoms. After the initial symptoms and signs plateau and may improve a little bit, then there is a secondary worsening.


Lt. Gen. (R) Mahmud Ahmad Akhtar

While every patient is different, the studies at the hospitals in the USA and other countries have shown that day five to day 10 are often the most worrisome for respiratory complications. This is the period when the corona virus gets attached to the ACE1 enzyme of the upper respiratory tract i.e. nose, nasal sinuses and throat and moves down to the lower respiratory tract i.e. lungs when worrisome respiratory complications start particularly for older patients i.e. 60 years and above more in 80 and above and those having underlying conditions i.e. respiratory problems COPD etc., high blood pressure, diabetes mellitus, obesity, smokers and other debilitating disorders. Some recent studies have shown that the risk increases after the age of 55, after the age of 85 the risk increases 184 times of a younger patient. Younger patients who develop complications may have breathing difficulties a little later, day 10 to 12.Other patients who reach Day 14 without any severe symptoms other than fatigue, aches and pain are likely to be on the way to recovery.


It is important to ask for medical aid, whatever day of illness if there is breathlessness or any bothersome symptom. Tracking symptoms and paying special attention as the illness enters its second week has taken new urgency as more patients in the UK and USA arrive at the hospital with an insidious form of pneumonia. On scans patient with Covid pneumonia have a finding called ground glass appearance in the lower parts of the lungs usually bilateral.

The condition develops so slowly, a condition called silent hypoxia: The patient feels breathless when the O2 saturation falls to a dangerously low levels causing severe shortness of breath then the patient seeks medical help. The best way to monitor clinical condition during this period is by using Pulse Oximeter. The normal O2 concentration is 96 to 99%. If it drops to 92%, it is time to seek hospital admission. One can improve breathing by sitting upright, on sides or in prone position not on the back.

It is important that the Health Authorities in Pakistan make Pulse Oximeter available in the markets and make people aware about its use through media (all types) and utilize the services of general practitioners and paramedicals so that hospitals health care facilities are not over-whelmed. Telephone Apps have not proved trustworthy. The first part of the illness is viral and the second part is severe inflammatory part due to over stimulation of the immunological system- the release of cytokines storm. This causes acute worsening. It is usually seen around seven to 10 days. It may cause sudden deaths. The kidneys, pancreas, brains, skin, blood vessels (finger toes) may be blocked with clots.


Patients should follow their bodies not time- lines, clinical judgment is the best. The human body does not follow the perfect manual-it has been noted by the clinicians dealing with coronavirus patients. The public should be made aware. Sadly the Pakistan’s Health Care System is poor. There is a dire need of the Public Health education emphasis on prevention, promotion of health, early diagnosis, and early treatment. In our health systems, rural areas are badly neglected. There is a dire need to set the priorities right. There is a need to have Universal Health Care System- not building disease palaces- elitist policy for the elite by the elite. Where a traffic light was needed fly over was built, where country road was needed an avenue was built, where buses were needed expensive metros were built. For health-care money is denied.

Many patients are not specific about the time lines. It is imperative that the doctor takes a good history, listens carefully- unfortunately a dying clinical skill- a thorough physical examination should be done. Pulse Oximeter should be used. Patient and his relatives/attendants should be informed about the disease. The signs of blue lips i.e. cyanosis should be well known. The subtle sign of falling oxygen is that the patient’s may start talking short, fast breaths to compensate, although patients may not notice they are doing so. A small number of patients develop neurological complications having clots in the cerebral blood vessels. The clots keep on appearing even after intervention treatment of clot removal at neurological centers. Some children aged 1-5 may get signs, symptoms like Kawasaki disease, elder children 7-15 may get heart, renal failure (cytokine storm).

Day One to Three: Early symptoms vary widely. It may start with throat irritation, cough, fever, headache, aches and pains, feeling winded or a little chest tightness with a bout of diarrhea. Children often get G.I. symptoms. Some have decreased sense of smell and taste. Some feel just tired. Many get many symptoms but no fever. Some with gastrointestinal symptoms go on to develop respiratory symptoms others do not.

Day Four to Six: Some patients do not develop more than mild symptoms or develop none at all. Others have severe symptoms with persistent fever, aches, pains, chills, cough etc. Some children and younger adults with mild disease develop rashes, itching, red patches, swelling and blisters on fingers and toes like frost bite.

Day Seven to Eight: For some lucky patient with mild illness, the worst is over after a week. Guidelines from the USA Disease Control and Prevention Centre say patients whose symptoms are improved and who had no fever for three days can leave isolation but some patients continue or get worse, some start feeling better briefly then take turn for the worse,. Patient blood oxygen level should be continuously monitored.

Day Eight to Twelve: Monitoring should continue for the second week of the illness. Day 8 to 12 are the days which give an idea whether the patient will get better or worse. The major worry is worsening of breathing or cough. Pulse Oximeter is very helpful. Kidneys, nervous system, liver and pancreas may be involved-blood vessels blocked with clots (Disseminated Intra Vascular Coagulation-DIC).

Day Thirteen to Fourteen: Patient with mild illness should recover. Patients with worse symptoms but maintaining oxygen saturation should mostly recover. However patient with severe symptoms and those who needed additional treatment because of low oxygen may still feel unwell, fatigued and take longer to recover. With above mentioned guidance issued in USA, UK and other advanced countries patients can be managed at domiciliary facilities, district hospitals, primary care centers etc.


Prevention is most important. It consists of quarantine, locking, testing, diagnosing, tracing contacts, isolation, distancing etc. Sadly Pakistan has the lowest testing rate-also lowest preventive measures. The sources of information are from the publication of ‘Disease Control and Prevention Agency’ of USA. They collect information from all hospitals/ clinics of USA and also from abroad- countries in the European Union, UK, Nordic countries, Korea, Taiwan, Singapore, Hong Kong, New Zealand, Australia and also other countries including those with poor surveillance, SAARC etc. WHO also issues news bulletin. Information has also been collected from doctors (my old students) working in the USA, UK-many working at frontline.

Information from the local sources is poor due to the poor health care system. A senior most Physician of Islamabad working at a major Public Health Facility recommended the use of chloroquin/hydroxychloroquin for prophylaxis of Covid 19 on television, the print and social media and also gave a dosage schedule. A major hospital at Rawalpindi also placed its health care workers on prophylactic chloroquin. Senior retired professors claimed that tea made from Senna Makki leaves cures Covid 19.

The reported mortality rate is 1% even less than one in South Korea. In Pakistan it is high, 2%. The point is that 98 to 99% even more recover due to body’s defense mechanisms like immunity etc. The effectiveness of the drug can only be proved by doing “Clinical Trials” scientifically using double blind placebo controlled methods on a large number of patients at many centers arriving at conclusions by doing Meta-analysis. If the drug reduces mortality, the duration and intensity of the disease with acceptable side-effects then the drug has therapeutic value. In India P.M. Modi has claimed “Cows Urine”- to be effective for many ailments- has got patents on many Cow-urine products but scientific proof is needed? In Pakistan, research culture is lacking. Japan had an earth quake, the Japanese discovered the new disease- the Broken Heart Syndrome. Pakistan had earth quakes- there was no discovery. Prevention is the answer. There are many trials of the approved drugs for prevention. Super spreaders need to be checked.

Teaching hospitals should share departments of Clinical Therapeutics/Clinical Pharmacology like departments of Cardiology, Pulmonology etc. to teach medical students and do research as recommended by WHO. Complications of this disease are being studied. There are signs of development of pulmonary fibrosis, asthma, cerebral, renal and other complications, also episodes of delirium, in older people- also dementia- result of lack of oxygen and vascular thrombi.

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