Leeds Covid-19 Recovery Follow-up in Primary Care

Word Version

Managing the Long Term Effects of Covid-19 - Guidance for Primary Care

Post COVID Symptom Considerations specific to COVID-19 Initial investigations to complete as part of clinical assessment and prior to referral When to deviate from the pathway: Red Flags
Fatigue
  • Very common post COVID
  • Consider impact of fatigue on role – e.g. caregiving, vocation, time off work and phased return.
  • Self-management advice in the LTHT Leeds Health Pathway COVID- 19 patient rehabilitation booklet
    http:// flipbooks.leedsth.nhs.uk/LN 004864.pdf
  • Direct patient to NHSE/I
    www.yourcovidrecovery.nhs.uk
  • Reassure that with time and selfmanagement fatigue usually improves gradually
  • If no improvement after 3 months, worsening of symptoms or impacting significantly on life, refer to Community Based Services via SPUR
  • Investigate modifiable contributors to fatigue, considering individual comorbidities and clinical assessment.
    Would usually include:
  • FBC, Fe, B12 and Folic Acid, U+Es, TFTs, vitamin D, Ca
  • Assess and monitor fatigue using the Modified Fatigue Impact Scale
    https:// www.sralab.org/sites/default/LeedsPathways/files/2017 -06/mfis.pdf
    (cognitive and physical domains should be scored separately).
 
Anxiety, depression and PTSD
  • Consider a screening tools PHQ9 for depression or GAD7 for anxiety
  • Quality of life questionnaire - Work & Social Adjustment Scale (WSAS)
  • PTSD more likely in context of premorbid trauma
  • Mood impeding recovery/ causing protracted symptoms where physical examinations are normal.
  • Complex presentation i.e. contribution of several factors/ lack of progress despite physical recovery/ difficulties completing ADLs or work. Consider referral to CMHT or Leeds Mental Wellbeing Service
  • Systemic distress/ carer strain contributing to reactive distress/ relationship breakdown/ loss of support. Refer to Leeds Mental Wellbeing Service
  • Suicidal ideation or immediate risk of harm to self or others refer to Mental health crisis team
  • Neurocognitive problems in the presence of a new or pre-existing neurological diagnosis; refer to Community Neurological Rehab Team
Breathlessness
  • Very common post COVID
  • Exertional breathlessness often persists for many weeks. Usual pattern is a gradual recovery.
  • Review at 3 months post Covid if not improving.
  • Unexplained crackles on auscultation refer for CXR. Depending on the results of this a HRCT scan may also be indicated. Chest X-ray appearances alone should not determine the need for further care. Be aware that a plain chest X-ray may not be sufficient to rule out lung disease
  • Consider increased risk of VTE / PE post-COVID
  • BNP normal result will exclude cardiac failure as a cause
  • Bloods: FBC, U&E, LFT, Ca2+, TFT, BNP
  • Consider sputum sample if productive cough
  • ECG
  • CXR.
  • O2 saturation at rest - SpO2-93%
  • Oxygen desaturation on exercise – One minute sit to stand test (protocol attached)
    Results
  • If <4 weeks post-acute Covid-19 – and SpO2<93% or 4% drop from baseline - Acute assessment (PCAL)
  • If 4 weeks post-acute Covid-19 SpO2<93% or 4% drop from baseline - Refer to Community Respiratory Service for Ambulatory oxygen Assessment.
  • Acute onset (<48 hours) /severe sob O2<93% (if new for the patient)
  • Resting Pulse<60bpm or >120bpm RR > 30 breaths/minute Refer PCAL for exclusion of Acute Pathology inc. PE.
  • Myocardial ischaemia (chest pain)
  • Syncope/postural dizziness
  • Heart failure
  • Shock (hypotension)
Cough
  • Cough is a common symptom.
  • Dry cough likely to be post-viral and self-limiting though can persist for weeks as airways remain hypersensitive.
  • Haemoptysis
  • Unintentional weight loss night sweats
  • and/or a strong smoking history
  • urgent 2 week referral is appropriate
Chest Pain
  • Non-specific chest pain is common post Covid-19 Syndrome. It does not signify In the absence of other typical clinical features
    Oxygen saturation normal:
    PLUS normal chest x-ray:
  • Consider non-respiratory causes (e.g. infection or inflammation elsewhere).
    PLUS chest x-ray abnormal/showing consolidation:
  • Symptoms may be explained by pneumonia:and assess and treat appropriately
    Typical pericardial pain (positional, inspiratory component) can be managed with analgesia +/-colchicine. Imaging is not usually helpful for uncomplicated cases
    Chest pain suggestive of myocardial ischaemia should be managed conventionally (RACPC for stable exertional symptoms, urgent admission for possible ACS)
  • Bloods: FBC, CRP
  • CXR
  • ECG
  • O2 sats
  • Acute hypoxia, O2<93% (if new for the patient
  • Acute severe breathlessness,
  • Pulse rate >120/min
Palpitations / tachycardia
  • Palpitations are common. Up to 30% at 3 months
  • Positional Orthostatic Tachycardia Syndrome is seen post COVID – ensure adequate fluid and salt intake as a first line
  • Blood tests (including thyroid function)
  • Erect and supine BP and HR
  • ECG
  • Syncope,
  • Myocardial ischaemia
  • Complete heart block
Anosmia
  • Associated nasal symptoms
  • Neurological symptoms
  • ENT referral if anosmia >3 months
  • Anosmia>6 weeks with focal neurological symptoms-MRI recommended
Abnormal liver function (mild rise in liver transaminases)
  • Mild abnormalities in ALT <3xULN will be common post Covid-19.
  • Approximately 25-30% of tested population in Leeds have abnormal ALT.
  • Check any past LFTs.
  • Check alcohol history
  • Stop any NSAIDS. Do not introduce statins at this stage.
  • If abnormalities are mild, statins could be continued in diabetic patients
  • ALT <x3ULN and new: Monitor monthly. It should normalise. Investigate at 3 months if not
  • ALT >x3ULN and new: Monitor again 2-4 weeks. Investigate at 1 month if not normalised or reducing.
  • Address any history of excess alcohol, optimise diabetic control, introduce exercise as possible.
  • Isolated raised bilirubin: Request conjugated/unconjugated bilirubin split.
  • Isolated raised ALP: Optimise vitamin D levels, Consider Ultrasound scan (to check biliary tract) with Doppler (to check vascular supply); Check BNP as cardiac impairment may give this picture
  • Jaundice not attributable to Gilberts syndrome or not in isolation.
  • Acute liver injury ALT>10xULN
  • Start investigations immediately and refer for specialist opinion
Reduction in kidney function following an episode of Acute kidney injury (reduced eGFR from pre- COVID baseline)
  • Observed in small proportion of recovering patients
  • Assess for improvement or worsening of eGFR over one year
  • Consider referral if progressive fall in eGFR or increasing ACR
  • BP
  • Dip urine for blood and protein
  • Urinary Protein/Creatinine ratio
  • Monitor renal function 2 monthly
  • Review medication
  • Urinary Protein/ Creatinine ratio > 50
  • Haematuria • Sustained fall in eGFR > 5ml/min/month
  • eGFR<30ml/min (new for patient)

Resources