Post Covid Symptoms
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Show notes:
SO many patients are dealing with post covid symptoms lately. Fatigue, shortness of breath, chest pain… it’s frustrating for patients and providers alike.
Managing Post-Covid Symptoms in Primary Care
In this video, I’m sharing what we know so far, the common presentations, and the general approach to diagnosis and treatment for new nurse practitioners in primary care.
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well hey there it's liz rohr from real
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world np and you're watching np practice
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made simple the weekly videos to help
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save you time frustration
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and help you learn faster so you can
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take the best care of your patients
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uh in this video i'm going to be talking
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about post covered symptoms
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and it's a really common chief complaint
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right now and i just want a bottom line
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spoiler alert for you that um
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this is as much as we know which is not
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a lot
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so it's a little bit frustrating i did a
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lot of deep diving trying to find out
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more information
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um but this is all we have so just know
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that at the time of this recording at
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the time that this is live this is the
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most up-to-date information so if you're
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watching this at a later time
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there might be some more up-to-date
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stuff and so definitely referencing cdc
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and world health organization and other
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resources that could potentially help
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be helpful in terms of updates but in
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this video i'm going to be going over
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the most common presentations that we're
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seeing what to watch out for
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and the most common things that you can
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do for patients
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ultimately i think it comes down to
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understanding it and then
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understanding it enough so that you can
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number one
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treat patients appropriately and triage
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them appropriately because it really
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does kind of come down to triage in a
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way which i'll talk about
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and then also feeling comfortable enough
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to explain to patients and
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and have empathy and reassurance for
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them
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because it's frustrating we don't have a
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ton of answers but anyway just to start
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when it comes to timing so covid
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typically uh sars kov2 the virus causes
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the disease covid19 and covin 19
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initially starts uh symptomatically so
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there's actually a covet update video
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which i can link to at the end of this
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video i made a video at the very
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beginning of the pandemic in march of
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2020
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but it quickly became outdated so i took
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it down but there's going to be an
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updated one as well so i'll tag
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that on here but um
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when it comes to covid the initial
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symptoms
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typically they're contagious for about
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seven to ten days after the onset of
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their symptoms up to 20 days
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depending on their underlying immune
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status immunocompromised patients can be
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contagious for longer
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but then in terms of the timing of
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postcode symptoms
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under four weeks from the initial onset
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of symptoms is still considered to be
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related to the initial coven infection
Post Covid Symptoms
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four weeks to 12 weeks is considered to
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be like long coven
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which is still related to the initial
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code infection
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and then any symptoms that happen after
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12 weeks is considered to be that
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post-covet syndrome which i'm
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have air quotations here because we
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don't actually know if it's a syndrome
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or related to covet itself
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or it's just a constellation of side
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effects that can happen with other
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illnesses
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as well so what are this what are the
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symptoms here so the most common ones
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are fatigue
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dyspnea chest pain cough
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cognitive impairments things like word
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finding difficulty
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short-term memory loss difficulty with
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multitasking poor concentration
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as well as anxiety and ptsd especially
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in patients who have been hospitalized
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the less common ones but still things
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that we're seeing
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are loss of sense of taste and smell
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that is persistent
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anosnia and disgusa i love those words
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they're so cool
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rhinitis poor appetite and dizziness
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dizziness can either be from vertigo or
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can be from orthostasis
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my all just you know muscle pains
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insomnia
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alopecia hair loss sweating and diarrhea
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so those are the lesser common ones that
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can still persist for a while
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the resolution really depends on a lot
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of things so this is also frustrating so
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as you would expect
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patients who had more severe illness to
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start with whether or not they were
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hospitalized including the patients who
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had severe illness but were not
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severe enough to need hospitalization
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but it was a severe presentation
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who also have underlying risk factors of
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pre-existing comorbidities and
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increasing age are more likely going to
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have more severe
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more prolonged postcode symptoms however
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there's huge variability here so you can
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have patients who
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are previously weren't healthy didn't
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have any comorbidities
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and were in their 20s or 30s that can
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still have persistent
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symptoms so it is really frustrating so
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the
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fevers uh pers the fevers
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that you can come with the initial
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infection tend to resolve earlier
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fever chills loss of sense of taste and
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smell can resolve within two to four
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weeks
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the other constellation of all those
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other symptoms i was telling you about
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can last between two and six months
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actually plus so anecdotally speaking i
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know some
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people who have had covet and eight
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months out are still dealing with some
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respiratory
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issues of chronic cough as well so there
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are
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some the ideal world is that patients
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who have post-coveted symptoms
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can ideally go to a specialized
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post-covid center
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right in larger cities and larger
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metropolitan areas you may have that
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luxury
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where they are doing some studies where
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they can do a lot of testing and
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gathering of information and they can
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match you up with the appropriate
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specialist but that's kind of the gist
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of what's happening and i don't work in
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one and i'm not
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intimately familiar with one but
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anecdotally again hearing from patients
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who have gone to these places
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that's typically what's happening so
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when it comes to the provider side on
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the outpatient outpatient setting
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that's really what our role here is is
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to
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detect it in the first place think about
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what the other options are
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right differential diagnosis and it's
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kind of a diagnosis of exclusion
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if you've already looked at the other
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possibilities in those body systems
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and it's not turning out to be any of
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those dangerous red flag ones or any
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other etiologies then it's kind of a
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postcovid diagnosis of exclusion and
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once we figure that out we either do
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that ourselves in primary care or we
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refer to the appropriate specialist so
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when it comes to the testing so what are
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what are we doing here so it really
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comes down to breaking down what the
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body system they're dealing with it so
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do they have chest pain and palpitations
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do they have a tachycardia
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we want to think about what are the
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potential differential diagnoses
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for the heart that is it related to cova
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is that related to a new thing
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or is it just kind of persisting from
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the previous thing and that's another
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really important diagnostic point here
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is that our job is to see is this and i
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always ask this in every symptom-based
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visit but especially with this
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is this new is it worsening or is it
Differential Diagnosis
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improving
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or is it some or is it just staying the
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same from before because that
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information really colors your
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differential diagnosis right so for
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example with
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cardiac say they were hospitalized you
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have the whole discharge summary
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hopefully you have the discharge how
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many fingers crossed
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um but if you have the discharge summary
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you can get a sense of the workup and
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everything that they did there
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and then they can kind of let you know
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what the underlying status is because
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some of the risks of covid and this is
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not comprehensive
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but for the most part we have there's a
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risk of car myocardial injury
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there's a risk of myocarditis resulting
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in cardiomyopathy
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there's a whole host of other cardiac
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abnormalities
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so our job is to really just look and
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see do we have do we
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well usually it's an ekg right and then
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considering
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what other diagnostic things we can do
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in the physical exam in the history to
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help us
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figure out the differential diagnosis
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there and figure out what the path
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is what are the most dangerous things
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can we rule those out and then
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looping in cardiology to help us with
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our further workup right and not
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everybody needs an echo necessarily
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definitely starting with an ekg in a
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history and all of that stuff can be
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really helpful and then referring to
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cardiology as we need to and i and i
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apologize this is super high level
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because i
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i love getting into the nitty gritty
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practical details but
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if i were to talk about each of those
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for each of the body systems like this
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would be like hours long so
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if you want me to talk about them
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further i'm happy too but there is
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there is a phenomenon where we're seeing
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people who have persistent chest pain
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they've done the full cardiac workup
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in-house as well as in cardiology they
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did a halter monitor they did an echo
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um they did stress testing potentially
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and they're still having persistent
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chest pain
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and so i guess just a segway and that
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potential like treatment
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uh it's basically that we just treat it
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as if we treat any tachycardia so if
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somebody has persistent topics
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persistent sinus tachycardia postcovid
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their resting heart rate is a hundred
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we're just treating it like any other
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thing if we've ruled out the other
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things if that makes sense right
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so utilizing your resources and
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typically just off hand
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that is typically some sort of beta
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blocker um monitoring or just giving it
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some time right and then working in
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collaboration with your resources with a
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specialist with your supervisor et
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cetera et cetera
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so that's kind of like the cardiac stuff
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in a nutshell and in terms of like the
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chest pain that people can have
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as long as we've ruled out the other
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dangerous things
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it depends on the underlying conditions
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but nsaids are really the only thing
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that
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i can find to help patients we try to
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use the lowest
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as possible for the shortest time
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possible and we just fingers crossed
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hope that it continues to get better and
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better
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and then it could potentially last for
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two to three months hopefully gets
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better
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at that time so this is really
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frustrating i'm like pain's telling you
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this because i wish i had better
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information to share
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so i just want to briefly touch on like
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the other body components
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so same thing applies the same
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coordinate site kind of scenario here
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of if it's pulmonary right if they have
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dyspnea if they have shortness of breath
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if they have a cough
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is it new is this new excuse me compared
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to the baseline
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is it worsening or is it improving and
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you take your information from there
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so if we're typically if somebody
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depending on their history right were
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they hospitalized were they not
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did they have a baseline chest x-ray or
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baseline imaging to compare to
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usually resolves lung abnormal lung
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findings will start to resolve around
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the four-week mark but can take about 12
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weeks
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so if they have abnormal imaging at the
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time of diagnosis
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it's been 12 weeks they still have they
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still have dyspnea a cough especially if
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it's new
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considering doing another chest x-ray to
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compare findings
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depending on your findings they might
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need further testing right they might
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need pfts they might need a chest ct
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but like at that point it's the same
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framework and i apologize this is not
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more detailed but
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it's really taking the approach of what
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are the other potential problems here
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so is it that they have a new pneumonia
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is this persistent lung damage is there
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is there lung fibrosis is there um
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pulmonary vasculature issues going on do
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they at risk for a pe
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and at risk for empyema taking that
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whole history that whole story and
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taking a look at that
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what are the things that we can do in
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primary care is there anything
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imminently dangerous where they need to
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go to the er
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what work up can we do depending on
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their history and the physical
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presentation
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and at what point do we need to tag in
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pulmonary so and each of these like i
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said really ties into
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your kind of like understanding of each
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of those workups when it comes to chest
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pain when it comes to dismantling it
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comes to shortness of breath
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etc etc and the same thing for hair loss
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right as an example
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we're just looking at alopecia hair loss
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there's not a whole ton to say about
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covid related hair loss we just have to
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look at the differential diagnosis for
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hair loss
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look at those other things and then see
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what happens right
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so a little bit of a frustrating uh
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frustrating scenario to to kind of find
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yourself in but
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that's really what we know so far when
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it comes to the other interventions for
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pulmonary specific i think that those
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are kind of the main most
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uncomfortable ones that provide that
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patients are having that providers are
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really wrangling with is the persistent
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chest pain the persistent fatigue is
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persistent dyspnea
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so again taking the fatigue work up and
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looking at other fatigue related things
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and then
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ruling out diagnosis of exclusion this
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is related to your
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covid otherwise referring to a
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specialist if we can't figure it out in
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primary care
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and when it comes to pulmonary again
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similar things we're referring to
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pulmonology for further testing
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potentially like allowing them to do the
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chest ct
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allowing them to do the pfts there might
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be ways that they want to order that
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that we might not order that in primary
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care so it depends on your philosophy of
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practice and what is generally
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recommended when you refer to specialist
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but
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taking that general approach and then
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once you've figured out your diagnosis
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when it comes to the pulmonary stuff
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there are some potential things you can
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do you may consider doing a rehab like
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either a physical therapy if they have a
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generalized deconditioning
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if they were hospitalized in a prolonged
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way versus do you want to consider
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cardiac
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rehab but typically those patients need
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to be evaluated by
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cardiology first and then they can give
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that recommendation if cardiac cardiac
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rehab is actually
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more impactful than doing physical
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therapy and then
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some other things and i can link to this
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down below when it comes to the the
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dyspnea and the difficulty with that
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there are some things that we can do
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some minor things again physical therapy
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can be helpful in terms of general
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holistic deconditioning but also um
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some tips about how to deal with the
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dyspnea until it get gradually gets
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better and better but
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but yeah that's really that's really all
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i have for postcoping symptoms
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really a little bit not that helpful but
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hopefully it helps you understand
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what the general features are what to
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expect hopefully it will resolve within
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those two or three months
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and we can do our best to rule out the
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the red flag diagnoses
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let it be a diagnosis of exclusion and
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then really just do supportive care
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depending on whatever the diagnosis
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turns out to be right so
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if it's if it's uh sinus tachycardia
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considering beta blockers depending on
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the underlying workup
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uh sending to pulmonology having them do
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the work up
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considering those kind of like lifestyle
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modifications for dyspnea and physical
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therapy or rehabilitation
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uh and then just doing the workouts from
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there so anyway i hope this video was
13:24
helpful
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13:26
have or what video topics you'd like to
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thank you so much for watching hang in
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there and i'll see you soon
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[Music]
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you
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