Transcript: Post Covid Symptoms

​Liz Rohr:
Well, hey there, it's Liz Rohr from Real World NP. And you're watching NP Practice Made Simple, the weekly videos to help save you time, frustration and help you learn faster so you can take the best care of your patients. In this video, I'm going to be talking about post COVID symptoms. And it's a really common chief complaint right now. And I just want to bottom line spoiler alert for you that this is as much as we know, which is not a lot. So it's a little bit frustrating. I did a lot of deep diving trying to find out more information, but this is all we have. So just know that at the time of this recording, at the time that this is live, this is the most up to date information. So if you're watching this at a later time, there might be some more up to date stuff.

And so definitely referencing CDC and World Health Organization and other resources that could potentially be helpful in terms of updates. But in this video, I'm going to be going over the most common presentations that we're seeing, what to watch out for and the most common things that you can do for patients. Ultimately, I think it comes down to understanding it enough so that you can number one, treat patients appropriately and triage them appropriately because it really does kind of come down to triage in a way, which I'll talk about. And then also feeling comfortable enough to explain to patients and have empathy and reassurance for them, because it's frustrating we don't have a ton of answers. But anyway, just to start, when it comes to timing, so SARS-CoV-2, the virus causes the disease COVID 19. And COVID 19 initially starts symptomatically.

So there's actually a COVID update video, which I can link to at the end of this video. I made a video at the very beginning of the pandemic in March, of 2020. But it quickly became outdated, so I took it down but there's going to be an updated one as well, so I'll tag that on here. But when it comes to COVID, the initial symptoms typically they're contagious for about seven to 10 days after the onset of their symptoms, up to 20 days depending on their underlying immune status. Immunocompromised patients can be contagious for longer. But then in terms of the timing of post COVID symptoms, under four weeks from the initial onset of symptoms is still considered to be related to the initial COVID infection. Four weeks to 12 weeks is considered to be like long COVID, which is still related to the initial COVID infection.

And in any symptoms that happen after 12 weeks is considered to be that post COVID syndrome, which have air quotations here because we don't actually know if it's a syndrome or related to COVID itself. Or it's just a constellation of side effects that can happen with other illnesses as well. So what are the symptoms here? So the most common ones are fatigue, dyspnea, chest pain, cough, cognitive impairments, things like word finding difficulty, short term memory loss, difficulty with multitasking, poor concentration, as well as anxiety and PTSD especially in patients who have been hospitalized. The less common ones, but still things that we're seeing are loss of sense of taste and smell that is persistent, anosmia and dysgeusia... I love those words, they're so cool, rhinitis, poor appetite and dizziness. Dizziness can either be from vertigo or can be from orthostasis. Myalgias, muscle pains, insomnia, alopecia, hair loss, sweating and diarrhea.

So those are the lesser common ones that can still persist for a while. The resolution really depends on a lot of things. So this is also frustrating. So as you would expect, patients who had more severe illness to start with, whether or not they were hospitalized, including the patients who had severe illness but were not severe enough to need hospitalization, but it was a severe presentation who also have underlying risk factors of preexisting comorbidities and increasing age, are more likely going to have more severe, more prolonged post COVID symptoms. However, there's huge variability here. So you can have patients who are previously were healthy, didn't have any comorbidities and were in their twenties or thirties that can still have persistent symptoms. So it is really frustrating. So the fevers that can come with the initial infection tend to resolve earlier. Fever, chills, loss of sense of taste and smell can resolve within two to four weeks.

The other constellation of all those other symptoms I was telling you about can last between two and six months, actually plus. So anecdotally speaking, I know some people who have had COVID and eight months out are still dealing with some respiratory issues or chronic cough as well. So the ideal world is that patients who have post COVID symptoms can ideally go to a specialized post COVID center. In larger cities, in larger metropolitan areas you may have that luxury where they are doing some studies, where they can do a lot of testing and gathering of information. And they can match you up with the appropriate specialist but that's kind of the gist of what's happening. And I don't work in one, and I'm not intimately familiar with one. But anecdotally again, hearing from patients who have gone to these places, that's typically what's happening.

So when it comes to the provider side in the outpatient setting, that's really what our role here is. Is to detect it in the first place. Think about what the other options are, differential diagnosis. And it's kind of a diagnosis of exclusion if you've already looked at the other possibilities in those body systems, and it's not turning out to be any of those dangerous red flag ones or any other etiologies. And it's kind of a post COVID diagnosis of exclusion. And once we figure that out, we either do that ourselves in primary care or we refer to the appropriate specialist. So when it comes to the testing, so what are we doing here? So it really comes down to breaking down what the body system they're dealing with is. So do they have chest pain and palpitations? Do they have a tachycardia?

We want to think about what are the potential differential diagnoses for the heart, that is it related to COVID? Is it related to a new thing? Or is it just kind of persisting from the previous thing? And that's another really important diagnostic point here, is that our job is to see... And I always ask this in every symptom based visit but especially with this, is this new, is it worsening, or is it improving, or is it just staying the same from before? Because that information really colors your differential diagnosis. So for example with the cardiac, say they were hospitalized, you have the whole discharge summary... Hopefully you have the discharge summary, fingers crossed. But if you have the discharge summary, you can get a sense of the workup and everything that they did there. And then they can kind of let you know what the underlying status is, because some of the risks of COVID and this is not comprehensive, but for the most part there's a risk of myocardial injury, there's a risk of myocarditis resulting in cardiomyopathy.

There's a whole host of other cardiac abnormalities. So our job is to really just look and see, do we... Well, usually it's an EKG. And then considering what other diagnostic things we can do in the physical exam and the history to help us figure out the differential diagnosis there, and figure out what the path is. What are the most dangerous things, can we rule those out? And then looping in cardiology to help us with our further workup. And not everybody needs an echo necessarily, definitely starting with an EKG and a history and all of that stuff can be really helpful. And then referring to cardiology as we need to. And I apologize, this is super high level because I love getting into the nitty gritty practical details. But if I were to talk about each of those for each of the body systems, this would be hours long.

So if you want me to talk about them further, I'm happy to. But there is a phenomenon where we're seeing people who have persistent chest pain, they've done the full cardiac workup in house as well as in cardiology. They did a Holter monitor, they did an echo, they did stress testing potentially and they're still having persistent chest pain. And so I guess just to segue in that potential treatment, it's basically that we just treat it as if we treat any tachycardia. So if somebody has persistent sinus, tachycardia, post COVID their resting heart rate is 100, we're just treating it like any other thing if we've ruled out the other things, if that makes sense. So utilizing your resources and typically just offhand, that is typically some sort of beta blocker monitoring or just giving it some time. And then working in collaboration with your resources, with a specialist, with your supervisor, et cetera, so that's kind of like the cardiac stuff in a nutshell.

And in terms of the chest pain that people can have, as long as we've ruled out the other dangerous things, it depends on the underlying conditions but NSAIDs are really the only thing that I can find to help patients. We try to use the lowest dose possible for the shortest time possible. And we just fingers crossed hope that it continues to get better and better and that it could potentially last for two to three months. Hopefully it gets better at that time. So this is really frustrating, I'm like pained telling you this because I wish I had better information to share. So I just want to briefly touch on the other body components. So same thing applies, the same kind of scenario here of if it's pulmonary, if they have dyspnea, if they have shortness of breath, if they have a cough, is this new... Excuse me, compared to the baseline? Is it worsening or is it improving? And you take your information from there.

So typically if somebody, depending on their history, were they hospitalized, were they not, do they have a baseline chest x-ray or baseline imaging to compare to, usually abnormal lung findings will start to resolve around the four week mark but can take about 12 weeks. So if they have abnormal imaging at the time of diagnosis, it's been 12 weeks, they still have dyspnea, a cough especially if it's new, considering doing another chest x-ray to compare findings. Depending on your findings, they might need further testing. They might need PFTs, they might need a chest CT, but at that point it's the same framework. And I apologize this is not more detailed, but it's really taking the approach of what are the other potential problems here. So is it that they have a new pneumonia? Is this persistent lung damage?

Is there lung fibrosis? Is there pulmonary vasculature issues going on? Do they have risk for a PE? Are they at risk for empyema? Taking that whole history, that whole story, and taking a look at that. What are the things that we can do in primary care? Is there anything imminently dangerous where they need to go to the ER? What workup can we do depending on their history and a physical presentation? And at what point do we need to tag in pulmonary? And each of these like I said, really ties into your kind of understanding of each of those workups when it comes to chest pain, when it comes to dyspnea, when it comes to shortness of breath, et cetera. And the same thing for hair loss. As an example, we're just looking at alopecia, hair loss, there's not a whole ton to say about COVID related hair loss.

We just have to look at the differential diagnosis for hair loss, look at those other things and then see what happens. So a little bit of a frustrating scenario to kind of find yourself in but that's really what we know so far. When it comes to the other interventions for pulmonary specific, I think that those are kind of the most uncomfortable ones that patients are having that providers are really wrangling with, is the persistent chest pain, the persistent fatigue, there's persistent dyspnea. So again, taking the fatigue work up and looking at other fatigue related things and then ruling out, diagnosis of exclusion this is related to your COVID. Otherwise, referring to a specialist if we can't figure it out in primary care. And when it comes to pulmonary, again, similar things. We're referring to pulmonology for further testing, potentially allowing them to do the chest CT, allowing them to do the PFTs.

There might be ways that they want to order that. We might not order that in primary care. So it depends on your philosophy of practice and what is generally recommended when you refer to specialist. But taking that general approach. And then once you've figured out your diagnosis, when it comes to the pulmonary stuff, there are some potential things you can do. You may consider doing a rehab, like either a physical therapy if they have a generalized deconditioning, if they were hospitalized in a prolonged way versus do you want to consider cardiac rehab. But typically those patients need to be evaluated by cardiology first and then they can give that recommendation of cardiac rehab as actually more impactful than doing physical therapy. And then some other things and I can link to this down below, when it comes to the dyspnea and the difficulty with that there are some things that we can do, some minor things.

Again, physical therapy can be helpful in terms of general holistic deconditioning, but also some tips about how to deal with the dyspnea until it gradually gets better and better. But yeah, that's really all I have for post COVID symptoms, really a little bit not that helpful. But hopefully it helps you understand what the general features are, when to expect, hopefully it will resolve within those two to three months. And we can do our best to rule out the red flag diagnosis, let it be a diagnosis of exclusion. And then really just do supportive care depending on whatever the diagnosis turns out to be. So if it's sinus tachycardia, considering beta blockers depending on the underlying workup, sending them to pulmonology, having them do the workup. Considering those kind of lifestyle modifications for dyspnea and physical therapy or rehabilitation, and then just doing the workups from there.

So anyway, I hope this video was helpful. Please let me know what questions you have or what video topics you'd like to hear more about. I'm happy to talk more about them. If you have not grabbed the ultimate resource guide for the new NP, head over to RealWorldNp.Com/Guide. You'll get these videos sent straight to your inbox every week with notes from me, patient stories and bonus content that I really just don't share anywhere else. Thank you so much for watching. Hang in there and I'll see you soon.