Addressing Post-COVID Symptoms: A Guide for Primary Care Physicians

Heather Vance; Amelita Maslach; Emily Stoneman; Kathryn Harmes; Andrea Ransom; Katharine Seagly; Wendy Furst

doi:10.3122/jabfm.2021.06.210254

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Figure 1.
An updated breathing thinking functioning model.
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Figure 2.
Possible factors influencing symptom reporting acutely, postacutely, and long after a COVID-19 infection. PTSD, post-traumatic stress disorder.

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Table 1.

Systems, Symptoms, and Treatments for Post-COVID Patients^*

System	Symptom	Initial Workup	Treatment by Primary Care	Referrals for Further Evaluation	Reasons to Refer
Cardiovascular	Cardiac symptoms (palpitations, new arrhythmia, chest pain, edema, and so forth)	CBC High-sensitivity troponin BNP D-Dimer CRP Sed rate EKG Consider: CXR Echo	Treat underlying cause as appropriate	Multidisciplinary post-COVID clinic (cardiology)	All patients with cardiac complications (myocarditis, pericarditis, MI, dysrhythmia, etc) should be evaluated by cardiology.
	Dysautonomia	CMP CBC TSH Orthostatic blood pressures Tilt table test	Hydration Increase salt intake Compression stockings Meditation and breathwork POTS: consider adding midodrine or fludrocortisone Hyperadrenergic POTS: beta-blocker Patient education: POTS AVS^{^†}	Multidisciplinary post COVID clinic (cardiology)	Symptoms refractory to treatment
	Anosmia	Evaluate for underlying etiology (allergies, postnasal drip, and so forth)	Nasal steroid sprays if appropriate Patient education: Anosmia and smell training AVS^{^†}	ENT	If >6 months
	Poor glycemic control	Routine labs	Lifestyle modifications Medication management Patient education: Diabetes education	Multidisciplinary post-COVID clinic (MEND)
	Transaminitis/liver complications post-COVID	LFT Hepatitis panel Iron panel ANA SMA Ferritin US abdomen w/Doppler flow	Avoid alcohol, acetaminophen, and other liver toxic substances and medications	Hepatology/GI	Labs: If ALT and/or AST >5 x ULN If baseline pre-COVD value known to be > 5 x ULN: Increase of ALT and/or AST to > 2 x baseline • If baseline pre-COVD value known to be 2 to 5 x ULN: Increase of ALT and/or AST to > 3 x baseline • Evidence of hyperbilirubinemia (T. Bil > 2.5) or coagulopathy (INR >1.5) Clinical Features: If Features of decompensated liver disease (e.g., ascites, hepatic encephalopathy)
	Thromboembolism and other thrombotic complications	Evaluate for underlying etiology	Patient education: Anticoagulation education	Hematology
	Severe secondary pulmonary infections	Imaging or labs identifying concern		Multidisciplinary post-COVID clinic (infectious disease)
	Post-COVID kidney dysfunction (AKI, hematuria, proteinuria)	Routine labs	Treat underlying condition	Multidisciplinary post-COVID clinic (nephrology)
	Chronic headaches	MRI brain if escalating pattern or other red flag symptoms	Lifestyle modifications (exercise, sleep, diet) Gabapentin Pregabalin Tricyclics Duloxetine Patient education: Chronic headache AVS^{^†}	Multidisciplinary post-COVID clinic (PM&R and/or neurology)	Symptoms refractory to initial treatment
	Neurologic symptoms (weakness, paresthesias, impaired mobility, and so forth)	CBC CMP TSH Vitamin B12 Vitamin D Hgb A1c if paresthesias MRI brain if: • Moderate-severe COVID • >50 years of age • Medical comorbidities/risk factors • Impact on job or iADLs • Focal neurological deficits or symptoms	Gabapentin Pregabalin TricyclicsDuloxetine Patient education: Paresthesias AVS^{^†}	Multidisciplinary post-COVID clinic (PM&R and/or neurology) PT/OT
	Chronic fatigue	CMP CBC TSH Screen for OSA^{^†} (STOP-BANG) ^*consider adding ANA, CRP/ESR myalgia, arthralgia	Pacing of exercise: low-impact and short duration Don't push to recondition • Pacing activity^{^†} • Planning out your day^{^†} • Break larger tasks into smaller ones^{^†} Resource for clinicians^{^†} Consider stimulants in severe cases Patient education: Chronic fatigue AVS^{^†} Return to exercise Post-COVID AVS^{^†}	Sleep study if indicated Sleep medicine	Suspicion for sleep disorder
	Chronic pain	ANA with reflex ENA CRP Sed rate Rheumatoid factor Anti-ccp	Lifestyle modifications (exercise, sleep, diet) Gabapentin Pregabalin Tricyclics Duloxetine Patient education: Chronic pain AVS^{^†} Chronic pain patient^{^†} Education class	Multidisciplinary post-COVID clinic (PM&R)	Symptoms refractory to initial treatment
	Return to activity		Resource for clinicians^{^†} Patient education: Return to exercise post-COVID AVS^{^†}	Multidisciplinary post-COVID clinic (cardiology)	Competitive athlete Severe COVID-19 infection or requiring hospitalization Abnormal return to play cardiac testing (echo, EKG, hs-trop) Cardiac injury diagnosed subsequent to COVID-19 infection
	Depression Anxiety PTSD	PHQ-9 GAD-7 TSH CBC	Counseling Consider medication SNRI if concurrent HA or paresthesias Patient education: Mental health support AVS^{^†}	Psychiatry Social work Group therapy Support groups	Symptoms refractory to initial treatment Need for additional support
	Decreased concentration Brain fog Memory loss	CBC CMP TSH Vitamin B12 Vitamin D Severe cognitive decline: Folate, thiamine, HIV, RPR, and neuropsychological testing MRI brain if: • Moderate to severe COVID • >50 years of age • Medical comorbidities/risk factors • Impact on job or iADLs • Focal neurological deficits or symptoms	If symptoms significant: Atomoxetine Dextroamphetamine/amphetamine Methylphenidate Modafinil Cognitive therapy Patient education: Brain fog AVS^{^†}	Multidisciplinary post-COVID clinic (neuropsychology)
	Chronic dyspnea	CBC BNP Resting pulse ox 1 minute sit to stand test Slow gradual recovery with persistent sx >8 to 12 weeks: CXR Adult complete PFT Progressive dyspnea and/or dry/velcro crackles on exam: CXR Adult complete PFTReferral to pulmonary Screen for OSA (STOP-BANG) ^{^†} CT chest if concerning exam or PFT findings	Incentive spirometer Consider pulse ox for patient reassurance Patient education: Breathlessness AVS^{^†} Breathing exercises: Belly breathing^{^†} Pursed-lip breathing^{^†} Boxed breathing^{^†} 1:2 ratio, inhale:exhale	Multidisciplinary Post COVID Clinic (Pulmonary) Sleep study if indicated	Progressive dyspnea and/or dry/velcro crackles on exam Symptoms >12 weeks Sit to stand test ≥4% desaturation Concerning findings on CXR or spirometry/DLCO STOP-BANG ≥3
Chronic cough	Evaluate for common causes including GERD, postnasal drip, ACEI, and so forth Consider chest imaging if not resolving in 6 to 8 weeks after infection or if evidence of secondary bacterial infection	Treat underlying cause if applicable Consider cough suppressants (dextromethorphan, benzonatate)		Symptoms refractory to treatment Concerning symptoms or findings on imaging
Insomnia	TSH CBC Iron studies Screen for OSA (STOP-BANG)^{^†}	CBT-I Sleep hygiene Sleep aids: Melatonin • Mirtazapine •Gabapentin • Amitriptyline (if paresthesias or headaches are also present) Patient education: Insomnia AVS^{^†}	Sleep medicine	Symptoms refractory to initial treatment

ACEI, angiotensin-converting-enzyme inhibitors; AKI, acute kidney injury; ALT, alanine transaminase; ANA, antinuclear antibody; AST, aspartate transaminase; AVS, after visit summary; BNP, brain natriuretic peptide; CBC, complete blood count; CBT-I, cognitive behavioral therapy for insomnia; CMP, complete metabolic panel; CRP, C-reactive protein; CT, computed tomography; CXR, chest radiograph; DLCO, diffusing capacity; EKG, electrocardiogram; ENA, extractable nuclear antigen; ENT, ear, nose, and throat; ESR, erythrocyte sedimentation rate; GAD-7, General Anxiety Disorder-7; GERD, gastroesophageal reflux disease; GI, gastrointestinal; HA, headache; HgbA1c, hemoglobin A1c; iADLs, instrumental activities of daily living; LFT, liver function tests; MEND, Division of Metabolism, Endocrinology & Diabetes; MRI, magnetic resonance imaging; OSA, obstructive sleep apnea; PFT, pulmonary function test; PHQ-9, Patient Health Questionnaire; PM&R, physical medicine and rehabilitation; POTS, postural orthostatic tachycardia syndrome; PT/OT, physical therapy/occupational therapy; PTSD, post-traumatic stress disorder; RPR, rapid plasma reagin; SMA, smooth muscle antibody; SNRI, serotonin-norepinephrine reuptake inhibitor; TSH, thyroid- hormone; ULN, upper limit of normal; US, ultrasound.
↵* Workup and recommendations listed are based on level 3 evidence.
↵† These tools can be found on this resource page (https://docs.google.com/document/d/154kOFvVK-_9iCVsr7emgd5sjoeoQR0xlTj38dlE-MAA/edit?usp=sharing).

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Table 2.

Return to Exercise Guidance Chart

	Severity of Symptoms
Recommendations	No Symptoms	Mild Symptoms	Moderate Symptoms^*	Severe Symptoms or Hospitalized
Rest	No exercise for 10 days from positive test result	No exercise for 10 days or more since symptom onset AND no symptoms for >10 days	No exercise for >10 days since symptom onset AND no symptoms for >10 days	See your medical provider or cardiologist before returning to exercise
Cardiovascular testing	Not advised	Not advised	Evaluation by a medical provider and consideration of cardiovascular testing
Return to exercise guidance	Paced and gradual return to activity	Paced and gradual return to activity	Clearance from medical provider to return to activity

Note: Stop activity and see your medical provider if new symptoms such as dizziness, chest pain, shortness of breath, or palpitations develop while returning to exercise.
↵* Patients above 65 years old or those with significant cardiovascular risk factors such as diabetes, hypertension, coronary artery disease, atrial fibrillation, or kidney disease would also fall into this category.