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).