A Practice-Based Approach to Urgent Care Evaluation and Management of Patients With Postacute Sequelae After COVID-19 Infection: Long COVID

Table of Contents

 

About This Issue

Long COVID is a diagnosis of exclusion that will not be made during an urgent care visit. However, patients may present to the urgent care clinic following acute COVID-19 infection with a constellation of symptoms that have been associated with long COVID. Urgent care clinicians must be prepared to deliver effective care to these patients for the presenting symptoms and to recognize when referral is warranted for further evaluation. In this issue, you will learn:

The definitions of COVID-19 infection and the risk factors for progression to long COVID

The potential etiologies and mechanisms of the diverse symptoms that have been associated with long COVID

What to look for in patients with persistent pulmonary and cardiovascular complaints that may signal a life-threatening event

The highest-value laboratory and imaging studies, and when referral for further testing is indicated

Which symptoms pediatric patients are most prone to

CODING & CHARTING: When coding for an urgent care visit for possible long COVID, the level of service will be highly dependent on the presenting symptoms and patient history.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
   1. Acute COVID Infection
   2. Long COVID Manifestations
   3. Long COVID Pathophysiology
      1. Postural Orthostatic Tachycardia Syndrome
      2. Persistent Fatigue
      3. Musculoskeletal and Dermatologic Disorders
      4. Pulmonary Pathology
      5. Cardiovascular and Coagulation Disorders
7. Differential Diagnosis, Urgent Care Evaluation, and Diagnostic Studies: Long COVID as a Phenotype and Diagnosis of Exclusion
   1. Initial Evaluation
   2. Laboratory Testing
      1. Ordering Further Testing
   3. Imaging Studies
   4. Cardiac Evaluation
      1. Neurologic Evaluation
      2. Psychiatric Evaluation
8. Treatment
   1. Pulmonary Symptoms
   2. Persistent Cough
   3. Fatigue
   4. Neurological Sequelae
   5. Depression and Mood Disorders
9. KidBits: Long COVID in Pediatric Patients
10. Disposition
11. Cutting-Edge Research
12. Summary
13. Time- and Cost-Effective Strategies
14. Risk Management Pitfalls for Urgent Care Patients With Long COVID
15. 5 Things That Will Change Your Practice
16. Case Conclusions
17. Coding & Charting: What You Need to Know
    1. Number and Complexity of Problems Addressed
    2. Amount and/or Complexity of Data to be Reviewed and Analyzed
    3. Risk of Complications and/or Morbidity or Mortality of Patient Management
    4. Medical Decision Making
18. References

Abstract

Afflicting millions of people across the world, “long COVID” is a new disease entity that can present with a diverse array of symptoms of variable severity, affecting nearly every organ system. The presumptive diagnosis of long COVID is largely clinical and should be made only after other serious etiologies have been excluded. Workup is driven by the patient‘s presenting acute symptoms, comorbidities, and physical examination findings. This issue reviews the research and current evidence on the etiology of COVID-19 infection and long COVID and presents a practice-based approach to the management of patients presenting with its postacute sequelae.

Case Presentations

A 35-year-old woman presents to the UCC complaining of palpitations and retrosternal chest pain that is mostly relieved by sitting forward…

• The patient, who works as a paralegal and has been healthy all her life (although she smokes a half-pack of cigarettes daily), reports that her symptoms occasionally prompt anxiety so severe that she has self-treated with recreational marijuana. The palpitations have recurred frequently over the past 3 months, but she dates their initial incidence to a PCR-confirmed diagnosis of COVID-19 about 2 weeks before that.
• Her temperature is 37.8°C; heart rate,122 beats/min; blood pressure, 124/84 mm Hg; and respiratory rate, 24 breaths/min, with shallow breathing. Her ECG shows pronounced sinus arrhythmia.
• The patient reports that her initial COVID infection was treated conservatively as an outpatient but caused 2 weeks’ absence from work. Since then, her more-constant symptoms have been dyspnea with even minimal activity such as climbing 1 flight of stairs. She also complains of cough that is sometimes productive of yellowish sputum, with both tussive chest pain and back pain. The palpitations are worse than usual today and make her feel like she is “having a heart attack, or an aneurysm, or something bad.” This is her first UC visit for these symptoms, but she has visited her primary care provider’s office several times and been encouraged to hydrate and take acetaminophen.
• You consider whether there is anything that can be done to pinpoint a treatable cause of her symptoms—always following a “consider the worst case first” (here, perhaps pulmonary embolism), while also assuaging her anxiety...

A 25-year-old male healthcare worker presents to the UCC complaining of several days of subjective fever, generalized fatigue and myalgias, sore throat, headache, and anosmia…

• The patient’s vital signs are normal, as are his cardiovascular and pulmonary examinations. There is a localized 4-cm-wide scaly, pink, macular eruption on his back that is notably pruritic. With his eyes covered, he cannot differentiate the odors of coffee, iodine solution, and water.
• The patient reports that similar symptoms have waxed and waned over the preceding 6 to 8 weeks, but the anosmia had been consistent since he was diagnosed with COVID-19 about 3 months ago. Upon further questioning, he reports 3 episodes over the past several weeks of mucoid, non-bloody diarrhea, which resolved with over-the-counter medications; relatively persistent nausea and poor appetite (though he reported no weight loss); easy fatigability; and recurrent episodes of “hives” that he had never experienced before and with which he had identified no potential precipitant.
• Other than being obese (body mass index, 32.1 kg/m²) and having a history of childhood asthma, he considers himself to be healthy. He presents today because he feels believes that these symptoms are related to his prior COVID infection, and he is concerned he may still be “carrying” the virus and putting both coworkers and patients at risk.
• You consider what the etiology of his rash might be, how ill he is, and how to discuss contagion risk with him at this point in his clinical course...

A 45-year-old woman presents to the UCC complaining of 2 days of persistent diaphoresis and lightheadedness, with bilateral upper extremity “pins-and-needles” shooting pain…

• The patient reports that she had a confirmed COVID-19 diagnosis 8 weeks ago. Her acute COVID symptoms were mild headache and dizziness as well as typical upper respiratory infection symptoms. She was treated with nirmatrelvir/ritonavir but had rebound symptoms after the treatment course. Her symptoms eventually subsided 2 weeks after stopping the medication.
• On physical examination, the patient has a normal temperature of 36.6°C; heart rate, 104 beats/min; blood pressure, 112/62 mm Hg; respiratory rate, 22 breaths/min; and oxygen saturation, 92% on room air. She is diaphoretic, but has an otherwise unremarkable physical examination, and a normal neurological examination.
• On further history, she reports that her upper extremity neurological symptoms occur several times a day. They are associated with activity and exertion and are usually relieved by rest. She has seen several neurologists and had been put on a trial of pregabalin, without relief. This visit to the ED was prompted by the associated diaphoresis and lightheadedness that had not occurred in the past.
• At this point, what other diagnostic testing should be done for this patient, or should she be reassured and discharged?

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Risk Management Pitfalls for Urgent Care Patients With Long COVID

1. “He just had a positive COVID test 2 weeks ago, and his symptoms were nonspecific, so I diagnosed long COVID without an expensive workup.” It is true that long COVID is epidemiologically common, and indeed many patients present having self-diagnosed. Most of the time, an extensive workup is not indicated in an urgent care visit, but given that long COVID is a diagnosis of exclusion, worrisome candidates in the differential diagnosis of the patient’s complaints should be evaluated as with ED patients without a history of recent COVID.

8. “He said he had COVID 4 months ago. His cough and shortness of breath this week must be residual from long COVID. I didn’t think it was worth re-testing him for COVID.” Re-infections with COVID are not unusual, especially in elderly and immunocompromised populations. Consider re-testing for acute COVID illness when patients present with concerning symptoms.

9. “Her respiratory rate was only mildly elevated, and she did not look anxious at all. Most people are just more anxious nowadays, so we sent her out with reassurance that nothing was wrong.” Tachypnea also creates anxiety. Both respiratory symptoms and mood disorders, including anxiety, are common components of a long COVID presentation, but should not be ascribed to that diagnosis unless other elements of the differential diagnosis are considered and excluded.

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

3. Johns Hopkins University of Medicine. Johns Hopkins Coronavirus Resource Center. Accessed February 10, 2024. (Coronavirus database)

12. COVID-19 Treatment Guidelines Panel. Coronavirus disease 2019 (COVID-19) treatment guidelines. Accessed February 10, 2024. (Guidelines)

13. U.S. Centers for Disease Control and Prevention. Underlying medical conditions associated with higher risk for severe COVID-19: information for healthcare professionals. 2020. Accessed February 10, 2024. (Guidelines)

16. de Jesús EG. Who has the highest risk of long COVID? It’s complicated. ASBMB Today. 2022. Accessed February 10, 2024. (Magazine article)

17. * U.S. Centers for Disease Control and Prevention. Long COVID or post-COVID conditions. 2022. Accessed February 10, 2024. (CDC website)

19. U.S. Department of Health and Human Services. COVID Data Tracker. Accessed February 10, 2024. (CDC website)

20. Xie Y, Choi T, Al-Aly Z. Nirmatrelvir and the risk of post-acute sequelae of COVID-19. medRxiv. 2022. (Preprint, retrospective) DOI: 10.1101/2022.11.03.22281783

24. * Deer RR, Rock MA, Vasilevsky N, et al. Characterizing long COVID: deep phenotype of a complex condition. EBioMedicine. 2021;74:103722. (Review) DOI: 10.1016/j.ebiom.2021.103722

25. * Greenhalgh T, Knight M, A’Court C, et al. Management of post-acute COVID-19 in primary care. BMJ. 2020;370:m3026. (Review) DOI: 10.1136/bmj.m3026

26. * Mahase E. COVID-19: what do we know about “long COVID”? BMJ. 2020;370:m2815. (Review) DOI: 10.1136/bmj.m2815

41. * Mizrahi B, Sudry T, Flaks-Manov N, et al. Long COVID outcomes at one year after mild SARS-CoV-2 infection: nationwide cohort study. BMJ. 2023;380:e072529. (Retrospective nationwide cohort study) DOI: 10.1136/bmj-2022-072529

45. * Korompoki E, Gavriatopoulou M, Hicklen RS, et al. Epidemiology and organ specific sequelae of post-acute COVID-19: a narrative review. J Infect. 2021;83(1):1-16. (Review) DOI: 10.1016/j.jinf.2021.05.004

54. * Silva Andrade B, Siqueira S, de Assis Soares WR, et al. Long-COVID and post-COVID health complications: an up-to-date review on clinical conditions and their possible molecular mechanisms. Viruses. 2021;13(4):700. (Review) DOI: 10.3390/v13040700

56. * Disser NP, De Micheli AJ, Schonk MM, et al. Musculoskeletal consequences of COVID-19. J Bone Joint Surg Am. 2020;102(14):1197-1204. (Review) DOI: 10.2106/JBJS.20.00847

82. * Estiri H, Strasser ZH, Brat GA, et al. Evolving phenotypes of non-hospitalized patients that indicate long COVID. BMC Med. 2021;19(1):249. (Retrospective elecronic health record analysis; >96,000 patients) DOI: 10.1101/2021.04.25.21255923

89. Haute Autorité de Santé. Symptômes prolongés suite à une COVID-19 de l’adulte - diagnostic et prise en charge. Accessed February 10, 2024. (Guideline)

103. *Sanchez-Ramirez DC, Normand K, Zhaoyun Y, et al. Long-term impact of COVID-19: a systematic review of the literature and meta-analysis. Biomedicines. 2021;9(8):900. (Review; 24 articles, 5323 adult patients) DOI: 10.3390/biomedicines9080900

143. National Institutes of Health. “NIH launches long COVID clinical trials through RECOVER Initiative, opening enrollment.” U.S. Department of Health and Human Services; 2023. Accessed February 10, 2024. (News release)

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Keywords: COVID-19, COVID, long COVID, fatigue, postacute sequelae, PASC, SARS-CoV-2; cytokine storm, POTS