History and examination

Factors to look out for

• Onset on or after Jan 2020
• Course may be constant or relapsing/remitting, perhaps with specific triggers
• Fatigue made worse by minor exertion
• Functional impairment - unable to do normal job or activities

Red flags

• Chest pain on exertion
• Tachycardia > 100 at rest
• Desaturation > 3% on exertion
• Oxygen Sats <94% at rest
• Syncope on exertion
• Acute and progressive dyspnoea
• New onset confusion
• Symptoms suggestive of stroke

Organ specific symptoms

Investigations

Guided by history and examination but consider:

• FBC, U&E, LFT, TFT, CRP, Vit D, HbA1c
• Blood-borne virus testing - HIV, Hep B, Hep C
• Coeliac screen
• Sats
• CXR +-  spirometry
• ECG
• BNP
• Testing for orthostatic hypotension/Postural orthostatic tachycardia syndrome:
  • Measure blood pressure with the person lying on their back (or consider a seated position, if it is inconvenient to measure blood pressure with the person lying down). Repeat BP measurements while active standing for at least 1 minute to assess for orthostatic hypotension (OH) or postural orthostatic tachycardia syndrome (PoTS).
    • OH is defined as a progressive and sustained fall in systolic blood pressure from baseline of more than or equal to 20 mmHg, or diastolic blood pressure of more than or equal to 10 mmHg, or a decrease in systolic blood pressure to less than 90 mmHg that reproduces spontaneous symptoms.
    • PoTS is defined as an orthostatic heart rate increase (more than 30 beats per minute, or increasing to more than 120 beats per minute) within 10 minutes of active standing, in the absence of OH which reproduces spontaneous symptoms.

Diagnosis

Long covid is a diagnosis of exclusion and can be made in primary care if there are prolonged (>3 months) symptoms following covid infection with no alternative diagnosis.

Code the diagnosis using Post-COVID-19 syndrome code.

Management

People who have had suspected COVID or confirmed acute COVID-19 should be given advice and written information on:

• the normal recovery trajectory (signpost to Your Covid Recovery)
  • explain that recovery time is different for everyone but for many people symptoms will resolve by 12 weeks
  • advise that if new or ongoing symptoms occur, they can change unpredictably, affecting them in different ways at different times
• what they might expect during their recovery e.g., common symptoms and self-management of these
• advise about symptoms to look out for that mean they should contact their healthcare professional
• Give patient the long covid workbook

Postural orthostatic tachycardia syndrome (POTS)/orthostatic hypotension

If identified, consider management of POTS/ orthostatic hypotension

All patients receiving a diagnosis of long covid, or if continued functional limitations are present, can be referred to the Long Covid Pathway via the AHP Regional Rehab Team for holistic assessment and care & support planning for management of this energy limiting condition.

Referral is via SCI-gateway to Mountainhall...Regional rehab service...Physio comm rehab.

A SCI Gateway advice request can also be submitted to further discuss a case with the specialist team.

Consider specialist referral:

• Respiratory for severe breathlessness
• Cardiology if POTS is severe or diagnosis is in doubt
• ENT for tinnitus or markedly altered voice
• Memory clinic for cognitive dysfunction impairing ability to work
• Gastroenterology for difficulty swallowing or chronic diarrhoea