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
ENT
- Tinnitus, poor hearing
- Altered smell
- Altered voice
Respiratory
- Breathlessness
- Altered breathing pattern
Neurocognitive
- Impaired executive function
- Sleep disturbance
- Poor memory
- Poor concentration
- Headache
Mental health
- Anxiety
- Depression
Gastrointestinal
- Reflux
- Bloating
- Difficulty swallowing
- Diarrhoea
Cardiovascular
- Microvascular angina
- Dizziness
- Tachycardia, especially on standing
Gynaecological
- Menstrual irregularity
- Premature menopause
Skin and hair
- Hair loss
- Urticaria
- Chilblains
Musculoskeletal
- Muscle and joint pain
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.
- 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).