The most common scenario: Non-specific multisystem post-viral symptoms
While the specific sequelae of COVID-19 are vast, the majority of patients seeking support from general practice will more than likely experience a range of symptoms, as outlined in Box 2.
|Box 2. Post-acute COVID-19 symptoms2,3,12,15
|Common symptoms include:
- joint pain
- chest pain
- change in sense of smell or taste
- cognitive disturbances
- hoarse voice
|Less common symptoms include:
- low-grade fevers
- neurocognitive difficulties
- myalgia and weakness
- gastrointestinal symptoms
Management of these presentations will usually be pragmatic and symptomatic. Support your patient to maximise their personal wellbeing through diet, exercise and sleep.
Consider and exclude serious complications and possible alternative causes of ongoing symptoms, such as anaemia. Investigate new or worsening symptoms that could indicate delayed sequelae, such as venous thromboembolism (VTE), cardiac complications or pneumonia.
Where possible, optimise the management of the patient’s other chronic conditions.
Identify other social factors that could intersect with their personal health and wellbeing, including smoking, alcohol intake, drug use, risk of mental health issues, risk of family and intimate partner violence, and risk of social isolation.
Consider current recommendations for management of specific symptoms (refer to Box 3). Management should be guided by the patient’s specific clinical circumstances and be evidence based. Specialist referral should be undertaken, as required.
|Box 3. Management of common symptoms
- Optimise management of pre-existing respiratory conditions
- Recommend respiratory muscle conditioning (pulmonary rehabilitation)
- Consider chest X-ray at 12 weeks for patients who have had significant respiratory illness
- Corticosteroids could be considered for inflammatory lung disease on the advice of a respiratory physician
- Recommend gradual commencement or return to symptom-limited exercise guided by tertiary-trained exercise professionals
- Referral to a speech pathologist for management of chronic cough, hoarse voice or dysphagia
- Consider home pulse oximetry measurement
- Referral to an Accredited Practising Dietitian if symptoms interfere with nutrition, and speech pathology if dysphagia is present
- Maximise self-care, sleep, relaxation and nutrition
- Recommend that patients pace and be selective when prioritising daily activities
- Recommend caution with return to exercise (reduce if there is any increase in symptoms)
- A monitored return to exercise can be supported by an exercise physiology, physiotherapy or rehabilitation referral
- If fatigue is causing difficulty with activities of daily living (ADLs), recommend energy conservation techniques and home visits by an occupational therapist or rehabilitation service
- Exclude acute coronary syndrome, myocarditis, pericarditis, pulmonary effusion or pulmonary embolism, and arrhythmia
- Provide education regarding symptoms of concern
- Patients who have had myocarditis or pericarditis as a component of their acute illness should abstain from vigorous exercise for 3–6 months, and athletes should have cardiology supervision for return to training
- Refer for graded increase in low-to-moderate activity to increase mobility, exercise capacity and quality of life; this should be facilitated by a physiotherapist or exercise physiologist, or cardiac rehabilitation program
Headaches, low-grade fevers and myalgia:2
- Exclude COVID-19 reinfection or recrudescence
- Prescribe simple supportive measures and analgesia or antipyretics, as needed
- Check for secondary infections and prescribe antibiotics, as appropriate
- Provide supportive management
- If severe enough to cause difficulty with ADLs, consider cognitive testing, occupational therapy support and speech pathology support for cognitive communication impairment
- Provide information about post–COVID-19 recovery
- Use existing standardised screening tools
- Address multifactorial contributors that might require assistance with pain management, independence with ADLs, financial and other social supports, and loneliness
- Facilitate access to mental health services or online support if patient is unwilling to access face-to-face counselling
- Encourage individualised moderate-intensity exercise initiated and supervised by a tertiary-trained exercise professional
- Refer to an Accredited Practising Dietitian for nutrition support and access to food services
Thrombosis risk and contraceptive choice:19
- COVID-19 causes a hypercoagulable state in some people, which might worsen the VTE risk associated with combined hormonal contraception. The incidence of VTE in biological females of reproductive age with COVID-19 infection is currently not known
- Patients should be advised of this risk to allow informed choice of contraceptive option
- For biological females who have had mild or moderate COVID-19 and stopped oral menopausal hormone therapy, also known as hormone replacement therapy, if recommencing, consider using a transdermal preparation
- For biological females who have had COVID-19 and who are taking oestrogen-containing contraception, manage these medications as per usual care
- For biological females who have stopped or suspended contraception when they have contracted COVID-19, contraception can be restarted when acute symptoms have resolved
Collaborate with the patient to develop an individualised management plan to support their recovery. This might also present an opportunity for the development of multidisciplinary models of care guided by the general practice team, using chronic disease management plans, team care plans and case conference items.
It is important to ensure that if you use specific Medicare Benefits Schedule (MBS) items for this (eg Item 721: GP management plan) that you are familiar with and follow the specific item requirements (including descriptors and notes).
Allied health and other specialist collaboration
Your initial assessment will help inform your management plan. Your patient could benefit from allied health input. Consider collaborating with community and hospital-based allied health, rehabilitation medicine and geriatric medicine services to support individual management planning where appropriate. This might include:
- exercise physiologists
- occupational therapists
- speech pathologists
- occupational and environmental physicians
- rehabilitation medicine physicians
- geriatric medicine physicians
- rehabilitation medicine services including outpatients, day rehabilitation and inpatient rehabilitation
- geriatric medicine services including outpatients, and geriatric evaluation and management units.
Multidisciplinary clinics for the management of post–COVID-19 conditions have been established in some jurisdictions. It may be appropriate to refer eligible patients with post–COVID-19 sequalae to these clinics. Eligibility criteria and referral processes will be defined by each jurisdiction. Check your local Health Pathways or contact your PHN for information on clinics in your area. Alternately your local Health Pathways might have referral pathways for other allied health and specialist clinics.
Barriers in accessing allied health services might exist for culturally and linguistically diverse (CALD) patients with low English proficiency due to lack of interpreter funding. When referring your patients, ensure the service is able to provide the appropriate care.