History and exam

Your Organizational Guidance

ebpracticenet urges you to prioritize the following organizational guidance:

Opvolging en revalidatie van patiënten met aanhoudende klachten na COVID-19 in de eerste lijnPublished by: KU Leuven | Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2023Suivi et revalidation des patients présentant des symptômes persistants après la COVID-19 en première lignePublished by: KU Leuven | Groupe de Travail Développement de recommmandations de première ligneLast published: 2023

Key diagnostic factors

common

previous diagnosis of COVID-19 or history of suspected acute COVID-19 illness

A positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral test is not necessary to establish a diagnosis of long COVID. A long COVID diagnosis can be made on the basis of a previous patient-reported or clinical diagnosis of coronavirus disease 2019 (COVID-19).[4][39]

Other diagnostic factors

common

fatigue/weakness

Reported in 31% to 58%.[80] Also reported in 51% of patients 4-12 weeks after COVID-19 diagnosis and in 47% after 12 weeks or more.[1] Includes persistent tiredness even after sleep, exhaustion after minimal exertion, or needing several days of recovery after a time of increased activity.[82]

cognitive impairment (brain fog)

Reported in 12% to 35%. May include lack of concentration or attention, slower movements, poor memory, language problems, mental fatigue, and poor planning or multitasking.[88][92]

Lack of concentration was found in up to 60% of patients 4 weeks or more after COVID-19 diagnosis.[1]

Rule out dementia. Ask about drugs (including nonprescription drugs), substance misuse, and sleep disturbance.[88]

impaired sleep

Reported in 11% to 44% of patients presenting with long COVID.[80]

headache

Reported in up to 79% of patients 4 weeks or more after COVID-19 diagnosis.[1]

dizziness

Present in up to 48% of patients 4 weeks or more after COVID-19 diagnosis.[1] Determine if the symptoms are more consistent with vertigo or presyncope. Can be a symptom of autonomic dysfunction. Rule out vascular causes (brainstem or cerebellar stroke), vestibular conditions (e.g., vestibular neuritis, benign paroxysmal positional vertigo, or Meniere disease), deconditioning, dehydration, anemia, hypoxia, anxiety, uncontrolled diabetes, lung disease, and cardiac disease, including sinus node dysfunction, myocarditis, and heart failure.[88][94] Assess for drugs that could be contributing to symptoms.

dyspnea

Reported in 22% to 40%. Reported in 38% of patients 4-12 weeks after COVID-19 diagnosis and 22% after 12 weeks or more.[1] More likely in patients with more severe initial COVID-19. Patients who did not experience hypoxemia or require hospitalization are less likely to have post-acute pulmonary function problems or imaging abnormalities.[88]

Differentiate between dyspnea at rest or with movement or on exertion. Rule out urgent considerations, such as pulmonary embolism and urgent cardiovascular causes of breathlessness.[88]

cough

Reported in 7% to 29%. Reported in 28% of patients 4-12 weeks after COVID-19 diagnosis.[1] A worsening cough may indicate pneumonia.[88] Rule out gastroesophageal reflux disease, postnasal drip, pulmonary fibrosis, and iatrogenic causes (e.g., use of ACE inhibitors).[88]

anosmia/dysgeusia

Anosmia/dysgeusia is present in up to 46% of patients 4 weeks or more after COVID-19 diagnosis.[1] Consider an altered sense of smell and taste as well as an absence of it, and whether the patient is experiencing any smells that are not really present (phantosmia). Rule out sinus disease and rhinitis.

pain (including arthralgias and myalgias)

Reported in 9% to 19% of patients with long COVID.[80] Use a scale to determine the severity.

chest pain

Reported in 6% to 17% of patients 12 weeks or more after COVID-19 diagnosis.[1][80][88][95]

Rule out cardiovascular conditions associated with chest pain.[78][88]

postexertional malaise

Present in the majority of patients with long COVID related fatigue.[13] Note that any physical tests may worsen the patient’s symptoms of fatigue or malaise in the following days.[4]

anxiety/depression

Consider if an assessment for suicidality is warranted.[88] Assess if sleep disturbance, substance misuse, or other lifestyle factors are contributing.[88]

Use mental health scales to identify and to assess for any changes in severity.

palpitations

Can be a symptom of autonomic dysfunction. Rule out deconditioning, dehydration, anemia, hypoxia, anxiety, lung disease, and cardiac disease, including sinus node dysfunction, myocarditis, and heart failure.[88]

thirst/dry mouth

May be related to underlying autonomic dysfunction. Also consider a possible underlying rheumatologic disorder or a drug adverse effect.[87]

loss of sexual drive or capacity

Possibly related to coexisting fatigue, pain, neurocognitive issues, neuropathy, and cardiovascular dysfunction. Evaluate for possible hypogonadism, diabetes, or cardiopulmonary dysfunction.[80]

numbness/tingling

May be a symptom of underlying autonomic dysfunction.[87] Consider the possibility of large or small fiber neuropathy.[96]

hair loss

New-onset hair loss may be due to telogen effluvium from the initial cytokine storm.[97]

gastrointestinal symptoms

May be related to underlying autonomic dysfunction.[87] Rule out an adverse reaction from drugs and acute abdominal conditions, such as biliary colic, appendicitis, gastroenteritis, and inflammatory bowel disease. COVID-19 may also be a trigger for new-onset irritable bowel syndrome.[98]

Risk factors

strong

severe COVID-19 illness (requiring hospitalization or ICU admission)

People with severe COVID-19 illness who were hospitalized and/or admitted to the intensive care unit (ICU) have a significant risk of developing long COVID (odds ratio [OR] 2.37 and 2.48, respectively).[42] A population-based study in Sweden found the proportion of people receiving a long COVID diagnosis to be 1% among those not hospitalized, 6% among those hospitalized, and 32% among those treated in the ICU.[63] Of note, the pathophysiology of ongoing symptoms following severe or critical acute COVID-19 illness may be distinct from the pathophysiology of long COVID in people with mild, acute COVID-19. Instead, ongoing symptoms in people with severe acute COVID-19 may be more typical of post-intensive care syndrome.[43] See Differentials.

not vaccinated or only partially vaccinated against COVID-19

People vaccinated against COVID-19 with two doses had a 40% lower risk of developing long COVID (OR 0.57).[42] Vaccination against COVID-19 reduces the risk of long COVID.[64] This occurs even when controlling for other risk factors including age and body mass index (BMI).[35]

female sex

Female sex has been found to have an OR of 1.56 for the development of long COVID.[42][43] Multiple potential mechanisms for this sex difference have been suggested, including differences in antibody response and the effects of sex hormones on the immune system.[32]

weak

age >40 years

People older than 40 years have a higher risk of developing long COVID compared with adults younger than 40 years (OR 1.21).[42]

BMI >30 kg/m²

People with a BMI >30 kg/m² have a higher risk of developing long COVID (OR 1.15).[42] Obesity may promote inflammatory processes that contribute to long COVID symptoms.[65]

smoking

Current smoking status is associated with a higher risk of developing long COVID (OR 1.10).[42]

anxiety/depression

Comorbid anxiety or depression are associated with a higher risk of developing long COVID (OR 1.19).[42]

asthma

Comorbid asthma is associated with a higher risk of developing long COVID (OR 1.24).[42]

chronic kidney disease

Comorbid chronic kidney disease is associated with a higher risk of developing long COVID (OR 1.12).[42]

chronic obstructive pulmonary disease (COPD)

Comorbid COPD is associated with a higher risk of developing long COVID (OR 1.38).[42]

diabetes

Comorbid diabetes is associated with a higher risk of developing long COVID (OR 1.06).[42]

immunosuppression

Immunosuppression is associated with a higher risk of developing long COVID (OR 1.50).[42]

ischemic heart disease

Comorbid ischemic heart disease is associated with a higher risk of developing long COVID (OR 1.28).[42]

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