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Common PASC system manifestations, symptoms, additional testing/studies and referral options

Common PASC system manifestations, symptoms, additional testing/studies and referral options
  Cardiovascular Pulmonary Endocrine Autoimmune Mood disorders Sleep disorders
Common symptoms and signs Symptoms: Symptoms: Symptoms: Symptoms: Symptoms: Symptoms:
  • Chest pains, palpitations, sweating, nausea, fatigue, leg swelling, shortness of breath - at rest/on exertion/lying flat/waking up at night, dizziness on standing, feeling faint/fainting
  • Shortness of breath - at rest/on exertion, cough, wheeze, fatigue, poor activity tolerance
  • Palpitations, fatigue, dizziness, weight gain/loss, sense of chills/fever, irregular menstrual cycle, poor diabetic control, excessive thirst/urination
  • Rash, joint/muscle pain and stiffness, fever, mouth sores/ulcers, cold/pale/blue/red fingers, sharp chest pain, numbness/tingling/burning in fingers/toes, blurry/decreased vision
  • Anxiety, irritability, chest tightness, low frustration tolerance, depression, fatigue, mood swings, palpitations, change in memory/recall
  • Poor sleep - hard to fall asleep/wakes frequently/wakes early, nonrestorative/refreshing sleep - "tired" on waking, snoring, frequent urination at night, bad dreams/nightmares, falls asleep during the day, morning headaches
Signs: Signs: Signs: Signs: Signs: Signs:
  • Pallor, tachypnea, tachycardia, diaphoresis, pulmonary rales, lower extremity edema, hypotensive sitting/standing - orthostatic hypotension, presyncopal/syncopal, poor activity tolerance/endurance
  • Tachypnea, tachycardia, cough, hypoxia/low pulse oximeter, pulmonary wheezes/rhonchi/"Velcro" rales, poor activity tolerance/endurance
  • Tachycardia, poor activity tolerance, weight gain/loss, low/elevated temperature, elevated fingerstick/urine glucose, ketotic (fruity) breath
  • Rash, arthropathy - swelling/warmth/decreased ROM, myopathy - tenderness/weakness, fever, Raynaud phenomena, pleuritic pain on deep breathing, altered sensation, decreased visual acuity
  • Flat affect/low mood, emotional lability that is, crying/laughing inappropriately, limited impulse control, psychosis
  • Snoring, restless legs, observed apneic episodes, hypertension, arrhythmias, narcolepsy, congestive heart failure, impaired neurocognition, poorly controlled mood disorder
Further studies to consider in addition to basic laboratory evaluation BNP, troponins, D-dimer, CXR, EKG, ECHO, EST/CPET, Holter monitor, cardiac magnetic resonance imaging D-dimer, PFTs, CXR, CT chest (with contrast if concerned for a pulmonary embolism) TSH/thyroxine, cortisol levels, growth hormone, LH, FSH, testosterone (men), estradiol (women) Imaging of affected joints, antibody screen based on ongoing symptoms An anxiety and depression screen (for example, HADS, BDI fast screen; PHQ-2/9, GDS Sleep apnea screen (eg, the STOP-Bang questionnaire or ESS) overnight sleep study for oximetry and sleep apnea
Referral Cardiology Pulmonology Endocrinology Rheumatology Psychiatry Sleep medicine
PASC: postacute sequelae of SARS-CoV-2 infection; ROM: range of motion; BNP: B-type natriuretic peptide; CXR: chest x-ray; EKG: electrocardiogram; ECHO: echocardiogram; EST/CPET: exercise stress test/cardiopulmonary exercise test; PFTs: pulmonary function tests; CT: computed tomography; TSH: thyroid-stimulating hormone; LH: luteinizing hormone; FSH: follicle-stimulating hormone; HADS: Hospital Anxiety and Depression Scale; BDI: Beck Depression Inventory; PHQ: Patient Health Questionnaire; GDS: Geriatric Depression Scale; ESS: Epworth Sleepiness Scale.
From: Herrera JE, Niehaus WN, Whiteson J, et al. Multidisciplinary collaborative consensus guidance statement on the assessment and treatment of fatigue in postacute sequelae of SARS-CoV-2 infection (PASC) patients. PM R 2021; 13:1027. https://onlinelibrary.wiley.com/doi/10.1002/pmrj.12684. Copyright © 2021 John Wiley & Sons Ltd. Reproduced with permission of John Wiley & Sons Inc. This image has been provided by or is owned by Wiley. Further permission is needed before it can be downloaded to PowerPoint, printed, shared or emailed. Please contact Wiley's permissions department either via email: [email protected] or use the RightsLink service by clicking on the 'Request Permission' link accompanying this article on Wiley Online Library (https://onlinelibrary.wiley.com/).
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