Evidence informed advice on how to carry out a remote consultation for COVID as recently published in the BMJ. You may find the full paper and infographic useful.
Before the History
Do a quick assessment of whether the patient is sick or not sick?
- Is the patient too breathless to talk? Can you hear them gasping on the phone? Can they speak a full sentence or only a word at a time? Do they look very sick on the video (pale, cyanotic, gasping for breath)
If YES then will need an in-person assessment. If dyspnea is severe refer to ED immediately without examination.
- Do they have chest pain/pressure? If yes, then will need at minimum an in-person examination and cardiovascular risk assessment.
Refer to ED if chest pain suggestive of severe COVID or ischemia.*
Note COVID also commonly gives myalgia affecting chest wall which does not necessarily mean severe COVID
If the patient does not sound or appear SICK, clarify what they expect from the appointment.
- Do they want a sick note?
- Do they want reassurance?
- Do they want advice on self-isolation?
- Do they need a referral?
- Do they want a clinical assessment? (may need to dissuade and reassure if not unwell)
Close contact with a COVID-19 case?
Immediate family member unwell?
Healthcare worker/ at occupational risk of COVID?
- Record when symptoms began
- Record symptoms
Common presentation symptoms
Cough (dry, may have sputum – ask about hemoptysis)
Fever (up to 50% don’t have fever at initial presentation)
Less common: muscle aches, sore throat, headache, chills, diarrhea, nausea
Note: Elderly and immunocompromised may present atypically
- Ask about urine output
- Check record: Is there underlying chronic disease that indicates increased risk of poorer outcome? (asthma, COPD, diabetes, CVD, immunocompromise)
RED FLAG SYMPTOMS
- Severe shortness of breath at rest
- Difficulty in breathing
- Cold, clammy, or pale and mottled skin Reduced level of consciousness or new confusion
- Blue lips or face
- Little / no urine output
- Pain or pressure in the chest
- Neck stiffness
- Non-blanching rash
Assess physical and mental function as best you can
Phone: Ask patient or caregiver to describe state of breathing( see questions below) and colour of face and lips
Video: In addition, assess demeanor, colour above, the extent of respiratory effort and count respiratory rate
Should I use the Roth score? NO This performs poorly and has underestimated severe illness when used in COVID, resulting in harm. Click here for more detail.
- Ask the patient (or caregiver) to describe the problem with their breathing in their own words, and assess the ease and comfort of their speech. Ask open-ended questions and listen to whether the patient can complete their sentences.
- “How is your breathing today?”
- Then specifically check symptoms
- “Are you so breathless that you are unable to speak more than a few words?”
- “Are you breathing harder or faster than usual when doing nothing at all?”
- “Are you so ill that you’ve stopped doing all of your usual daily activities?”
- Focus on change. A clear story of deterioration is more important than whether the patient currently feels short of breath. Ask questions like
- “Is your breathing faster, slower or the same as normal?”
- “What could you do yesterday that you can’t do today?”
- “What makes you breathless now that didn’t make you breathless yesterday?”
Interpret the breathlessness in the context of the wider history and physical signs. For example, a new, audible wheeze and a verbal report of blueness of the lips in a breathless patient are concerning.
In addition, a video examination will add key detail such as whether the patient is blue, the extent of respiratory effort and the opportunity to count the respiratory rate.
Patients who are dyspneic need a face to face assessment (if severe dyspnea refer to hospital for this)
Assess vital signs
The patient or caregiver may be able to assess temp, pulse, BP and O2 sats depending on home equipment. Interpret self-monitoring results with caution in the context of your wider assessment.