Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint: Follow-up for long COVID symptoms / New or worsening long COVID symptoms (specify)
History of Present Illness:
Briefly describe the patient’s initial COVID-19 illness (severity, hospitalization, symptoms).
Inquire about the onset, duration, and character of long COVID symptoms.
For follow-up visits, mention any changes or new developments since the last encounter (improvement, worsening, new symptoms).
Explore the impact of long COVID symptoms on the patient’s daily life (work, social activities, functional limitations).
Past Medical History:
Include any relevant past medical history (e.g., pre-existing health conditions).
Mention any risk factors for severe COVID-19 illness (e.g., obesity, diabetes).
Medications:
List all current medications, including those specifically used to manage long COVID symptoms (if any).
Social History:
Inquire about lifestyle habits (diet, exercise, sleep quality) that may influence long COVID symptoms.
Briefly mention social support system and any limitations imposed by long COVID.
Family History:
Not typically relevant for long COVID, but can be included if pertinent.
Physical Exam:
Perform a focused physical exam based on the reported symptoms. This may include:
Vital signs: Monitor for fever or tachycardia (may suggest ongoing inflammation).
Cardiovascular exam: Listen for heart murmurs (possible post-COVID myocarditis).
Pulmonary exam: Assess for respiratory function (may reveal persistent cough or shortness of breath).
Neurological exam: Evaluate for cognitive dysfunction or fatigue.
Laboratory Tests (if performed):
There is no specific diagnostic test for long COVID. Testing may be done to rule out other conditions with similar symptoms or assess for underlying issues that may contribute to long COVID (e.g., thyroid function tests, inflammatory markers).
Imaging Studies (if performed):
Imaging studies are not routinely used for long COVID diagnosis but may be performed if specific symptoms warrant investigation (e.g., chest X-ray for persistent cough).
Assessment:
Diagnosis: State that the patient is experiencing long COVID symptoms following a documented COVID-19 illness.
Symptom burden: Describe the specific long COVID symptoms and their impact on the patient’s function.
Differential diagnosis: Consider and briefly rule out other potential explanations for the patient’s symptoms.
Plan:
Management:
Outline a management plan based on the specific symptoms and their severity. This may include:
Supportive care: Optimize sleep hygiene, promote healthy diet and exercise habits, address anxiety and depression (common with long COVID).
Symptom-specific treatments: Medications for fatigue, pain management, cough suppressants (if needed).
Referral to specialists: Consider referral to specialists for specific long COVID symptoms (e.g., pulmonologist for persistent cough, cardiologist for suspected myocarditis, physical therapist for fatigue and deconditioning).
Rehabilitation: Physical and/or occupational therapy may be helpful for regaining function and managing limitations.
Education: Educate the patient about long COVID, the course of the illness, and available management strategies.
Follow-up: Schedule regular follow-up visits to monitor symptom progression, response to treatment, and overall well-being.