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Chapter 1. Screening/Physical Exam/Health…
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Chapter 2
Covid-19 forthePrimary
Care Clinician: Current
Recommendations—Don’t
Blink!
MatthewLove
Introduction
Writing a chapter about Covid-19 for inclusion in a hardcopy
book is a fool’s errand. Already, in the course of the 2-plus
years of the pandemic, diagnostics and therapeutics and preventive strategies have undergone wholesale changes. Even
the presenting symptoms and signs of the disease have
changed within the last year. What’s safe to say is that the
virus will evolve [1]. So this chapter will not include information about Wuhan and alpha and delta variants of the virus
that is no longer relevant to current practice. More so than
with any other known disease, you must keep abreast of current recommendations of the CDC and your state and city
health departments. Knowing the local status of the epidemic
will affect the assessment of symptoms, the interpretation of
diagnostic tests, and the choice of treatment for many of the
individual patients you see.
M. Love (*)
Albert Einstein College of Medicine, Bronx, NY, USA
e-mail: matthew.love@nychhc.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
E. Sydney et al. (eds.), Handbook of Outpatient Medicine,
https://doi.org/10.1007/978-3-031-15353-2_2
45
46
M. Love
Covid-19 illness typically has several phases. The presymptomatic phase occurs a few days after exposure. Viral
replication in the upper respiratory tract may have reached a
point such that the patient feels nothing but harbors a viral
load sufficient to render him contagious. In the next phase, the
viral load increases exponentially, and symptoms appear. The
virus circulates widely in the body, replicating in the lower
respiratory tract, the brain, the blood, adipose tissue, and other
organs. In the next phase, typically beginning several days
after symptom onset, a massive inflammatory response contributes to the multisystem devastation caused by the virus.
Usually by day 10 of symptoms, the immune system has nearly
cleared the virus from the body. In the convalescent phase,
lasting several weeks, the body usually heals and recuperates
fully. However, a significant percentage of patients suffers
persistent symptoms and apparently permanent damage—
most commonly called long covid. Vaccination, antiviral treatment, passive antibody infusion, and other treatments alter
the arc of disease, and individual patients often deviate from
the typical course. Indeed, most people infected with the SarsCoV-2 virus do not develop Covid-19.
Below, I confine my discussion to the areas encountered in
the outpatient practice setting, not the emergency room or
the inpatient service.
Symptoms
The symptoms of Covid-19 were well known to all—fever,
cough, myalgia, and headache were the most common; rhinorrhea and gastrointestinal symptoms were also quite common; dyspnea, the most dreaded, was common too [2]; loss of
smell and taste were almost pathognomonic. But then, in
early December 2021, I saw three patients in a row in walk-in
clinic complaining of sore throat without any other symptoms. All were elderly with underlying conditions, but they
looked fine, and their throats looked normal. They did not
have much in support of a diagnosis of Covid-19—and were
Chapter 2. Covid-19 for the Primary Care…
it not for the drumbeat of Omicron warnings coming from
the CDC and a comment on a WhatsApp group chat that
included European physicians about the unusual frequency
of sore throat as a single symptom, I might have foregone
Covid-19 testing.
As of this moment, with Omicron being the major extant
variant—cough, sore throat, and rhinorrhea are now the top
three symptoms [3, 4]. The others listed above still occur,
though loss of taste and smell is much less common now.
It should be noted that, especially for Omicron, asymptomatic infection is probably the most common “presentation” of all.
47
Other History
The risk factors for severe Covid-19—obesity, immunosuppression, cardiopulmonary disease, diabetes, advanced age,
and vaccination status—are well known and should be ascertained for each patient. These are detailed in the Treatment
section below. The patient’s exposure risk should also be
reviewed. Patients often underestimate their risk or fail to
identify obvious exposures. The patient may trumpet their
caution—they never leave the house, they only meet their
friends outdoors—but fail to mention that their home health
aide is coming into their small apartment daily, after traveling
on the bus or that their son, who lives with them, is going to
work every day. While the FDA-authorized vaccines have not
been effective at preventing mild/moderate upper respiratory
infection, they have proven very effective at preventing infection severe enough to require hospitalization.
Physical Exam
Vital signs should be taken carefully. The most ominous finding is a low oxygen saturation. Anything in the high 90s is
reassuring. Patients with resting saturations in the mid-90s
should be made to ambulate for a couple of minutes to see if
48
M. Love
they desaturate. (Desaturation, even in patients who are
obese or deconditioned, is not normal.) Patients with resting
saturations in the low 90s (unless this is their baseline) should
be referred for admission. Hypoxemia often worsens quickly
and dramatically. The HEENT exam is often normal—the
rhinorrhea is not usually profuse, and the Covid-19-infected
throat usually does not show any exudate or erythema. Any
abnormal finding on lung exam warrants a CXR.The extremities should be checked for swelling, bearing in mind that
Covid-19 is a hypercoagulable state—DVTs and PEs are
frequent.
Lab Tests
The patient should be tested for Covid-19 if they haven’t been
tested yet. Which test to use will depend on test availability,
the circumstances of the testing situation, the rapidity of the
turnaround, the season of the year, and the particulars of the
Covid-19 variant. For the purposes of this chapter, I will
assume that the testing circumstance is the evaluation of a
recently symptomatic patient. There are two kinds of tests
which are widely available. The polymerase chain reaction
(PCR), which copies and amplifies minute amounts of viral
RNA to make it detectable, has accurately and sensitively
diagnosed all known Covid-19 variants to date. “Rapid PCR”
tests, with results available in 1–2 h, are available but have
been in short supply during the pandemic waves. Rapid antigen tests are immunoassays that detect the presence of specific viral antigens typically within 15–30min.
Figure 2.1 [5] illustrates the usual timeline of infection and
test results. In the pre-symptomatic period, the PCR (called
an RNA test in the figure), with its amplification of RNA,
may be positive. The rapid antigen test only becomes positive
when there is a higher viral load in the sample, usually right
around the time symptoms appear. After several days when
both are positive, the patient’s immune system catches up and
antibody production (first IgM and then IgG) increases and
viral load decreases. At a certain point (about 5 days after
Limit of
detectio
RNA test
+
Time after onset of symptoms (days)
Chapter 2. Covid-19 for the Primary Care…
49
Viral load
copies per mL:
10
>10
Limit of
detection
Ag-RDT
n
s
102 to 10
3
RNA
+
Antigen
6
105 to 10
Threshold
of infectiousness
0714
Period of infectiousness
IgG
IgM
+
Antibody response
+
F . PCR/RAPID Ag detection
Omicron symptom onset or first positive test), the viral load
will decrease sufficiently that the patient is no longer infectious. The PCR will continue to be positive—the test will
amplify the relatively few whole viral particles remaining as
well as the blasted bits of viral RNA in the mucosa—while
the rapid antigen will turn negative, more accurately reflecting the infectivity of the patient. (This is why, early on in the
pandemic, health departments stopped requiring negative
tests to end isolation in non-immunocompromised patients.
Instead, pre-specified isolation periods were designated.)
If the patient is a candidate for interruptive/abortive
therapy (see below), a rapid test, either rapid PCR or rapid
antigen, must be used so that the patient can obtain the medication in a timely manner. Although there are approved fast
PCRs with results available in an hour, these have been hard
to obtain in previous waves, so a rapid antigen test—an
immunoassay that detects the presence of a specific viral
antigen—is the next best choice. In the setting of an epidemic
wave of infection, the false negative rate of the rapid antigen
test is quite low, and a positive rapid test can be considered
sufficient to initiate treatment.
If the patient is not a candidate for interruptive/abortive
therapy, a regular PCR will be the most useful, presuming a
reasonable turnaround time. The PCR will be positive even
when the viral load is low, enabling accurate targeting of isolation and quarantining advice.
50
M. Love
PCRs are now available that simultaneously test for influenza and RSV. All other things being equal, these will be
helpful in some cases.
For mildly symptomatic patients, laboratory tests beyond
the Covid-19 test itself are not particularly helpful. The decision about whether to send the patient home or refer the
patient to the ER can be made based on the history and
physical alone. In elderly patients, a CBC and chemistry may
help to identify conditions lower down on the differential
diagnosis—such as hyponatremia, hyperglycemia, or bacterial infection.
Differential Diagnosis
There is so much overlap in symptoms with other respiratory
infections like influenza that no symptom or symptom complex is distinct enough to be pathognomonic. The most
important variable in assessing whether a particular patient is
more likely or less likely to have Covid-19 is the status of the
epidemic in your local area. When the wave is crashing upon
your local shores and the prevalence is high, almost every
patient with an upper respiratory symptom or a sore throat
and most patients with diarrhea, pneumonia, altered mental
status, chest pain, or syncope will have Covid-19. Conversely,
when the prevalence is low, a large majority of patients with
these symptoms will not have Covid-19. During the latest
Omicron wave of the pandemic (when the estimated prevalence of the coronavirus infection was 50% of the NewYork
City population), one challenge was making sure to not
attribute everything to Covid-19. The usual background frequencies of bacterial pneumonia, enteritis, strokes, and heart
attacks were unchanged. Indeed, there were far fewer patients
hospitalized with symptomatic Covid-19 than there were
patients hospitalized with incidental Covid-19—i.e., patients
admitted for trauma, cholecystitis, strokes, heart attacks, and
other problems who happened to test positive for Covid-19.