Hufsa Tayyab

COVID intro</p> <div id="quicknote-wrapper" contenteditable="true"> Video consultation due to COVID pandemic. Ability to assess and manage patient limited due to infection risks [Kirklees in lockdown again]. <br>Very limited and much delayed access to bloods, diagnostics and secondary care and other health services due to pandemic. <br>Confirmed 3 identifiers with patient, alone, at home and consents to have consultation via video. <br> <br>NOT in any of the clinically vulnerable groups. <br> <br>In clinically vulnerable as: <br> - aged 70 or older <br> - under 70 with an underlying health condition: <br> - chronic (long-term) mild to moderate respiratory disease - asthma / COPD, emphysema or bronchitis <br> - chronic heart disease - IHD / HF <br> - chronic kidney disease <br> - chronic liver disease <br> - chronic neurological conditions - PD / MND / MS <br> - diabetes <br> - Immunosuppressed due to DMARDs / Steroids <br> - ^ BMI &gt; 40 <br> - pregnant women </div> <p>

Covid History</p> <div id="quicknote-wrapper" contenteditable="true"> First symptoms: <br> <br> <br>No fever - No cough - No anosmia - No loss of taste - No fatigue <br>No SOB - No collapse - No chest pain - No haemoptysis <br>No loss of appetite - No myalgia - No sore throat - No nasal congestion <br>No diarrhoea - No nausea - No vomiting <br>No headache - No confusion - No rash <br>No urinary symptoms - PU normally <br> <br> <br> - “How is your breathing today?” <br> - “Do you have an oximeter at home or have you noticed any blue discolouration of your lips?” <br> - “Are you more breathless than usual on walking or climbing stairs?” <br> - “When was the last time you went to the toilet and passed urine?” <br> - Are you so breathless that you are unable to speak more than a few words? - [Yes / No] <br> - “Are you breathing harder or faster than usual when doing nothing at all?” - [Yes / No] <br> - “Are you so ill that you've stopped doing all of your usual daily activities?” - [Yes / No] </div> <p>

Remote exam</p> <div id="quicknote-wrapper" contenteditable="true"> Looks well, alert and looks comfortable, no obvious pain or SOB. <br>Dressed in day time clothes - Sat up in chair <br>Speaking normally in full sentences <br>Pulse rate by [patient palpation / pulse oximeter / app] = <br>Respiratory rate = <br>BP: No BP machine <br> - Dizziness or faintness: reports [none / all the time / on getting up from chair / on getting up from bed] <br>Pt reports skin colour looks [normal / pale / mottled] and hands and feet feel [normal / warm / cold]. <br>No change in behaviour. No obvious confusion. <br> <br>No hoarse voice. No stridor. No SOB. <br>On self palpation of neck - No pain/tenderness. No Lumps. <br>View of back of throat looks [normal / abnormal]. No tonsillar exudate. No abscess. No Uvula deviation. <br> <br>Cardio-respiratory <br> - Are you so breathless that you are unable to speak more than a few words? - [Yes / No] <br> - “Are you breathing harder or faster than usual when doing nothing at all?” - [Yes / No] <br> - “Are you so ill that you've stopped doing all of your usual daily activities?” - [Yes / No] <br> - Looks well. Not SOB on speaking. Completing sentences. <br> - Sitting comfortably. No obvious accessory muscle use. No recession. No audible wheeze or added sounds. <br> - 1 min sit-stand test: still able to speak in sentences without any difficulty. <br> - No nasal flaring. Lips not blue or pursed. Peripheries not mottled. <br> - Pt reports skin colour looks [normal / pale / mottled] and hands and feet [normal / warm / cold / blue]. <br> - No leg swelling or redness. <br> <br>Not in obvious pain. Able to 'suck in and blow out' abdomen without any problems. No grimacing. <br>On standing localises pain to <br>Self palpation : reports abdomen is [soft / hard], [non / tender], and no lumps are felt. </div> <p>

Covid Assessment and Management</p> <h4>Mild symptoms</h4> <div id="quicknote-wrapper" contenteditable="true"> No new breathlessness on walking - Not Dizzy/faint on walking - No severe headache - Passing urine - No tight chest/wheezy <br>HR = 90 | RR = 20 | Sats = 94% | NEWS2 ~ 0-2 <br> <br>Impression: Mild symptoms <br>Advised self isolation, getting testing and symptomatic management as per latest guidance > https://www.nhs.uk/conditions/coronavirus-covid-19/self-isolation-and-treatment/ <br>Advised of risk of deterioration (esp in week 2) and safety netting regarding worsening symptoms as per https://www.nhs.uk/conditions/coronavirus-covid-19/self-isolation-and-treatment/what-to-do-if-symptoms-get-worse/ - to call us/111 if worse and 999 if red flags </div> <h4>Moderate symptoms - medium risk signs</h4> <div id="quicknote-wrapper" contenteditable="true"> Deteriorating symptoms: No new breathlessness on walking - Not Dizzy/faint on walking - No severe headache - Passing urine - No tight chest/wheezy <br>HR = 91-130 | RR = 21-24 Speaking full sentences | Sats = 93-94% - No Desaturation with exertion on desaturation test or ≤ 2% from resting values | NEWS2 ~ 3-4 <br>Impression: Currently medium risk - Moderate symptoms and medium risk signs <br> <br>Added to practice list of known/suspected Covid 19 patients (and notify public health) <br>Options discussed including risks - decided on trial of treatment at home <br>Considered treatment to prevent secondary bacterial pneumonia (Doxycycline 200mg day 1 then 100mg for 4 days OR Amoxicillin 500mg tds for 5 days) <br>Treat an exacerbation of asthma or COPD IF known steroid-responsive <br>Consider high dose bronchodilators (4-8 puffs salbutamol via large volume spacer (or nebuliser) <br> <br>Advised self isolation, getting testing and symptomatic management as per latest guidance > https://www.nhs.uk/conditions/coronavirus-covid-19/self-isolation-and-treatment/ <br>Advised of risk of deterioration and safety netting regarding worsening symptoms as per https://www.nhs.uk/conditions/coronavirus-covid-19/self-isolation-and-treatment/what-to-do-if-symptoms-get-worse/ - to call 999 if worse <br> <br>Arrange daily follow up call via hot site or GP to assess breathlessness at rest/with usual activity and daily pulse oximetry <br>Follow up until 48 hours of improvement in symptoms and O2 Saturations <br>refer to secondary care if deteriorating saturations </div> <h4>Moderate symptoms + high risk signs or severe symptoms</h4> <div id="quicknote-wrapper" contenteditable="true"> Deteriorating symptoms: New breathlessness on walking - Dizzy/faint on walking - Severe headache - Mot passing urine - Moderate tight chest/wheezy - Cardiac chest pain - Confusion <br>HR = 131 | RR = 25 | Sats = 92% - or Desaturation with exertion > 3% from resting values | NEWS2 ~ ≥ 5 <br>Impression: Currently high risk > 999 hospital admission <br> </div> <p>

First symptoms started

– Features suggestive of shock or peripheral shutdown – A reduced level of consciousness – Extremities: cold and clammy to touch – Skin is mottled, ashen, blue or very pale – Reduced urine output: little or no urine in the last 24 hours

– Severe breathlessness – Rapid, significant deterioration in breathing in the last hour – New breathlessness at rest – Newly unable to complete sentences – Sudden onset breathlessness

– Other red flags: severe central chest pain – collapse – severe headache – neck stiffness/non-blanching rash

– – No shock or peripheral shutdown features – Normal consciousness – Extremities: warm and well perfused – Not pale – No cyanosis – Normal urine output
– No severe breathlessness – No recent or sudden deterioration in breathing – No breathlessness at rest – Able to complete sentences

No fever – No chills/rigors – No cough – No anosmia – No loss of taste – No fatigue
No SOB – No collapse – No chest pain – No haemoptysis
No headache – No confusion – No rash
No myalgia – No sore throat – No nasal congestion
No loss of appetite – No nausea – No vomiting – No diarrhoea
No urinary symptoms – PU normally

RED FLAGS
?Shock or peripheral shutdown: Reduced level of consciousness | Extremities – cold and clammy to touch | Pallor – skin is mottled, ashen, blue or very pale | Reduced urine output – little or no urine in the last 24 hours
Severe breathlessness: Rapid, significant deterioration in breathing in the last hour | New breathlessness at rest | Newly unable to complete sentences | Sudden onset breathlessness
Others: Severe central chest pain | Collapse

Temp = ≤ 38 °C | 38.1 – 39 °C | 39 °C or 35 °C |
HR = 51 – 90 | 41 – 50 or 91 – 110 | 111 – 130 | ≤ 41 or > 130
RR = 12 – 20 | 21 – 24 | 9 – 11 or 25 – 29 | ≤ 8 or ≥ 30
Sats at rest = ≥ 96% | 95% | 94% | ≤ 93%
Sats after 40 steps = Fall of 0 – 1% | | Fall of 2% | Fall of ≥ 3%
No SOB | Breathless on moderate exertion | Breathless on mild exertion | Severe breathing difficulty
SOB better/same as yesterday | Breathlessness, worse than yesterday | | Significant deterioration in last hour
No fatigue | Noticeably more tired doing usual activities | Struggling to get out of bed | Unable to speak because of tiredness
No/Mild muscle aches | Moderate muscle aches | Severe muscle aches |
No confusion | Less mentally alert than usual | New and worsening confusion | Reduced level of consciousness