How should primary care clinicians remotely manage patients with acute respiratory tract symptoms and possible infection with the novel coronavirus disease 2019 (COVID-19)?
Study design Practice guideline
Synopsis This expert-based review offers best practices for how to set up remote care via telephone or video and how to assess patients with possible COVID-19 infection.
To get started, assure you have remote access to patient records and, if using video, that your equipment works.
Take a history, starting with broad questions of the patient's state of health to determine why he or she has decided to seek care now. Assess for cough and degree of breathlessness using general questions and probing for recent change. Ask for a history of contact with a confirmed or presumed patient with infection. Ask about any comorbidities that might increase risk.
Probe for red flag symptoms that warrant more urgent assessment, including temperature higher than 38 degrees, respiratory rate greater than 20, heart rate more than 100 with new confusion, or, if available, an oxygen saturation less than 95%.
Remote physical examination
A physical examination will be almost impossible by phone and difficult by video, so you will have to make compromises. In a video consultation, assess the patient’s demeanour, whether they are lying in bed or up and about, skin features (such as flushing, pallor, cyanosis—though note that if lighting is suboptimal this can be difficult to assess), and oropharynx. Congestion of the throat and tonsillar swelling are both rare (present in about 2% of covid-19 cases).
Assess respiratory function as best you can (box 1). It may be possible to get the patient to take readings from instruments they have at home—for example, temperature, pulse, blood pressure, blood glucose, peak expiratory flow rate, and oxygen saturation.
If you are using video, you can check whether the patient is using their equipment correctly (they may have purchased it only recently)... patients may have a home oximeter.