What is the management for a COVID-19 patient presenting with fever, cough, paresthesia (numbness) in hands and feet, dizziness, and chest pain?

Management of COVID-19 Patient with Multiple Symptoms on Televisit

A COVID-19 patient with fever, cough, numbness in hands and feet, dizziness, and chest pain requires immediate evaluation for possible cardiac involvement and should be directed to emergency care due to the concerning constellation of symptoms.

Initial Assessment and Triage

• Chest pain in a COVID-19 patient should raise immediate concern for potential cardiac involvement, including myocarditis or acute myocardial infarction, requiring urgent evaluation 1
• The combination of chest pain with paresthesia (numbness in hands and feet) and dizziness suggests possible cardiovascular complications that warrant in-person evaluation 1
• COVID-19 patients with respiratory symptoms (cough) plus chest pain should be considered high-risk and not managed solely via televisit 1

Immediate Management Steps

• Instruct the patient to call emergency services (911) for immediate transport to an emergency department for proper evaluation of chest pain 1
• If the patient refuses emergency transport, strongly recommend immediate in-person evaluation at the nearest emergency department 1
• Advise the patient to take aspirin (if no contraindications) while awaiting emergency services if acute coronary syndrome is suspected 1

Rationale for Emergency Evaluation

• COVID-19 can cause direct cardiac injury, myocarditis mimicking STEMI, stress cardiomyopathy, or true acute myocardial infarction requiring immediate intervention 1
• The combination of chest pain, paresthesia, and dizziness suggests possible neurological and/or cardiovascular complications that cannot be adequately assessed via televisit 1
• Delays in seeking care for cardiac symptoms during COVID-19 have been documented and can lead to worse outcomes 1

Hospital-Based Management (to be initiated upon arrival)

• Immediate ECG to evaluate for ST-segment elevation or other abnormalities 1
• Laboratory testing including cardiac troponin, complete blood count, and inflammatory markers 1
• Chest imaging (X-ray or CT) to assess for COVID-19 pneumonia and cardiac abnormalities 1
• Echocardiography if myocardial involvement is suspected based on symptoms and initial testing 1

Treatment Considerations

• If STEMI is confirmed, primary PCI remains the standard of care even during the COVID-19 pandemic 1
• For confirmed COVID-19 with respiratory symptoms, consider remdesivir, which should be initiated as soon as possible after diagnosis 2
• Supportive care including oxygen therapy if oxygen saturation is below recommended levels 1, 3
• Monitor for signs of clinical deterioration including worsening respiratory status or hemodynamic instability 3

Pitfalls to Avoid

• Delaying cardiac evaluation due to focus on COVID-19 respiratory symptoms can lead to missed cardiac events 1
• Managing chest pain via televisit alone without proper cardiac workup is dangerous in COVID-19 patients 1
• Attributing all symptoms to COVID-19 infection without considering cardiac, neurological, or other complications 1
• Failing to recognize that numbness in extremities may indicate neurological involvement or vascular complications requiring in-person assessment 1, 3

Special Considerations

• If the patient has known cardiovascular disease, they are at higher risk for complications and mortality from COVID-19 1
• Patients with COVID-19 and cardiac symptoms may have delayed presentation times, which can worsen outcomes 1
• The combination of fever, cough, and chest pain in COVID-19 patients should always prompt consideration of myocarditis 1