1. INTRODUCTION​  ​​​​​​​​

       COVID-19 has spread rapidly across the globe, causing significant loss-of-life. Outcomes vary widely from asymptomatic, to flu-like symptoms, to pneumonia and respiratory failure. Coagulopathy is now recognized as a marker of disease severity in patients with COVID-19. It is imperative that we understand why infections in certain individuals are so much more severe than in others. The most common complication that develops in COVID-19 is bilateral pneumonia. There is an urgent need to distinguish those patients who will have a mild disease course from those who are at-risk for respiratory failure and pulmonary intravascular coagulopathy and to reduce morbidity and mortality due to this virus. ​COVID-19 primarily infects respiratory epithelial cells and, through interaction with the extracellular domain of the angiotensin converting enzyme 2 (ACE2) receptor, airway epithelium is a key site for viral entry. Spread is person-to-person through droplets of saliva or nasal discharge during coughing, speaking or sneezing. It may also be acquired by contact with contaminated environmental surfaces. In order to avoid unnecessary exposure and potential transmission of COVID-19 in healthcare facilities and physician offices, telehealth has taken on an increasingly important role.

2. DIAGNOSIS

​​​       The most common presenting symptoms of COVID-19 are respiratory-related and often non-specific (Table 1). In some patients, initial symptoms are gastrointestinal with diarrhea and/or nausea and vomiting. The gold standard method for definitive diagnosis is presence of SARS-CoV-2 nucleic acid upon reverse transcription polymerase-chain-reaction (RT-PCR) testing of specimens obtained by nasopharyngeal swab sampling. For this type of detection, which can determine whether the infection is active and the patient is contagious, the window is short and limited to the period of viral excretion. Immunoassays, based on the presence or absence ​of antibodies against the virus in the blood, may be useful in later stages of infection.

Table 1. COVID-19 Symptoms: initially may present like a common cold or flu​ ​

** Highly suspicious of COVID-19

3. THE TELEHEALTH VISIT

       The initial telehealth encounter for suspected COVID-19 is focused on acute patient assessment and management ​(Table 2, Table 3 and Table 4).

​​Table 2. Telemedicine Evaluation​

Table 3. Covid-19 Assessment Questions

Table 4. The Telemedicine Medical History

       ​Particular attention should be given to specific aspects of the medical history and patient characteristics that increase vulnerability to severe illness from this viral infection. It has been established that certain groups of individuals are at a higher risk of developing serious complications from COVID‐19. Increased age and comorbidities are risk factors for becoming severely or critically ill (Figure 1).​

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       The physical examination performed virtually cannot be as extensive as face-to-face, but substantial information can be gleaned, especially with the assistance of the patient (Table 5). The physician can observe the overall appearance and determine whether breathing is labored. Color of skin and mucous membranes can be visualized. Patient can report temperature and pulse and perhaps blood pressure.

Table 5. The Telemedicine Physical Exam

4. LABORATORY TESTING

       A large number of studies have shown that key hematologic data may be helpful in predicting who is likely to have a poor outcome from COVID-19 so that more aggressive measures can be instituted for these patients. A hypercoagulable state with propensity to form micro- and macro-thromboses is an ominous sign reflected in elevated D-dimer. Inflammatory markers such as C-reactive protein may also signal a more difficult course. Lab tests routinely administered in COVID-19 can be found in Table 6.

 Table 6. COVID-19 Laboratory Testing

5. CONCLUSIONS

       The urgent need to evaluate persons for COVID-19 infection while limiting spread of this infectious disease has accelerated use of telemedicine and virtual visits by physicians, healthcare providers and patients. Telemedicine is a form of real-time, audio and visual communication that has shown its value during the pandemic and that will need to be scrutinized formally in well-designed studies with the goal of optimizing delivery and attaining the best possible outcomes.​

       In order to maintain good health through this pandemic and in general, see recommendations in Table 7.

Table 7. Advice for Health Maintenance During Pandemic