The patient who has been disbelieved — long COVID CASC communication station

FRANZCP/MRCPsych-style station: respond to a patient with long COVID who has been disbelieved — validate without over-promising, screen for post-exertional malaise and risk, decline unvalidated treatment without dismissal, and negotiate a pacing plan and a work letter while preserving the alliance.

Prompt

A 38-year-old intensive care nurse attends the long COVID clinic fourteen months after a non-hospitalised SARS-CoV-2 infection. She has disabling fatigue, cognitive symptoms, unrefreshing sleep and lightheadedness on standing, and is bed-bound for days after modest exertion. Investigations are normal and two previous letters record 'anxiety'. She opens by saying that she has read her file and asks whether you also think it is in her head. She wants anticoagulation for microclots and she wants a letter for her employer.

Candidate instructions (10 minutes)

Meet the patient. Address her three concerns — whether you believe her, the anticoagulation request, and the employer letter. Take enough history to make a safe plan. Do not promise what you cannot deliver.^[14]^[20]

References20Show

[1]Soriano JB, et al. A clinical case definition of post-COVID-19 condition by a Delphi consensus Lancet Infect Dis, 2022.PMID 34951953
[2]Shah W, et al. Managing the long term effects of covid-19: summary of NICE, SIGN, and RCGP rapid guideline BMJ, 2021.PMID 33483331
[3]Thaweethai T, et al. Development of a Definition of Postacute Sequelae of SARS-CoV-2 Infection JAMA, 2023.PMID 37278994
[4]Davis HE, et al. Long COVID: major findings, mechanisms and recommendations Nat Rev Microbiol, 2023.PMID 36639608
[5]Ceban F, et al. Fatigue and cognitive impairment in Post-COVID-19 Syndrome: A systematic review and meta-analysis Brain Behav Immun, 2022.PMID 34973396
[6]Taquet M, et al. Neurological and psychiatric risk trajectories after SARS-CoV-2 infection: an analysis of 2-year retrospective cohort studies including 1 284 437 patients Lancet Psychiatry, 2022.PMID 35987197
[7]Hampshire A, et al. Cognition and Memory after Covid-19 in a Large Community Sample N Engl J Med, 2024.PMID 38416429
[8]Reis Carneiro D, et al. Clinical presentation and management strategies of cardiovascular autonomic dysfunction following a COVID-19 infection - A systematic review Eur J Neurol, 2023.PMID 36694382
[9]Peluso MJ, Deeks SG Mechanisms of long COVID and the path toward therapeutics Cell, 2024.PMID 39326415
[10]Swank Z, et al. Persistent Circulating Severe Acute Respiratory Syndrome Coronavirus 2 Spike Is Associated With Post-acute Coronavirus Disease 2019 Sequelae Clin Infect Dis, 2023.PMID 36052466
[11]Pretorius E, et al. Persistent clotting protein pathology in Long COVID/Post-Acute Sequelae of COVID-19 (PASC) is accompanied by increased levels of antiplasmin Cardiovasc Diabetol, 2021.PMID 34425843
[12]Fernández-Castañeda A, et al. Mild respiratory COVID can cause multi-lineage neural cell and myelin dysregulation Cell, 2022.PMID 35768006
[13]Teodoro T, et al. A unifying theory for cognitive abnormalities in functional neurological disorders, fibromyalgia and chronic fatigue syndrome: systematic review J Neurol Neurosurg Psychiatry, 2018.PMID 29735513
[14]Sharpe M, Greco M Chronic fatigue syndrome and an illness-focused approach to care: controversy, morality and paradox Med Humanit, 2019.PMID 31213482
[15]Kingdon C, et al. What Primary Care Practitioners Need to Know about the New NICE Guideline for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome in Adults Healthcare (Basel), 2022.PMID 36553962
[16]White PD, et al. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial Lancet, 2011.PMID 21334061
[17]Pouliopoulou DV, et al. Prevalence and Impact of Postexertional Malaise on Recovery in Adults With Post-COVID-19 Condition: A Systematic Review With Meta-analysis Arch Phys Med Rehabil, 2025.PMID 39921187
[18]Kuut TA, et al. Efficacy of Cognitive-Behavioral Therapy Targeting Severe Fatigue Following Coronavirus Disease 2019: Results of a Randomized Controlled Trial Clin Infect Dis, 2023.PMID 37155736
[19]Wahlgren C, et al. Two-year follow-up of patients with post-COVID-19 condition in Sweden: a prospective cohort study Lancet Reg Health Eur, 2023.PMID 36855599
[20]Stelson EA, et al. Return-to-work with long COVID: An Episodic Disability and Total Worker Health® analysis Soc Sci Med, 2023.PMID 37918226

The patient who has been disbelieved — long COVID CASC communication station

Candidate instructions (10 minutes)

References20Show

[1]Soriano JB, et al. A clinical case definition of post-COVID-19 condition by a Delphi consensus Lancet Infect Dis, 2022.PMID 34951953
[2]Shah W, et al. Managing the long term effects of covid-19: summary of NICE, SIGN, and RCGP rapid guideline BMJ, 2021.PMID 33483331
[3]Thaweethai T, et al. Development of a Definition of Postacute Sequelae of SARS-CoV-2 Infection JAMA, 2023.PMID 37278994
[4]Davis HE, et al. Long COVID: major findings, mechanisms and recommendations Nat Rev Microbiol, 2023.PMID 36639608
[5]Ceban F, et al. Fatigue and cognitive impairment in Post-COVID-19 Syndrome: A systematic review and meta-analysis Brain Behav Immun, 2022.PMID 34973396
[6]Taquet M, et al. Neurological and psychiatric risk trajectories after SARS-CoV-2 infection: an analysis of 2-year retrospective cohort studies including 1 284 437 patients Lancet Psychiatry, 2022.PMID 35987197
[7]Hampshire A, et al. Cognition and Memory after Covid-19 in a Large Community Sample N Engl J Med, 2024.PMID 38416429
[8]Reis Carneiro D, et al. Clinical presentation and management strategies of cardiovascular autonomic dysfunction following a COVID-19 infection - A systematic review Eur J Neurol, 2023.PMID 36694382
[9]Peluso MJ, Deeks SG Mechanisms of long COVID and the path toward therapeutics Cell, 2024.PMID 39326415
[10]Swank Z, et al. Persistent Circulating Severe Acute Respiratory Syndrome Coronavirus 2 Spike Is Associated With Post-acute Coronavirus Disease 2019 Sequelae Clin Infect Dis, 2023.PMID 36052466
[11]Pretorius E, et al. Persistent clotting protein pathology in Long COVID/Post-Acute Sequelae of COVID-19 (PASC) is accompanied by increased levels of antiplasmin Cardiovasc Diabetol, 2021.PMID 34425843
[12]Fernández-Castañeda A, et al. Mild respiratory COVID can cause multi-lineage neural cell and myelin dysregulation Cell, 2022.PMID 35768006
[13]Teodoro T, et al. A unifying theory for cognitive abnormalities in functional neurological disorders, fibromyalgia and chronic fatigue syndrome: systematic review J Neurol Neurosurg Psychiatry, 2018.PMID 29735513
[14]Sharpe M, Greco M Chronic fatigue syndrome and an illness-focused approach to care: controversy, morality and paradox Med Humanit, 2019.PMID 31213482
[15]Kingdon C, et al. What Primary Care Practitioners Need to Know about the New NICE Guideline for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome in Adults Healthcare (Basel), 2022.PMID 36553962
[16]White PD, et al. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial Lancet, 2011.PMID 21334061
[17]Pouliopoulou DV, et al. Prevalence and Impact of Postexertional Malaise on Recovery in Adults With Post-COVID-19 Condition: A Systematic Review With Meta-analysis Arch Phys Med Rehabil, 2025.PMID 39921187
[18]Kuut TA, et al. Efficacy of Cognitive-Behavioral Therapy Targeting Severe Fatigue Following Coronavirus Disease 2019: Results of a Randomized Controlled Trial Clin Infect Dis, 2023.PMID 37155736
[19]Wahlgren C, et al. Two-year follow-up of patients with post-COVID-19 condition in Sweden: a prospective cohort study Lancet Reg Health Eur, 2023.PMID 36855599
[20]Stelson EA, et al. Return-to-work with long COVID: An Episodic Disability and Total Worker Health® analysis Soc Sci Med, 2023.PMID 37918226