Telephone Consultation During COVID-19: Guide for the Primary Care Doctors
Azidah Abdul Kadir, Siti Suhaila Mohd Yusof, Nani Draman, Norhaizee Hashim, Siti Noorfadhilah Mohd Amin
- Pengarang Koresponden:
Professor Dr Azidah Abdul Kadir
Family Medicine Specialist, Department of Family Medicine, School of Medical Sciences
Universiti Sains Malaysia, Health Campus, 16150, Kubang Kerian, Kelantan, Malaysia
The COVID-19 pandemic brought dramatic changes to our lives and have overwhelmed the healthcare system globally1. At primary care level specifically, we are adapting with the new ways of working. One of the most dramatic changes to primary care lies with the use of telemedicine or telephone consultation compared to face to face consultation that we are used to. This digital technology is playing important roles to fight the crisis of manpower and minimising the exposure of COVID-19 to both ill patients and health staff2.There was a lot of information regarding COVID-19, but it did not tackle the special needs of certain healthcare speciality in dealing with this situation. Primary care settings are in desperate need for this kind of information. Is there enough guidance about telephone consultation in primary care? We need to ensure that this new service is safe and effective.
General Guide in telephone consultation3
1. Before you make a telephone call
Look at the list of appointments, contact information and other patient’s data such as name, identification number, contact information and date of appointment. Make a list accordingly. If possible, check the patient’s medical records. Look for any comorbid illness that the patient has. If your clinic has online medical records or prescription lists that can give information about the patient, then you can do it while talking to patients. This is because the problem with a telephone consultation, the patient’s contact information may be incorrect, and you might not be able to contact them. Thus, spending time looking at a patient's medical background might be a waste of time if you cannot connect to the patient. If the phone call is not able to be made, you can call back at different times or you can send a message through chat apps such as WhatsApp or telegram for them to contact the clinic. Preferably in a clinic setting, you have prepare a hotline dedicated to receiving phone calls from patients.
2. Beginning the consultation
Introduce yourself and explain the reason you make the phone call. Based on our experience most patients are not surprised during this time of COVID-19 pandemic that they received a phone call from the hospital. But some patients might be afraid or have doubts if they received the calls because they are afraid it could be some scammer calls. Having some information about the patients might help reduce their uncertainty. Such as telling them that you make the phone calls to assess their conditions and the need to come to the clinic. Check or verify the patient identification before you continue.
Basically, the history is similar to what we conduct in the face to face consultation. Look for any acute complaint then ask for specific disease control. The detailed assessment for common illness will be covered below. Look for red flags. These are symptoms that require urgent management either to the outpatient clinic or emergency department. For example, chest pain that suggests acute coronary syndrome or bleeding tendency in patients on warfarin.
4. Physical examination or investigation
Physical examination is impossible but certain information you can ask the patient for example if the patient complains of difficulty in breathing. You can teach the patient to count his/her respiratory rate. Example of instructions to the patient or they can ask someone else to do it:
Kira nafas anda untuk satu minit
Kira turun naik dada dalam satu minit
You can also teach the patient to palpate for cervical lymphadenopathy.
Should you change to video calls? This depends on a certain aspect. Availability of technical aspects of both providers and patients. Most telephone consultations are made using office or clinic phones. Unless you are a private practitioner who allows the patient your own contact number, most doctors who work in big organizations are reluctant to let the patients know their private numbers for various reasons. However, if setting permits, then video consultations can give some information and help the doctor in making a diagnosis. Certain skin conditions can be diagnosed easily through this method. Observing how severe is leg oedema, patient general condition or conjunctivitis might be helpful.
If the patient has their own instruments to check blood pressure, glucose monitoring or a home thermometer, you can document those readings in your notes. Please verify that those measurements are properly done.
For patients with chronic illness, assess medication intake and balance of the medication. In COVID 19 pandemic, it is important their disease is controlled and they have adequate medications. The doctor will have to make justifications regarding the duration of their next appointment. In this setting, the assessment based on current consultation, patients previous record or investigations place an important role. If a patient's disease is well controlled, deferring the appointment to the time where you think the COVID 19 epidemic has cooled down and safe for the patient to come for face to face consultation is a good option. This guideline will include some of the questions to ask and advise the patient in a telephone consultation.
Patients that cannot be reliably diagnosed as having a mild illness on the basis of telephone assessment need to be seen in person. Safety netting advice is important even if the patient is well. This includes those that live alone. Examples of safety netting advice are chest pain or difficulty in breathing; they should consult the nearest health centre or hospital. It is important to document that the doctor has advice regarding safety netting. In a well-prepared environment, patient information leaflets can be sent electronically.
6. Getting the medication
In the Ministry of Health Malaysia, there are various ways for patients to continue their prescriptions to ensure social distancing and reduce the risk of COVID19. Among the services include postage, drive-through pharmacy, using locker or appointment basis. The doctor will ask the patient, which service they prefer and use.
In other institutions where these services are not available, it is better to advise those with chronic illness or elderly patients to get someone else to go to the hospital to get the medication. Certain hospitals advise certain time to reduce the overcrowding at the pharmacy side.
Handling chronic diseases
Diabetes management during COVID-19 Pandemic 4
i) Recognise symptoms
● Symptoms of hypoglycaemia: palpitation/ sweating/ irritable/ tremor
● Symptoms of hyperglycemia: dry mouth, thirsty, lethargy/ headache/ increased frequency of urination
● Symptoms of diabetes complication:
-Retinopathy – blurring of vision
-Neuropathy – Peripheral paraesthesia -sensory, motor and autonomic
-Nephropathy – leg oedema
-Erectile dysfunction problems
-Coronary heart disease – angina, exertional dyspnoea
-Cerebrovascular disease – limb weakness
-Peripheral vascular disease – calf pain on walking
● Psychological symptoms: anxiety/depression/stress
ii) Monitoring at home
● SMBG: range of SMBG
● Home BP: range of BP
● Latest HbA1c and other blood investigation result (if patient able to tell)
iv) General advice /consultation
DM and COVID during MCO: What you need to advise patients:
● Keep relevant contact details of HOTLINE Hospital number/or nearest clinic number or any personal family doctor.
● Strictly monitor your glucose level.
● If you have flu-like symptoms call the hotline hospital/clinic number to get advice BUT if you have symptoms or sign of chest infection you must immediately go to the hospital.
● Increase your fluid intake
● Make sure you have enough supply of medications (you have to think what you would need if you have to quarantine for a few weeks)
● Make sure you have enough food at home
● Make sure you have a mechanism of action in case you develop hypoglycaemia at home. (ex: some sweets or biscuits to eat whenever you have hypoglycaemia)
● If you live alone, find somebody to rely on or to contact if you need help.
● Keep a regular schedule, avoid overwork, have a good sleep at night
● Maintain to consume healthy food at home.
DM and COVID 19 during Ramadan4
General advice to those who want to fast
● Avoid skip sahur
● Do not delay breaking the fast or iftar
● Limit fried and fatty foods
● Limit intake of highly salted foods to reduce risk of dehydration
● Drink adequately at sahur, choose sugar-free drinks, aim for 8 glasses per day
● Avoid excessive binging of carbohydrates during non–fasting period
● Supper after Tarawih can be taken as replacement of pre-bed snack
● Increase fibre intake and limit fruits intake (one slice during iftar and sahur)
● Breaking the fast if having hypo/ hyper symptoms during daytime
All patient needs to break their fast if: -
❖ Blood glucose < 3.9 mmol/L
❖ Blood glucose > 16.7 mmol/L
❖ Symptom of hypoglycaemia or acute illness occur
Classify patient into very high risk, high risk, moderate/ and low risk group
Very High Risk
One or more of the following:
• Severe hypoglycaemia within the 3 months prior to Ramadan
• DKA within the 3 months prior to Ramadan
• Hyperosmolar hyperglycaemic coma within the 3 months prior to Ramadan
• History of recurrent hypoglycemia
• History of hypoglycemia unawareness
• Poorly controlled T1DM
• Acute illness
• Pregnancy in pre-existing diabetes, or GDM treated with insulin or SUs
• Chronic dialysis or CKD stage 4 and 5
• Advanced macrovascular complications
• Old age with ill health
One or more of the following:
• T2DM with sustained poor glycaemic control*
• Well-controlled T1DM
• Well-controlled T2DM on insulin
• Pregnant T2DM or GDM controlled by diet only or metformin
• CKD stage 3
• Stable macrovascular complications
• Patients with comorbid conditions that present additional risk factors
• People with diabetes performing intense physical labour
• Treatment with drugs that may affect cognitive function
-Well-controlled diabetes treated with short-acting insulin secretagogues
Well-controlled diabetes treated with lifestyle therapy, metformin, acarbose, thiazolidinediones, and/or incretin-based therapies in otherwise healthy patients
Medication adjustment during Ramadhan
Other oral medication:
DPP-4 inhibitors: No DOSE modification
SGLT2 inhibitors: No DOSE modification, advise take at iftar
- 8.30 am - 1.00 pm Sunday - Wednesday
- 1.00 - 2.00 pm rest
- 2.00 - 3.00 pm Sunday - Wednesday
- 8.30 am - 1 pm Thursday
Self-Monitoring Blood Glucose - monitoring advice during Ramadan
- Before sahur
- 2 hours after sahur
- 2 hours before breaking the fast or before iftar
- 2 hours after breaking iftar
- Feeling unwell
- Develop hypoglycemia symptoms
Assessment of Hypertension control
If the blood pressure is not controlled, assess any symptoms e.g. headache, blurring of vision, chest pain, shortness of breath
Assessment of complication of uncontrolled BP/red flags
Assessment of Current Medication
Assessment of asthma control
1. Asthma symptoms including concomitant allergic rhinitis if any
Control assessment questions
● Adakah anda mempunyai gangguan tidur kerana lelah/ simptom asma
● Adakah simptom asma anda seperti biasa ( batuk, lelah, nafas berbunyi)
● Adakah asma anda menganggu aktiviti harian
2. Ask about the use of short acting beta-agonists
3. Ask about any/number of acute episodes
4. Document peak flow measurement (if available)
5. Ask about any courses of oral corticosteroids or any hospital/ ED visits
Assessment of concordance with medication
· Review clinical record and prescriptions issued
· Address any compliance issues
· Discuss the treatment regime with patient
· Review the treatment regime
• Continue as before
• Step up
• Step down
• Document any change
Discuss Personal Asthma Action Plan
Review current plan
- Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. Journal of Autoimmunity. 2020;109:102433.
- Portnoy J, Waller M, Elliott T. Telemedicine in the Era of COVID-19. The Journal of Allergy and Clinical Immunology: In Practice. 2020.
- Greenhalgh T, Koh GCH, Car J. Covid-19: a remote assessment in primary care. BMJ. 2020;368:m1182.
- Malaysia MoH, Society MEM. Practical Guide to Diabetes Management in Ramadan: Ministry of Health Malaysia; 2019 [Available from: https://mdes.org.my/2019/04/21/1094/. (date retrieved on 26th Apr 2020)
- Bobrie G, Postel-Vinay N, Delonca J, Corvol P, 3 SI. Self-Measurement and Self-Titration in Hypertension*: A Pilot Telemedicine Study. American Journal of Hypertension. 2007;20(12):1314-20.
- WebMD. Follow-up Care for High Blood Pressure [Available from: https://www.webmd.com/hypertension-high-blood-pressure/guide/high-blood-pressure-follow-up-care (Date retrived on 26th. Apr 2020)
- Wolfe S. A protocol providing guidance on the use of telephone consultations for routine asthma review.: The Primary Care Respiratory Society; 2017 [Available from: https://www.pcrs-uk.org/resource/telephone-consultations-routine-asthma-review.
List of Abbreviations
DM diabetes Mellitus
SMBG self-monitoring blood glucose
BP blood pressure
MCO movement control order
CKD chronic Kidney disease
ED Emergency Department
HBPM home blood pressure measurement