Long COVID in Philadelphia is best managed in primary care with enough time to do the workup, screen for treatable comorbidities (POTS, MCAS, mast-cell activation, autonomic dysfunction, mood and sleep effects), and coordinate specialist care when needed. The standard 12-minute primary care visit cannot reliably handle a multi-system, multi-year condition. Fishtown Medicine builds a structured evaluation, treats what is treatable, supports pacing and recovery, and coordinates with neurology, cardiology, and rehabilitation as needed.
Long COVID has been one of the more difficult clinical conditions to manage in Philadelphia primary care over the past five years. The reasons are structural: the symptom picture is multi-system, the workup takes time, the pacing-based approach to activity is hard to deliver in a brief visit, and the patients are usually exhausted by the time they arrive.
This page is how Fishtown Medicine approaches long COVID: the workup, the treatable comorbidities, the pacing approach, and the role of specialty care.
What long COVID actually is
Long COVID (post-acute sequelae of SARS-CoV-2 infection, PASC) is the persistence of symptoms more than three months after acute COVID-19 infection that cannot be explained by another diagnosis. The CDC and WHO definitions overlap broadly.
Common symptom clusters:
- Profound fatigue with post-exertional malaise (worsening of symptoms after physical or cognitive activity).
- Cognitive dysfunction (brain fog, word-finding difficulty, slowed processing).
- Autonomic dysfunction, often presenting as postural orthostatic tachycardia syndrome (POTS).
- Sleep disruption.
- Mood changes (anxiety, depression, sometimes new-onset).
- Cardiovascular symptoms (palpitations, chest discomfort, shortness of breath out of proportion to findings).
- Mast cell activation patterns (flushing, urticaria, GI symptoms, food sensitivities).
- Exercise intolerance with abnormal recovery.
- Olfactory and gustatory changes.
The mechanisms are multiple and still being worked out: persistent viral antigen, immune dysregulation, microclotting, autonomic injury, endothelial dysfunction.
What a real long COVID workup includes
For someone presenting with persistent post-COVID symptoms, the workup we run includes:
- Comprehensive history with attention to acute COVID severity, symptom timeline, prior baseline, current symptom inventory, and impact on function.
- CBC, comprehensive metabolic panel, TSH and free T4. Rule out alternative diagnoses.
- Ferritin, iron studies, vitamin D, B12. Treat what is treatable.
- hsCRP, sedimentation rate. Inflammation markers.
- Cortisol (morning) if adrenal insufficiency is suspected.
- ANA, sometimes other autoimmune markers if the picture suggests autoimmune disease.
- EKG and sometimes echocardiogram if cardiovascular symptoms are prominent.
- Tilt table testing or active stand test if POTS or orthostatic intolerance is suspected.
- Sleep evaluation, often a home sleep study, given how commonly sleep apnea or other sleep pathology is present.
- D-dimer and lipid panel as appropriate.
We do not run "long COVID panels" of unvalidated tests sold by some clinics. We run the standard medicine workup well.
Treatable comorbidities we screen for and manage
Many long COVID patients have one or more treatable conditions contributing to symptoms:
- POTS / autonomic dysfunction. Beta blockers, fludrocortisone, midodrine, ivabradine, salt and fluids, compression garments, graded recumbent exercise. See POTS Treatment in Philadelphia.
- MCAS / mast cell activation. H1 and H2 blockers, cromolyn, sometimes ketotifen. See MCAS Treatment in Philadelphia.
- Sleep apnea. CPAP or oral appliance based on study findings.
- Iron deficiency or low ferritin. Iron supplementation, sometimes IV iron.
- Vitamin D, B12 deficiency. Replacement.
- Thyroid disease. Treatment when documented.
- Depression and anxiety. Talk therapy, sometimes medications.
- Dysautonomia-related GI symptoms. Symptom-driven management.
Treating these comorbidities does not always resolve long COVID, but it reliably improves quality of life and function.
The role of pacing
Post-exertional malaise (PEM) is one of the defining features of long COVID. The standard exercise advice ("just push through it, exercise will help") is wrong and often harmful for patients with PEM.
Fishtown Medicine
A 90-minute conversation with Dr. Ash. A written plan you can actually follow.
The right framework is pacing: staying within your energy envelope, gradually expanding it as tolerated, and avoiding the boom-and-bust pattern that frequently triggers crashes. We work with patients on heart-rate-based pacing, activity diaries, and structured graded return to activity when appropriate.
For patients with cardiovascular deconditioning without PEM, structured supervised exercise rehabilitation (often through cardiac rehab or specialized programs) is appropriate. The judgment between PEM-pacing and rehabilitation is part of the clinical work.
How long COVID care works at Fishtown Medicine
First visit is 90 minutes. We build the picture, decide on the workup, and discuss what is most disruptive to address first.
Follow-up is at 4-6 weeks for results review, then at 1-3 month intervals depending on what we are managing. Patients usually have multiple appointments with us as we work through the layered picture.
We coordinate with neurology, cardiology, pulmonology, rehabilitation medicine, and other specialties as needed. Many Philadelphia long COVID patients benefit from the Penn Post-COVID Recovery Clinic for specialty-specific evaluation; we coordinate referrals when appropriate.
What it costs
Membership at Fishtown Medicine covers all visits and ongoing management; see pricing for current rates. All visits and ongoing management are inside the membership. Labs and medications are billed separately. Specialty referrals go through their respective practices.
Key Takeaways
- Long COVID is real, multi-system, and frequently under-recognized.
- A real workup screens for treatable comorbidities and rules out alternative diagnoses.
- Pacing is the right approach for patients with post-exertional malaise.
- Fishtown Medicine has the time to do this work well in primary care.
Related Services and Reading
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Lyme Disease Care - acute and chronic Lyme management
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Sleep Disorders - from insomnia to OSA, the systematic sleep workup
Frequently Asked Questions
Common Questions
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Dr. Ash reads every intake himself, and answers questions personally - usually within a few hours.
