Age | Sex | Major comorbidities | Presenting symptoms | Vital signs | Lab/imaging findings | Most likely differential/explanation | COVID-19 index of suspicion | COVID-19 test status | Outcome(s) |
---|---|---|---|---|---|---|---|---|---|
40 | F | Malignancy with pulmonary metastasis | SOB, cough | Afebrile Baseline oxygen saturation | CT with progression of pulmonary metastasis | Progression of pulmonary metastasis | LOW | NOT DONE | Deceased—unclear whether due to metastasis or undiagnosed COVID-19 |
80 | M | Malignancy with pulmonary metastasis | SOB, cough | Afebrile Baseline oxygen saturation | Elevated D dimer CXR with unilateral infiltrates CT with pulmonary embolism | PE with possible post-obstructive pneumonia | LOW | NEG | Anticoagulated Given antibiotics Discharged home |
77 | F | End stage renal disease Heart failure | SOB, cough | Afebrile Baseline oxygen saturation | CXR with bilateral infiltrates BUT Elevated BNP | Heart failure exacerbation | LOW | NOT DONE | Diuresed Discharged home |
65 | F | Breast cancer Nephrostomy tubes Chronic pleural effusion | Fevers, SOB, flank pain | Hypotension Afebrile Normal oxygen saturation | UTI CXR unchanged | Urosepsis | LOW | NOT DONE | Given antibiotics Nephrostomy tubes replaced Discharged home |
63 | F | Hyponatremia | Subjective fevers, weakness | Afebrile Normal oxygen saturation | Acute on chronic hyponatremia | Acute on chronic hyponatremia due to increased dose of thiazide | LOW | NOT DONE | Intravenous fluids given Thiazide discontinued Discharged home |
105 | M | Large pulmonary nodules | SOB, cough, coryza | Afebrile Baseline oxygen saturation | CXR and CT unchanged | Respiratory bronchiolitis | LOW | NOT DONE | Given PRN antitussives and nebulizer treatments Discharged home |
77 | F | Renal transplant Diabetes mellitus Coronary artery disease | Encephalopathy | Hypotension Afebrile Normal oxygen saturation | Flu positive CXR and CT unchanged | Flu vs. BK viremia | LOW | NEG | Given Tamiflu Discharged home Delay in neurologic evaluation (lumbar puncture, EEG) while PUI |
86 | F | Diabetes mellitus Chronic kidney disease | SOB, cough | Afebrile Normal oxygen saturation | CXR with unilateral infiltrates Elevated procalcitonin | Community-acquired pneumonia | LOW | NOT DONE | Given antibiotics Discharged home |
45 | M | Pancreatic cancer | Cough | Febrile Hypotensive Hypoxic | CXR with unilateral infiltrates D dimer elevated Lactic acidosis | Community-acquired pneumonia | LOW | NEG | Given antibiotics Discharged home |
65 | F | Lupus Active recurrent pericarditis | SOB, weakness | Afebrile (though on steroids for pericarditis) Normal oxygen saturation | Leukocytosis BUT CXR unchanged | Sequela of active pericarditis vs. steroid use | LOW | NEG | Given empiric antibiotics Discharged home TTE deferred while PUI |
71 | F | Chronic angina Chronic SOB Myocardial infarction Hypertension | Acute on chronic angina, SOB, pharyngitis | Afebrile Normal oxygen saturation | CXR unchanged Troponemia ECG unchanged | Acute coronary syndrome vs. anxiety | LOW | NEG | Discharged home CCTA was done, but this was deferred while PUI |
46 | F | Heart failure Anxiety | Acute on chronic SOB | Afebrile Normal oxygen saturation | CXR unchanged Elevated BNP | Heart failure exacerbation | LOW | NEG | Diuresed Discharged home |
60 | F | Diverticulitis Partial bowel resection with ostomy | Abdominal pain, nausea, vomiting | Afebrile Normal oxygen saturation | CXR unchanged Severe acute kidney injury Severe hyperkalemia | Metabolic derangement due to delayed ostomy revision | LOW | NEG | Hyperkalemia treated Given fluids Ostomy bag revised Discharged home Ostomy bag revision had been delayed while PUI |
75 | F | Irritable bowel syndrome – diarrhea type | Nausea, acute on chronic diarrhea | Afebrile Normal oxygen saturation | CXR unchanged Hypokalemia | Viral enteritis | LOW | NEG | Given fluids Potassium repleted Discharged home |
83 | M | Atrial fibrillation Heart failure Chronic sinusitis | SOB, abdominal pain, diarrhea, fall | Afebrile Normal oxygen saturation | Lymphopenia BUT CT with stercoral colitis Acute hyponatremia CXR unchanged | Stercoral colitis | LOW | NEG | Given fluids Discharged home PT/OT needed for fall deferred while PUI |
49 | M | Bronchiectasis Multiple myeloma | Fever, cough, SOB | Febrile Baseline oxygen saturation | Lymphopenia BUT CXR unchanged | Community-acquired pneumonia | MOD | NEG | Improved on antibiotics Discharged home |
66 | M | End stage renal disease on peritoneal dialysis Coronary artery disease Diabetes mellitus | Abdominal pain nausea, vomiting | Afebrile Baseline oxygen saturation | CT with ground glass opacities concerning for pulmonary edema Normal BNP | Peritonitis | LOW | NEG | Given antibiotics Discharged home Testing ordered on basis of CT results, not symptoms |
53 | F | Heart transplant | SOB, abdominal pain | Afebrile Baseline oxygen saturation | CXR with bilateral infiltrates BUT Elevated BNP | Heart failure | LOW | NEG | Diuresed Admission to transplant service delayed while PUI |
90 | F | Chronic bilateral pleural effusions Failure to thrive | SOB, weakness, dysuria | Afebrile Baseline oxygen saturation | CXR unchanged UTI | UTI Deconditioning | LOW | NEG | Given antibiotics PT/OT needed for deconditioning deferred while PUI |
84 | F | Shoulder dislocation Mitral regurgitation | Shoulder pain | Afebrile Normal oxygen saturation | XRAY with shoulder dislocation | Shoulder dislocation | LOW | NEG | Orthopedic surgery delayed while PUI |
78 | M | Hypertension | Cough, melena | Afebrile Normal oxygen saturation | Acute blood loss anemia CXR unchanged | Acute blood loss anemia | LOW | NEG | Given blood transfusion Esophagogastroduodenoscopy delayed while PUI |
72 | M | Invasive gastric cancer Diabetes mellitus | Chest pain | Afebrile Baseline oxygen saturation | CXR unchanged No troponemia No ECG changes | Deconditioning | LOW | NEG | Admitted to discuss treatment for gastric cancer Treatment delayed while PUI |
30 | F | Portal vein thrombosis | Nausea, abdominal pain | Afebrile Normal oxygen saturation | Elevated liver enzymes US and CT with gallbladder sludge | Cholecystitis | LOW | NEG | Given fluids Cholecystectomy deferred while PUI |
81 | F | Dementia with psychosis Recurrent UTI Diabetes mellitus Aspiration pneumonia | Altered mental status, displaced G-tube | Afebrile Normal oxygen saturation | UTI CXR unchanged | UTI Displaced G-tube | LOW | NEG | Given fluids and antibiotics G-tube replaced |
54 | F | Poorly controlled hypertension | Angina | Severe hypertension Afebrile Normal oxygen saturation | Troponemia CXR unchanged | Hypertensive emergency with NSTEMI | LOW | NEG | Controlled blood pressure Catheterization delayed while PUI |
Open Access 01.12.2020 | COVID-19 | Letter to the Editor
Efficacy of clinical evaluations for COVID-19 on the front line
Erschienen in: International Journal of Emergency Medicine | Ausgabe 1/2020
To the Editor:
In the midst of the COVID-19 pandemic, there remains limited availability of Food and Drug Administration-approved tests for presence of the SARS-CoV-2 agent [1, 2]. Even as testing capacity expands, optimization of resource utilization in the healthcare setting remains a significant priority [3, 4]. Thus, the vast majority of front line work being done to evaluate for possible COVID-19 is highly dependent on the clinical assessment of a presenting patient’s signs and symptoms. The extent to which current clinical assessments are effective, in the era of rapidly evolving local and professional guidelines, is not entirely clear.
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We conducted a retrospective review of patients assessed for possible COVID-19 illness at our urban medical center in Los Angeles, California. The institutional review board deemed the study exempt. We carefully reviewed all clinical records to ascertain the provider’s level of clinical suspicion for COVID-19 illness and compared these assessments with available results of SARS-CoV-2 testing, in addition to longitudinal data on clinical outcomes. We found that the vast majority of patients (96% of N = 25) clinically assessed to have a low probability of COVID-19 illness were subsequently confirmed to have either a negative SARS-CoV-2 test result or, in the absence of testing, clinical stability without any further concern for COVID-19 illness (Table 1). All clinical assessments were performed by a physician, with some (16%) conducted by a nurse practitioner or physician assistant in conjunction with physician supervision.
Table 1
Characteristics, testing status, and clinical outcomes for N = 25 patients
In the absence of widespread readily available access to SARS-CoV-2 testing, clinical assessment is and will remain the standard of care for initially determining probability of COVID-19 illness and, in turn, appropriateness for receiving testing—especially in areas where testing availability is limited. This case series from an urban medical center suggests that despite the rapidly evolving body of knowledge around COVID-19 illness and its variable presentations among affected patients, clinical provider assessment of high versus low probability of active infection can be relatively reliable. This case series further supports the hypothesis that a well-informed clinical assessment, with or without concurrent access to rapid point-of-care SARS-CoV-2 testing, could be leveraged to more efficiently triage patients [5]—even those with medical comorbidities whose chronic illness burden may appear to pose a diagnostic challenge at the outset. In effect, a clinical evaluation that does not rely on viral testing results may be very accurate and substantially aid in ongoing efforts to conserve and appropriately prioritize the use of medical resources. Use of sound clinical judgment can also facilitate consideration of alternative diagnostic explanations.
Not applicable.
The institutional review board deemed the study exempt.
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Not applicable.
The authors declare that they have no competing interests.
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