History and exam

Key diagnostic factors

Reported in approximately 77% of patients.[41] In one case series, only 44% of patients had a fever on presentation, but it developed in 89% of patients after hospitalisation.[450] The course may be prolonged and intermittent, and some patients may have chills/rigors. In children, fever may be absent or brief and rapidly resolving.[451]

Reported in approximately 68% of patients.[41] The cough is usually dry; however, a productive cough has been reported in some patients. 

Reported in approximately 38% of patients.[41] Median time from onset of symptoms to development of dyspnoea is 5 to 8 days.[31][32][452] It is less common in children, but the most common sign in neonates.[369] May last weeks after initial onset of symptoms. Wheeze has been reported in 17% of patients.[453]

Olfactory dysfunction (anosmia/hyposmia) has been reported in approximately 41% of patients, and gustatory dysfunction (ageusia/dysgeusia) has been reported in approximately 35% of patients.[41] Prevalence appears to be higher in European studies.[454] May be an early symptom before the onset of other symptoms, or may be the only symptom in patients with mild to moderate illness.[455] Complete resolution or improvement in symptoms was reported in 89% of patients 4 weeks after onset.[456]

Other diagnostic factors

Reported in approximately 30% of patients.[41] Patients may also report malaise. Fatigue and exhaustion may be extreme and protracted, even in patients with mild disease. 

Reported in approximately 17% (myalgia) and 11% (arthralgia) of patients.[453] 

Reported in approximately 18% of patients.[41]

Reported in approximately 22.9% of patients.[401] 

Reported in 20% of patients. The weighted pooled prevalence of specific symptoms is as follows: loss of appetite 22.3%; diarrhoea 2.4%; nausea/vomiting 9%; and abdominal pain 6.2%. Gastrointestinal symptoms appear to be more prevalent outside of China, although this may be due to increased awareness and reporting of these symptoms as the pandemic progressed.[457] Gastrointestinal symptoms are not associated with an increased likelihood for testing positive for COVID-19; however, anorexia and diarrhoea, when combined with loss of smell/taste and fever, were 99% specific for COVID-19 infection in one prospective case-control study.[458] Children may present with gastrointestinal symptoms more commonly than adults, particularly newborns and infants, and these may be the only symptom.[369] Haematochezia has been reported.[459]

Reported in approximately 16% of patients.[41] Usually presents early in the clinical course.

Reported in approximately 16% of patients.[41]

Reported in approximately 11% of patients.[453]

Confusion has been reported in approximately 11% of patients.[453] Prevalence of confusion/delirium and agitation is high (65% and 69%, respectively) in patients in the intensive care unit.[460] Delirium is associated with an increased risk of mortality, and rapid onset may indicate clinical deterioration.[461] Anxiety, depression, and sleep problems have also been reported.[32]

Reported in 11.2% of patients. The most common ocular symptom is unilateral or bilateral conjunctivitis. Other reported symptoms include ocular pain, dry eye, and floaters. Most symptoms are mild and last for 4 to 14 days with no complications. Prodromal symptoms occur in 12.5% of patients.[462] Mild ocular symptoms (e.g., conjunctival discharge, eye rubbing, conjunctival congestion) were reported in 22.7% of children in one cross-sectional study. Children with systemic symptoms were more likely to develop ocular symptoms.[463]

The pooled prevalence of overall cutaneous lesions is 5.7%. The most common symptoms are a viral exanthem-like presentation (4.2%), maculopapular rash (3.8%), and vesiculobullous lesions (1.7%). Other manifestations include urticaria, chilblain-like lesions, livedo reticularis, and finger/toe gangrene.[464] In the UK COVID Symptom Study, 17% of respondents reported rash as the first symptom of disease, and 21% of respondents reported rash as the only clinical sign.[465] It is unclear whether skin lesions are from viral infection, systemic consequences of the infection, or drugs the patient may be on. Further data is required to better understand cutaneous involvement.  

Rhinorrhoea has been reported in approximately 8% of patients, and nasal congestion has been reported in approximately 5% of patients.[453]

Reported in approximately 7% of patients.[453] May indicate pneumonia. 

Reported in approximately 2% of patients.[453] May be a symptom of pulmonary embolism.[466]

May indicate pneumonia.

May be present in patients with acute respiratory distress.

May be present in patients with acute respiratory distress.

May be present in patients with acute respiratory distress.

May be present in patients with acute respiratory distress.

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