History and exam

Key diagnostic factors

common

fever

Reported in approximately 64.6% of patients.[491] 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.[630][631] Data from the UK COVID Symptom Study report that fever is one of the most common symptoms in unvaccinated people.[632]

cough

Reported in approximately 53.6% of patients.[491] The cough is usually dry; however, a productive cough has been reported in some patients. Can persist for weeks or months after infection.[633] Data from the UK COVID Symptom Study report that persistent cough is one of the most common symptoms in fully and partially vaccinated people and unvaccinated people.[632]

dyspnoea

Reported in approximately 19.8% of patients.[491] Associated with increased severity of disease.[634] Wheezing has been reported in 16.9% of patients.[491]

altered sense of smell/taste

Anosmia has been reported in approximately 18.7% of patients, and ageusia in 17.4% of patients.[491] Pathognomonic for previously circulating SARS-CoV-2 variants, but is less prevalent in people infected with the Omicron variant.[489][500][635][636] May be an early symptom before onset of other symptoms, or may be the only symptom.[637] Most patients recover within 30 days.[638] However, persistent smell or taste dysfunction may develop in approximately 5% of patients.[639] The majority of patients recover within 1 to 2 years.[640][641] Parosmia (misperception of an odour) has been reported as a late-onset symptom.[642] Many drugs are associated with taste and smell changes (e.g., antibiotics, ACE inhibitors) and should be considered in the differential diagnosis.[643]

Other diagnostic factors

common

fatigue

Reported in approximately 29.4% of patients.[491] Fatigue and exhaustion may be extreme and protracted, even in patients with mild disease. 

myalgia or arthralgia

Myalgia has been reported in approximately 18.7% of patients, and arthralgia in 7.5% of patients.[491] Arthritis has been reported rarely.[644]

sore throat

Reported in approximately 12.4% of patients.[491] Usually presents early in the clinical course. Data from the UK COVID Symptom Study report that sore throat is one of the most common symptoms in fully and partially vaccinated people and unvaccinated people.[632]

headache

Reported in approximately 11% of patients.[491] Data from the UK COVID Symptom Study report that headache is one of the most common symptoms in fully and partially vaccinated people and unvaccinated people.[632]

rhinorrhoea or nasal congestion

Rhinorrhoea has been reported in approximately 7% of patients, and nasal congestion in 5.1% of patients.[491] Data from the UK COVID Symptom Study report that rhinorrhoea is one of the most common symptoms in fully and partially vaccinated people and unvaccinated people.[632]

sneezing

Reported in approximately 4.4% of patients.[491] Data from the UK COVID Symptom Study report that sneezing is one of the most common symptoms in fully and partially vaccinated people, but is less common in unvaccinated people.[632]

expectoration

Reported in approximately 23.4% of patients.[491]

chest pain/tightness

Chest distress has been reported in approximately 12.7% of patients, and chest pain in 5.8% of patients.[491] May indicate pneumonia. 

malaise

Reported in approximately 12.1% of patients.[491]

dizziness

Reported in approximately 7.2% of patients.[491] May be a direct consequence of the virus affecting vestibular function, or may be an indirect effect of hypoxia, dehydration, or fever.[645]

confusion or delirium

Confusion has been reported in approximately 6.4% of patients, and delirium in 17.5% of patients.[491] Delirium has been associated with a 3-fold increase in mortality, and there is an increased prevalence in people >65 years of age.[646] Risk factors for delirium include benzodiazepine use and the lack of family visitation.[647]

gastrointestinal symptoms

Generally reported in <20% of patients. Anorexia has been reported in 12.9% of patients, diarrhoea in 8.1% of patients, nausea in 6.7% of patients, vomiting in 5.5% of patients, and abdominal pain in 3.7% of patients. Other less common symptoms include constipation, heartburn, haematemesis, melaena, and haematochezia.[491] More common in children.[492] Has been associated with increased severity of disease.[648][649][650] Patients who shed faecal viral RNA for longer periods of time may report ongoing gastrointestinal symptoms.[651] 

cutaneous symptoms

Generally reported in <20% of patients. Rash has been reported in 14% of patients, chilblain-like lesions in 24.6% of patients, urticaria in 16.8% of patients, chickenpox-like vesicles in 16.2% of patients, and livedo reticularis in 4.6% of patients. Lesions may be erythematous, vesicular, pustular, ulcerative, oedematous, petechial, or pruritic.[491] May be the only, or the first, presenting sign in children or adults.[652][653][654] Severe and potentially life-threatening mucocutaneous dermatological manifestations have been reported.[655] Further data are required to better understand cutaneous involvement and whether there is a causal relationship as there is conflicting evidence.[656][657][658]

British Association of Dermatologists: Covid-19 skin patterns Opens in new window

ocular symptoms

Generally reported in 5% to 20% of patients. Dry eye has been reported in 14.5% of patients, tearing in 12.8% of patients, itching in 9.2% of patients, eye pain in 6.9% of patients, and conjunctivitis in 5.5% of patients. Other less common symptoms include photophobia, chemosis, conjunctival congestion, blurred vision, and lid oedema. Relatively rare in children and pregnant women.[491] May be the initial presenting symptom. Usually mild with no complications.[659] However, retinal complications have been reported.[660][661][662] Has been associated with increased severity of disease.[663]

uncommon

signs of pneumonia or acute respiratory distress

Bronchial breath sounds may indicate pneumonia. Tachypnoea, tachycardia, crackles/rales (on auscultation), or cyanosis may be present in patients with acute respiratory distress.

haemoptysis

Reported in approximately 1.8% of patients.[491] May be a symptom of pulmonary embolism.[664]

audio-vestibular symptoms

Sudden sensorineural hearing loss (SSNHL), tinnitus, and rotatory vertigo have been reported in 7.6%, 14.8%, and 7.2% of patients, respectively. Otalgia has also been reported.[665] Data on SSNHL in patients with COVID-19 are inconsistent and contradictory. Therefore, it remains unknown whether COVID-19 contributes to the incidence of SSNHL.[666]

oral mucosal lesions

Aphthous, haemorrhagic, and necrotic ulcers have been reported in 36.3% of patients. Other lesions include pustules, macules, bullae, maculopapular enanthema, and erythema multiforme-like lesions.[667] SARS-CoV-2–associated reactive infectious mucocutaneous eruption has also been reported.[668] It is unclear whether oral lesions are from viral infection, systemic consequences of the infection, secondary to existing comorbidities, or drugs the patient may be on.[669]

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