History and exam

Key diagnostic factors

common

fever

Reported in approximately 64.6% of patients.[436] 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.[574][575] Data from the UK COVID Symptom Study report that fever is much less common now compared with early SARS-CoV-2 variants.[576]

cough

Reported in approximately 53.6% of patients.[436] The cough is usually dry; however, a productive cough has been reported in some patients. Can persist for weeks or months after infection.[577] Data from the UK COVID Symptom Study report that cough (with or without phlegm) is one of the most common symptoms.[576]

dyspnea

Reported in approximately 19.8% of patients.[436] Associated with increased severity of disease.[578] Wheezing has been reported in 16.9% of patients.[436]

altered sense of smell/taste

Anosmia has been reported in approximately 18.7% of patients, and ageusia in 17.4% of patients.[436] Pathognomonic for previously circulating SARS-CoV-2 variants, but is less prevalent in people infected with the Omicron variant.[449][579][580] May be an early symptom before onset of other symptoms, or may be the only symptom.[581] Most patients recover within 30 days.[582] However, persistent smell or taste dysfunction may develop in approximately 5% of patients.[583] The majority of patients recover within 1 to 2 years.[584][585] Parosmia (misperception of an odor) has been reported as a late-onset symptom.[586] Many drugs are associated with taste and smell changes (e.g., antibiotics, ACE inhibitors) and should be considered in the differential diagnosis.[587] Data from the UK COVID Symptom Study report that altered sense of smell is one of the most common symptoms.[576]

Other diagnostic factors

common

fatigue

Reported in approximately 29.4% of patients.[436] 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.[436] Arthritis has been reported rarely.[588] Data from the UK COVID Symptom Study report that myalgia is one of the most common symptoms.[576]

sore throat

Reported in approximately 12.4% of patients.[436] 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.[576]

headache

Reported in approximately 11% of patients.[436] Data from the UK COVID Symptom Study report that headache is one of the most common symptoms.[576]

rhinorrhea or nasal congestion

Rhinorrhea has been reported in approximately 7% of patients, and nasal congestion in 5.1% of patients.[436] Data from the UK COVID Symptom Study report that rhinorrhea and nasal congestion are two of the most common symptoms.[576]

sneezing

Reported in approximately 4.4% of patients.[436] Data from the UK COVID Symptom Study report that sneezing is one of the most common symptoms.[576]

expectoration

Reported in approximately 23.4% of patients.[436]

chest pain/tightness

Chest distress has been reported in approximately 12.7% of patients, and chest pain in 5.8% of patients.[436] May indicate pneumonia.

malaise

Reported in approximately 12.1% of patients.[436]

dizziness

Reported in approximately 7.2% of patients.[436] May be a direct consequence of the virus affecting vestibular function, or may be an indirect effect of hypoxia, dehydration, or fever.[589]

confusion or delirium

Confusion has been reported in approximately 6.4% of patients, and delirium in 17.5% of patients.[436] Delirium has been associated with a 3-fold increase in mortality, and there is an increased prevalence in people age >65 years.[590] Risk factors for delirium include benzodiazepine use and the lack of family visitation.[591]

gastrointestinal symptoms

Generally reported in <20% of patients. Anorexia has been reported in 12.9% of patients, diarrhea 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, hematemesis, melena, and hematochezia.[436] More common in children.[437] Has been associated with increased severity of disease.[592][593][594] Patients who shed fecal viral RNA for longer periods of time may report ongoing gastrointestinal symptoms.[595]

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, edematous, petechial, or pruritic.[436] May be the only, or the first, presenting sign in children or adults.[596][597][598] Severe and potentially life-threatening mucocutaneous dermatologic manifestations have been reported.[599] Further data are required to better understand cutaneous involvement and whether there is a causal relationship as there is conflicting evidence.[600][601][602]

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 edema. Relatively rare in children and pregnant women.[436] May be the initial presenting symptom. Usually mild with no complications.[603] However, retinal complications have been reported.[604][605][606] Has been associated with increased severity of disease.[607]

uncommon

signs of pneumonia or acute respiratory distress

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

hemoptysis

Reported in approximately 1.8% of patients.[436] May be a symptom of pulmonary embolism.[608]

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.[609] 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.[610]

oral mucosal lesions

Aphthous, hemorrhagic, and necrotic ulcers have been reported in 36.3% of patients. Other lesions include pustules, macules, bullae, maculopapular enanthema, and erythema multiforme-like lesions.[611] SARS-CoV-2–associated reactive infectious mucocutaneous eruption has also been reported.[612] 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.[613]

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