病史和体格检查
关键诊断因素
据报道出现于约 77% 患者。[133]Xie Y, Wang Z, Liao H, et al. Epidemiologic, clinical, and laboratory findings of the COVID-19 in the current pandemic: systematic review and meta-analysis. BMC Infect Dis. 2020 Aug 31;20(1):640. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457225/ http://www.ncbi.nlm.nih.gov/pubmed/32867706?tool=bestpractice.com 在一项病例系列研究中,仅 44% 患者表现为发热,但住院后患者却有 89% 出现发热。[515]Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020 Apr 30;382(18):1708-20. https://www.nejm.org/doi/full/10.1056/NEJMoa2002032 http://www.ncbi.nlm.nih.gov/pubmed/32109013?tool=bestpractice.com 持续时间可能较长,且呈间歇性,部分患者可能出现畏寒/寒战。在儿童中,可能无发热,或呈现短暂发热,并迅速消失。[516]Lu X, Zhang L, Du H, et al. SARS-CoV-2 infection in children. N Engl J Med. 2020 Apr 23;382(17):1663-5. https://www.nejm.org/doi/full/10.1056/NEJMc2005073 http://www.ncbi.nlm.nih.gov/pubmed/32187458?tool=bestpractice.com
据报道出现于约 68% 患者。[133]Xie Y, Wang Z, Liao H, et al. Epidemiologic, clinical, and laboratory findings of the COVID-19 in the current pandemic: systematic review and meta-analysis. BMC Infect Dis. 2020 Aug 31;20(1):640. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457225/ http://www.ncbi.nlm.nih.gov/pubmed/32867706?tool=bestpractice.com 通常为干咳;然而,部分患者出现咳痰。
据报道出现于约 38% 患者。[133]Xie Y, Wang Z, Liao H, et al. Epidemiologic, clinical, and laboratory findings of the COVID-19 in the current pandemic: systematic review and meta-analysis. BMC Infect Dis. 2020 Aug 31;20(1):640. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457225/ http://www.ncbi.nlm.nih.gov/pubmed/32867706?tool=bestpractice.com 症状出现至进展为呼吸困难的中位时间为 5-8 日。[45]Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 Feb 15;395(10223):497-506. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30183-5/fulltext http://www.ncbi.nlm.nih.gov/pubmed/31986264?tool=bestpractice.com [46]Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020 Feb 15;395(10223):507-13. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30211-7/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32007143?tool=bestpractice.com [517]Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020 Feb 7;323(11):1061-9. https://jamanetwork.com/journals/jama/fullarticle/2761044 http://www.ncbi.nlm.nih.gov/pubmed/32031570?tool=bestpractice.com 它在儿童中并不常见,但却是新生儿最常见征象。[406]Liguoro I, Pilotto C, Bonanni M, et al. SARS-COV-2 infection in children and newborns: a systematic review. Eur J Pediatr. 2020 Jul;179(7):1029-46. https://link.springer.com/article/10.1007/s00431-020-03684-7 http://www.ncbi.nlm.nih.gov/pubmed/32424745?tool=bestpractice.com 症状初步发作后,可能持续数周。据报道,哮鸣出现于 17% 患者。[518]Grant MC, Geoghegan L, Arbyn M, et al. The prevalence of symptoms in 24,410 adults infected by the novel coronavirus (SARS-CoV-2; COVID-19): a systematic review and meta-analysis of 148 studies from 9 countries. PLoS One. 2020 Jun 23;15(6):e0234765. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0234765 http://www.ncbi.nlm.nih.gov/pubmed/32574165?tool=bestpractice.com
据报道,嗅觉障碍(嗅觉丧失/嗅觉减退)见于约 41% 的患者,而味觉障碍(味觉缺失)见于约 35% 的患者。[133]Xie Y, Wang Z, Liao H, et al. Epidemiologic, clinical, and laboratory findings of the COVID-19 in the current pandemic: systematic review and meta-analysis. BMC Infect Dis. 2020 Aug 31;20(1):640. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457225/ http://www.ncbi.nlm.nih.gov/pubmed/32867706?tool=bestpractice.com 欧洲研究中,流行率似乎更高。[519]Agyeman AA, Chin KL, Landersdorfer CB, et al. Smell and taste dysfunction in patients with COVID-19: a systematic review and meta-analysis. Mayo Clin Proc. 2020 Aug;95(8):1621-31. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7275152/ http://www.ncbi.nlm.nih.gov/pubmed/32753137?tool=bestpractice.com 可能是其他症状发作前的早期症状,或者可能是轻中症患者唯一症状。[520]Eliezer M, Hautefort C, Hamel AL, et al. Sudden and complete olfactory loss function as a possible symptom of COVID-19. JAMA Otolaryngol Head Neck Surg. 2020 Jul 1;146(7):674-5. https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2764417 http://www.ncbi.nlm.nih.gov/pubmed/32267483?tool=bestpractice.com 嗅觉丧失/味觉缺失在其他症状之前出现的患病率为 13% 至 73%,与其他症状同时出现的患病率为 14% 至 39%,在其他症状之后出现的患病率为 27% 至 49%。[521]Santos REA, da Silva MG, do Monte Silva MCB, et al. Onset and duration of symptoms of loss of smell/taste in patients with COVID-19: a systematic review. Am J Otolaryngol. 2021 Jan 6;42(2):102889. https://www.sciencedirect.com/science/article/pii/S0196070920305834?via%3Dihub http://www.ncbi.nlm.nih.gov/pubmed/33445036?tool=bestpractice.com 发病后 4 周,89% 患者诉称症状完全缓解或得到改善。[522]Boscolo-Rizzo P, Borsetto D, Fabbris C, et al. Evolution of altered sense of smell or taste in patients with mildly symptomatic COVID-19. JAMA Otolaryngol Head Neck Surg. 2020 Jul 2;146(8):729-32. https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/10.1001/jamaoto.2020.1379 http://www.ncbi.nlm.nih.gov/pubmed/32614442?tool=bestpractice.com 嗅觉丧失或嗅觉减退与 COVID-19 检测阳性风险增加具有显著相关性,且为感染的良好预测指标。[523]Hariyanto TI, Rizki NA, Kurniawan A. Anosmia/hyposmia is a good predictor of coronavirus disease 2019 (COVID-19) infection: a meta-analysis. Int Arch Otorhinolaryngol. 2021 Jan;25(1):e170-4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857970/ http://www.ncbi.nlm.nih.gov/pubmed/33552295?tool=bestpractice.com 许多药物与味觉和嗅觉改变有关(例如抗生素、ACE 抑制剂),应在鉴别诊断时加以考虑。[524]Ferraro S, Tuccori M, Convertino I, et al. Olfactory and gustatory impairments in COVID-19 patients: role in early diagnosis and interferences by concomitant drugs. Br J Clin Pharmacol. 2020 Nov 13 [Epub ahead of print]. https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1111/bcp.14634 http://www.ncbi.nlm.nih.gov/pubmed/33185930?tool=bestpractice.com
其他诊断因素
据报道见于大约 30% 患者。[133]Xie Y, Wang Z, Liao H, et al. Epidemiologic, clinical, and laboratory findings of the COVID-19 in the current pandemic: systematic review and meta-analysis. BMC Infect Dis. 2020 Aug 31;20(1):640. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457225/ http://www.ncbi.nlm.nih.gov/pubmed/32867706?tool=bestpractice.com 患者也可能主诉周身不适。即使轻度疾病患者,乏力和衰竭也可能极端明显,并迁延不愈。
据报道出现于约 17%(肌痛)和 11%(关节痛)患者。[518]Grant MC, Geoghegan L, Arbyn M, et al. The prevalence of symptoms in 24,410 adults infected by the novel coronavirus (SARS-CoV-2; COVID-19): a systematic review and meta-analysis of 148 studies from 9 countries. PLoS One. 2020 Jun 23;15(6):e0234765. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0234765 http://www.ncbi.nlm.nih.gov/pubmed/32574165?tool=bestpractice.com 罕有关节炎报道。[525]Parisi S, Borrelli R, Bianchi S, et al. Viral arthritis and COVID-19. Lancet Rheumatol. 2020 Nov;2(11):e655-7. https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(20)30348-9/fulltext http://www.ncbi.nlm.nih.gov/pubmed/33043303?tool=bestpractice.com
据报道出现于约 18% 患者。[133]Xie Y, Wang Z, Liao H, et al. Epidemiologic, clinical, and laboratory findings of the COVID-19 in the current pandemic: systematic review and meta-analysis. BMC Infect Dis. 2020 Aug 31;20(1):640. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457225/ http://www.ncbi.nlm.nih.gov/pubmed/32867706?tool=bestpractice.com
据报道出现于约 22.9% 患者。[449]Zhu J, Zhong Z, Ji P, et al. Clinicopathological characteristics of 8697 patients with COVID-19 in China: a meta-analysis. Fam Med Community Health. 2020 Apr;8(2). https://fmch.bmj.com/content/8/2/e000406 http://www.ncbi.nlm.nih.gov/pubmed/32371463?tool=bestpractice.com
20% 的患者报告该情况。特定症状加权总体流行率如下:纳差 22.3%;腹泻 2.4%;恶心/呕吐 9%;腹痛 6.2%。胃肠道症状似乎在中国之外更为普遍,尽管其有可能归咎于随着大流行进展,对此类症状的认识和报道得到加强。[526]Tariq R, Saha S, Furqan F, et al. Prevalence and mortality of COVID-19 patients with gastrointestinal symptoms: a systematic review and meta-analysis. Mayo Clin Proc. 2020 Aug;95(8):1632-48. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7284248/ http://www.ncbi.nlm.nih.gov/pubmed/32753138?tool=bestpractice.com 胃肠道症状与 COVID-19 检测阳性的可能性增加无关;然而,一项前瞻性病例对照研究中,厌食和腹泻结合嗅觉/味觉丧失与发热,对于 COVID-19 感染具有 99% 特异性。[527]Chen A, Agarwal A, Ravindran N, et al. Are gastrointestinal symptoms specific for coronavirus infection? A prospective case-control study from the United States. Gastroenterology. 2020 Sep;159(3):1161-3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7229473/ http://www.ncbi.nlm.nih.gov/pubmed/32422209?tool=bestpractice.com 出现胃肠道症状可能是进展至重症的一项预测指标。[528]Aziz M, Haghbin H, Lee-Smith W, et al. Gastrointestinal predictors of severe COVID-19: systematic review and meta-analysis. Ann Gastroenterol. 2020 Nov-Dec;33(6):615-30. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7599357/ http://www.ncbi.nlm.nih.gov/pubmed/33162738?tool=bestpractice.com [529]Zeng W, Qi K, Ye M, et al. Gastrointestinal symptoms are associated with severity of coronavirus disease 2019: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol. 2021 Jan 18 [Epub ahead of print]. https://journals.lww.com/eurojgh/Abstract/9000/Gastrointestinal_symptoms_are_associated_with.97315.aspx http://www.ncbi.nlm.nih.gov/pubmed/33470700?tool=bestpractice.com 与成人相比,儿童更易出现胃肠道症状,尤其是新生儿和婴幼儿,其可能为唯一症状。[406]Liguoro I, Pilotto C, Bonanni M, et al. SARS-COV-2 infection in children and newborns: a systematic review. Eur J Pediatr. 2020 Jul;179(7):1029-46. https://link.springer.com/article/10.1007/s00431-020-03684-7 http://www.ncbi.nlm.nih.gov/pubmed/32424745?tool=bestpractice.com 便血表现已有报道。[530]Guotao L, Xingpeng Z, Zhihui D, et al. SARS-CoV-2 infection presenting with hematochezia. Med Mal Infect. 2020 May;50(3):293-6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141548/ http://www.ncbi.nlm.nih.gov/pubmed/32229159?tool=bestpractice.com
据报道出现于约 16% 患者。[133]Xie Y, Wang Z, Liao H, et al. Epidemiologic, clinical, and laboratory findings of the COVID-19 in the current pandemic: systematic review and meta-analysis. BMC Infect Dis. 2020 Aug 31;20(1):640. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457225/ http://www.ncbi.nlm.nih.gov/pubmed/32867706?tool=bestpractice.com 通常在临床病程早期出现。
据报道出现于约 16% 患者。[133]Xie Y, Wang Z, Liao H, et al. Epidemiologic, clinical, and laboratory findings of the COVID-19 in the current pandemic: systematic review and meta-analysis. BMC Infect Dis. 2020 Aug 31;20(1):640. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457225/ http://www.ncbi.nlm.nih.gov/pubmed/32867706?tool=bestpractice.com
据报道出现于约 11% 患者。[518]Grant MC, Geoghegan L, Arbyn M, et al. The prevalence of symptoms in 24,410 adults infected by the novel coronavirus (SARS-CoV-2; COVID-19): a systematic review and meta-analysis of 148 studies from 9 countries. PLoS One. 2020 Jun 23;15(6):e0234765. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0234765 http://www.ncbi.nlm.nih.gov/pubmed/32574165?tool=bestpractice.com
据报道,意识模糊出现于约 11% 患者。[518]Grant MC, Geoghegan L, Arbyn M, et al. The prevalence of symptoms in 24,410 adults infected by the novel coronavirus (SARS-CoV-2; COVID-19): a systematic review and meta-analysis of 148 studies from 9 countries. PLoS One. 2020 Jun 23;15(6):e0234765. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0234765 http://www.ncbi.nlm.nih.gov/pubmed/32574165?tool=bestpractice.com 重症监护病房患者意识模糊/谵妄和躁动的发生率较高(分别为 65% 和 69%)。[531]Helms J, Kremer S, Merdji H, et al. Neurologic features in severe SARS-CoV-2 infection. N Engl J Med. 2020 Jun 4;382(23):2268-70. https://www.nejm.org/doi/full/10.1056/NEJMc2008597 http://www.ncbi.nlm.nih.gov/pubmed/32294339?tool=bestpractice.com 谵妄与死亡风险增加相关,其起病迅速可能提示临床恶化。[532]Chen T, Wu D, Chen H, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ. 2020 Mar 26;368:m1091. https://www.bmj.com/content/368/bmj.m1091.long http://www.ncbi.nlm.nih.gov/pubmed/32217556?tool=bestpractice.com 使用苯二氮卓和缺乏家庭访视(视频或当面访视),被认为是谵妄的危险因素。[533]Pun BT, Badenes R, Heras La Calle G, et al. Prevalence and risk factors for delirium in critically ill patients with COVID-19 (COVID-D): a multicentre cohort study. Lancet Respir Med. 2021 Jan 8 [Epub ahead of print]. https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30552-X/fulltext http://www.ncbi.nlm.nih.gov/pubmed/33428871?tool=bestpractice.com 焦虑、抑郁和失眠的总体流行率分别为 15.2%、16% 和 23.9%。[534]Cénat JM, Blais-Rochette C, Kokou-Kpolou CK, et al. Prevalence of symptoms of depression, anxiety, insomnia, posttraumatic stress disorder, and psychological distress among populations affected by the COVID-19 pandemic: a systematic review and meta-analysis. Psychiatry Res. 2020 Nov 26;295:113599. https://www.sciencedirect.com/science/article/pii/S0165178120332601?via%3Dihub http://www.ncbi.nlm.nih.gov/pubmed/33285346?tool=bestpractice.com 一项研究中,意识状态改变在年轻住院患者(<60 岁)与老年患者中同样普遍。[535]National Institute for Health Research. Brain and nerve complications are more common than expected in younger patients with severe COVID-19. 2020 [internet publication]. https://evidence.nihr.ac.uk/alert/brain-and-nerve-complications-are-more-common-than-expected-in-younger-patients-with-severe-covid-19/ [536]Varatharaj A, Thomas N, Ellul MA, et al. Neurological and neuropsychiatric complications of COVID-19 in 153 patients: a UK-wide surveillance study. Lancet Psychiatry. 2020 Oct;7(10):875-82. https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30287-X/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32593341?tool=bestpractice.com
据报道出现于 11% 患者。最常见眼部症状包括干眼或异物感(16%)、充血(13.3%)、流泪(12.8%)、瘙痒(12.6%)、眼痛(9.6%)和分泌物(8.8%)。结膜炎是出现眼部表现的患者中最常见眼部疾病(88.8%)。[537]Nasiri N, Sharifi H, Bazrafshan A, et al. Ocular manifestations of COVID-19: a systematic review and meta-analysis. J Ophthalmic Vis Res. 2021 Jan-Mar;16(1):103-12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7841281/ http://www.ncbi.nlm.nih.gov/pubmed/33520133?tool=bestpractice.com 大多数症状呈轻度,持续 4 至 14 天,无并发症。前驱症状出现于 12.5% 的患者。[538]Inomata T, Kitazawa K, Kuno T, et al. Clinical and prodromal ocular symptoms in coronavirus disease: a systematic review and meta-analysis. Invest Ophthalmol Vis Sci. 2020 Aug 3;61(10):29. https://iovs.arvojournals.org/article.aspx?articleid=2770655 http://www.ncbi.nlm.nih.gov/pubmed/32797198?tool=bestpractice.com 一项横断面研究中,22.7% 儿童诉称出现轻度眼部症状(例如结膜分泌物、眼部摩擦感、结膜充血)。伴全身症状的儿童更易出现眼部症状。[539]Ma N, Li P, Wang X, et al. Ocular manifestations and clinical characteristics of children with laboratory-confirmed COVID-19 in Wuhan, China. JAMA Ophthalmol. 2020 Oct 1;138(10):1079-86. https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2769877 http://www.ncbi.nlm.nih.gov/pubmed/32845280?tool=bestpractice.com
据报道,约 8% 患者出现流涕,约 5% 患者出现鼻塞。[518]Grant MC, Geoghegan L, Arbyn M, et al. The prevalence of symptoms in 24,410 adults infected by the novel coronavirus (SARS-CoV-2; COVID-19): a systematic review and meta-analysis of 148 studies from 9 countries. PLoS One. 2020 Jun 23;15(6):e0234765. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0234765 http://www.ncbi.nlm.nih.gov/pubmed/32574165?tool=bestpractice.com
据报道出现于约 7% 患者。[518]Grant MC, Geoghegan L, Arbyn M, et al. The prevalence of symptoms in 24,410 adults infected by the novel coronavirus (SARS-CoV-2; COVID-19): a systematic review and meta-analysis of 148 studies from 9 countries. PLoS One. 2020 Jun 23;15(6):e0234765. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0234765 http://www.ncbi.nlm.nih.gov/pubmed/32574165?tool=bestpractice.com 可能提示肺炎。
全身皮肤病变的总体患病率为 5.7 %。最常见的症状为病毒性皮疹样表现(4.2%)、斑丘疹(3.8%)和大小疱性皮损(1.7%)其他表现包括荨麻疹、冻疮样皮损、网状青斑和手指/脚趾坏疽。[540]Bandhala Rajan M, Kumar-M P, Bhardwaj A. The trend of cutaneous lesions during COVID-19 pandemic: lessons from a meta-analysis and systematic review. Int J Dermatol. 2020 Sep 16 [Epub ahead of print]. https://onlinelibrary.wiley.com/doi/10.1111/ijd.15154 http://www.ncbi.nlm.nih.gov/pubmed/32936462?tool=bestpractice.com 在英国 COVID 症状研究中,17% 受访者报告皮疹为疾病首发症状,21% 受访者报告皮疹为唯一临床症状。[541]Bataille V, Visconti A, Rossi R, et al; medRxiv. Diagnostic value of skin manifestation of SARS-CoV-2 infection. 2020 [internet publication]. https://www.medrxiv.org/content/10.1101/2020.07.10.20150656v1 尚不清楚皮肤病损是来自于病毒感染、感染的全身性结局,还是是患者可能在服用的药物。仍需进一步的研究以更好地理解皮肤受累情况。
British Association of Dermatologists: Covid-19 skin patterns external link opens in a new window
据报道出现于约 2% 患者。[518]Grant MC, Geoghegan L, Arbyn M, et al. The prevalence of symptoms in 24,410 adults infected by the novel coronavirus (SARS-CoV-2; COVID-19): a systematic review and meta-analysis of 148 studies from 9 countries. PLoS One. 2020 Jun 23;15(6):e0234765. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0234765 http://www.ncbi.nlm.nih.gov/pubmed/32574165?tool=bestpractice.com 可能是肺栓塞症状之一。[542]Casey K, Iteen A, Nicolini R, et al. COVID-19 pneumonia with hemoptysis: acute segmental pulmonary emboli associated with novel coronavirus infection. Am J Emerg Med. 2020 Jul;38(7):1544. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141630/ http://www.ncbi.nlm.nih.gov/pubmed/32312574?tool=bestpractice.com
可能提示肺炎。
可能见于急性呼吸窘迫患者。
可能见于急性呼吸窘迫患者。
可能见于急性呼吸窘迫患者。
可能见于急性呼吸窘迫患者。
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