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Accuracy of Emergency Department Clinical Findings for Diagnosis of Coronavirus Disease 2019

      Study objective

      We seek to describe the medical history and clinical findings of patients attending the emergency department (ED) with suspected coronavirus disease 2019 (COVID-19) and estimate the diagnostic accuracy of patients’ characteristics for predicting COVID-19.

      Methods

      We prospectively enrolled all patients tested for severe acute respiratory syndrome coronavirus 2 by reverse-transcriptase polymerase chain reaction in our ED from March 9, 2020, to April 4, 2020. We abstracted medical history, physical examination findings, and the clinical probability of COVID-19 (low, moderate, and high) rated by emergency physicians, depending on their clinical judgment. We assessed diagnostic accuracy of these characteristics for COVID-19 by calculating positive and negative likelihood ratios.

      Results

      We included 391 patients, of whom 225 had positive test results for severe acute respiratory syndrome coronavirus 2. Reverse-transcriptase polymerase chain reaction result was more likely to be negative when the emergency physician thought that clinical probability was low, and more likely to be positive when he or she thought that it was high. Patient-reported anosmia and the presence of bilateral B lines on lung ultrasonography had the highest positive likelihood ratio for the diagnosis of COVID-19 (7.58, 95% confidence interval [CI] 2.36 to 24.36; and 7.09, 95% CI 2.77 to 18.12, respectively). The absence of a high clinical probability determined by the emergency physician and the absence of bilateral B lines on lung ultrasonography had the lowest negative likelihood ratio for the diagnosis of COVID-19 (0.33, 95% CI 0.25 to 0.43; and 0.26, 95% CI 0.15 to 0.45, respectively).

      Conclusion

      Anosmia, emergency physician estimate of high clinical probability, and bilateral B lines on lung ultrasonography increased the likelihood of identifying COVID-19 in patients presenting to the ED.
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      References

        • Park M.
        • Cook A.R.
        • Lim J.T.
        • et al.
        A systematic review of COVID-19 epidemiology based on current evidence.
        J Clin Med. 2020; 9: 967
        • 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; 395: 507-513
        • Huang C.
        • Wang Y.
        • Li X.
        • et al.
        Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.
        Lancet. 2020; 395: 497-506
        • Wu C.
        • Chen X.
        • Cai Y.
        • et al.
        Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China.
        JAMA Intern Med. 2020;
        • Xu X.W.
        • Wu X.X.
        • Jiang X.G.
        • et al.
        Clinical findings in a group of patients infected with the 2019 novel coronavirus (SARS-Cov-2) outside of Wuhan, China: retrospective case series.
        BMJ. 2020; 368: m606
        • Zhou F.
        • Yu T.
        • Du R.
        • et al.
        Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.
        Lancet. 2020; 395: 1054-1062
        • Vandenbroucke J.P.
        • von Elm E.
        • Altman D.G.
        • et al.
        Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration.
        PLoS Med. 2007; 4: e297
        • Grasselli G.
        • Zangrillo A.
        • Zanella A.
        • et al.
        COVID-19 Lombardy ICU Network. Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy region, Italy.
        JAMA. 2020; 323: 1574-1581
        • Du Y.
        • Tu L.
        • Zhu P.
        • et al.
        Clinical features of 85 fatal cases of COVID-19 from Wuhan: a retrospective observational study.
        Am J Respir Crit Care Med. 2020;
        • Yang X.
        • Yu Y.
        • Xu J.
        • et al.
        Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study.
        Lancet Respir Med. 2020; 8: 475-481
        • Bhatraju P.K.
        • Ghassemieh B.J.
        • Nichols M.
        • et al.
        Covid-19 in critically ill patients in the Seattle region. Case series.
        N Engl J Med. 2020; 382: 2012-2022
        • Song J.Y.
        • Yun J.G.
        • Noh J.Y.
        • et al.
        Covid-19 in South Korea. Challenges of subclinical manifestations.
        N Engl J Med. 2020; 382: 1858-1859
        • Wang Y.Y.
        • Jin Y.H.
        • Ren X.Q.
        • et al.
        • Zhongnan Hospital of Wuhan University Novel Coronavirus Management and Research Team
        Updating the diagnostic criteria of COVID-19 “suspected case” and “confirmed case” is necessary.
        Mil Med Res. 2020; 7: 17
        • Young B.E.
        • Ong S.W.X.
        • Kalimuddin S.
        • et al.
        Epidemiologic features and clinical course of patients infected with SARS-CoV-2 in Singapore.
        JAMA. 2020; 323: 1488-1494
        • Gane S.B.
        • Kelly C.
        • Hopkins C.
        Isolated sudden onset anosmia in COVID-19 infection. A novel syndrome?.
        Rhinology. 2020;
        • Vaira L.A.
        • Salzano G.
        • Deiana G.
        • et al.
        Anosmia and ageusia: common findings in COVID-19 patients.
        Laryngoscope. 2020;
        • Lechien J.R.
        • Chiesa-Estomba C.M.
        • De Siati D.R.
        • et al.
        Olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (COVID-19): a multicenter European study.
        Eur Arch Otorhinolaryngol. 2020;
        • Shi Y.
        • Yu X.
        • Zhao H.
        • et al.
        Host susceptibility to severe COVID-19 and establishment of a host risk score: findings of 487 cases outside Wuhan.
        Crit Care. 2020; 24: 108
        • Varga Z.
        • Flammer A.J.
        • Steiger P.
        • et al.
        Endothelial cell infection and endotheliitis in COVID-19.
        Lancet. 2020; 395: 1417-1418
        • Mao L.
        • Jin H.
        • Wang M.
        • et al.
        Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China.
        JAMA Neurol. 2020;
        • Bouaziz J.D.
        • Duong T.
        • Jachiet M.
        • et al.
        Vascular skin symptoms in COVID-19: a French observational study.
        J Eur Acad Dermatol Venereol. 2020;
        • Long C.
        • Xu H.
        • Shen Q.
        • et al.
        Diagnosis of the coronavirus disease (COVID-19): rRT-PCR or CT?.
        Eur J Radiol. 2020; 126: 108961
        • He J.L.
        • Luo L.
        • Luo Z.D.
        • et al.
        Diagnostic performance between CT and initial real-time RT-PCR for clinically suspected 2019 coronavirus disease (COVID-19) patients outside Wuhan, China.
        Respir Med. 2020; 168: 105980
        • Ai T.
        • Yang Z.
        • Hou H.
        • et al.
        Correlation of chest CT and RT-PCR testing in coronavirus disease 2019 (COVID-19) in China: a report of 1014 cases.
        Radiology. 2020;
        • Vetrugno L.
        • Bove T.
        • Orso D.
        • et al.
        Our Italian experience using lung ultrasound for identification, grading and serial follow-up of severity of lung involvement for management of patients with COVID-19.
        Echocardiography. 2020; 37: 625-627
        • Soldati G.
        • Smargiassi A.
        • Inchingolo R.
        • et al.
        Proposal for international standardization of the use of lung ultrasound for COVID-19 patients: a simple, quantitative, reproducible method.
        J Ultrasound Med. 2020;
        • Xing C.
        • Li Q.
        • Du H.
        • et al.
        Lung ultrasound findings in patients with COVID-19 pneumonia.
        Crit Care. 2020; 24: 174
        • Lu W.
        • Zhang S.
        • Chen B.
        • et al.
        A clinical study of noninvasive assessment of lung lesions in patients with coronavirus disease-19 (COVID-19) by bedside ultrasound.
        Ultraschall Med. 2020;
        • Fiala M.J.
        A brief review of lung ultrasound in COVID-19: is it useful?.
        Ann Emerg Med. 2020;
        • Simon L.E.
        • Kene M.V.
        • Warton E.M.
        • et al.
        Diagnostic performance of emergency physician gestalt for predicting acute appendicitis in patients age 5 to 20 years.
        Acad Emerg Med. 2020;
        • Oliver G.
        • Reynard C.
        • Morris N.
        • et al.
        Can emergency physician gestalt “rule in” or “rule out” acute coronary syndrome: validation in a multicenter prospective diagnostic cohort study.
        Acad Emerg Med. 2020; 27: 24-30
        • Roncalli J.
        • Picard F.
        • Delarche N.
        • et al.
        Predictive criteria for acute heart failure in emergency department patients with acute dyspnoea: the PREDICA study.
        Eur J Emerg Med. 2019; 26: 400-404
        • Penaloza A.
        • Verschuren F.
        • Meyer G.
        • et al.
        Comparison of the unstructured clinician gestalt, the Wells score, and the revised Geneva score to estimate pretest probability for suspected pulmonary embolism.
        Ann Emerg Med. 2013; 62: 117-124.e2