UCSF COVID-19 Adult Clinical Evaluation Guide - Updated April 10 2020 Clinical Presentation •

COVID-19 Clinical Presentation and Labs Common Symptoms • Fever in >75% at some point (~50% on admission) • Cough 45-80% (dry or productive) • SOB 20-40% • Myalgias 10-50% • Triad of fever, cough, SOB in only 15% Less Common Symptoms • URI symptoms (HA, sore throat, rhinorrhea) <15% • GI symptoms: N/V <10%, diarrhea <25% Routine Labs • Median WBC 4.7 with leukopenia in 17-54% and leukocytosis in <25% • Lymphopenia in 33-85% • Median platelets normal, with slight decrease in <35% • AST/ALT increase in 4-35% Biomarkers • CRP increased in 61-86% • LDH increased in 27-75% • Procalcitonin > 0.5 in 5-10% (but 14% if severe, 24% if ICU) UCSF Grand Rounds March 20 2020 #Presentation #Labs #Workup #Diagnosis #Symptoms #Signs #COVID19

Diagnostic approach to the admitted patient with possible COVID-19 Initial evaluation - Chest X-ray - Lung ultrasound (thorough "lawn-mower" exam to look for focal a-lines) - Nasopharyngeal PCR for COVID-19, influenza, RSV, and other viral pathogens (ideally should be performed simultaneously). - CBC with differential cell count - C-reactive protein (CRP) +/- Procalcitonin - Other diagnostics as clinically indicated (e.g. echocardiogram, EKG) Dr. Josh Farkas @pulmcrit via Internet Book of Critical Care @iBookCC #COVID19 #algorithm #schema #Diagnosis #SARSCoV2 #Coronavirus

MGH Laboratories for diagnosis, prognosis / risk stratification, and/or safety of agents Suggested for hospitalized patients with confirmed or suspected COVID-19 #Workup #Labs #Diagnosis #Evaluation #COVID19 #MGH #Coronavirus #SARSCOV2

$Possible approach to empiric anticoagulation in COVID-19 Is D-dimer above '"1,000-2,000 ng/ml? Contraindication to anticoagulation? Check fibrinogen level and/or$

Possible approach to empiric anticoagulation in COVID-19 Is D-dimer above '"1,000-2,000 ng/ml? Contraindication to anticoagulation? Check fibrinogen level and/or thromboelastography (TEG) Normal or hyper-coagulable pattern (nearly always) -> Therapeutic Anticoagulation - R-time low or normal on thromboelastography - Fibrinogen level is normal or elevated Hypo-coagulable pattern (rare, late-stage) -> No Anticoagulation - R-time prolonged on thromboelastography - Fibrinogen level low Dr. Josh Farkas @pulmcirt - Internet Book of Critical Care @iBookCC #empiric #anticoagulation #COVID19 #management #schema #criticalcare #algorithm #SARSCOV2 #Coronavirus

COVID-19 - A Seattle Intensivist's One-Page Cheat-Sheet on COVID-19 v2.7 Updated March 26 2020 (v2.7) incorporating newer published data, and more info about ventilator weaning. (v2.6) on caring for people with #COVID19 in the ICU, now reflecting new data from @matthewarentz et al JAMA paper as well as data on new treatment options. (v2.5) It reflects new data on mortality rate in the US and updated treatment recommendations. (v2.4) added more details and clarified the treatment section (several investigational therapies; steroids NOT recommended) (v2.3) updated to reflect newer info and with references. Nomenclature (NOT "Wuhan Virus") • Infection: Coronavirus Disease 2019 a.k.a. COVID-19 • Virus: SARS-CoV-2, 2019 Novel Coronavirus Epidemiology • Attack rate = 30-40% • Ro = 2-4 (similar to influenza) • CFR = 3.4% (worldwide numbers) • Incubation time = 4-14 days typically (up to 24 days) Timeline: • China notifies WHO 2019-12-31 • First US case in Seattle 2020-1-15 • WHO Declared pandemic 2020-3-11 • National emergency 2020-3-12 Diagnosis/Presentation Symptoms • 65-80% cough • 45% febrile on presentation (85% febrile during illness) • 20-40% dyspnea • 15% URI symptoms • 10% GI symptoms Imaging • CXR: hazy bilateral peripheral opacities • CT: ground glass opacities (GGO), crazy paving, consolidation, *rarely may be unilateral* • POCUS: numerous B-lines, pleural line thickening, consolidations w/ air bronchograms Nick Mark MD @nickmmark #COVID19 #Cheatsheet #Diagnosis #Management #Summary #SARSCoV2 #Coronavirus #CriticalCare ** GrepMed Recommended Text: Marino's The ICU Book - https://amzn.to/2WUVUwA

Type L: - Low elastance. The nearly normal compliance indicates that the amount of gas in the lung is nearly normal - Low ventilation-to-perfusion (VA/Q) ratio. Since the gas volume is nearly normal, hypoxemia may be best explained by the loss of regulation of perfusion and by loss of hypoxic vasoconstriction. Accordingly, at this stage, the pulmonary artery pressure should be near normal. - Low lung weight. Only ground-glass densities are present on CT scan, primarily located subpleurally and along the lung fissures. Consequently, lung weight is only moderately increased. - Low lung recruitability. The amount of non-aerated tissue is very low; consequently, the recruitability is low Type H: - High elastance. The decrease in gas volume due to increased edema accounts for the increased lung elastance. - High right-to-left shunt. This is due to the fraction of cardiac output perfusing the non-aerated tissue which develops in the dependent lung regions due to the increased edema and superimposed pressure. - High lung weight. Quantitative analysis of the CT scan shows a remarkable increase in lung weight (> 1.5 kg), on the order of magnitude of severe ARDS. - High lung recruitability. The increased amount of non-aerated tissue is associated, as in severe ARDS, with increased recruitability. Dr. Giuseppe Citerio @Dr_Cit #COVID19 #Phenotypes #Variations #Diagnosis #Management #SARSCOV2 #Coronavirus

Summary of Timeline of COVID-19 SARS-CoV-2 Infectivity Day 0 - Peak Viral Load and Infectivity Day 5 - Majority of Secondary Infections Occur Prior to This Point Day 10 - Virus Unable To Be Cultured in Mild- Moderate Ilness Beyond This Point Day 15 - <5% Probability of Culturing Virus in Severe-Critical Illness or Immuno-compromised Patients Beyond This Point Day 20 - Longest Duration of Infectious Shedding By Culture Reported To Date Day 90+ - Persistent or Recurrent Positive PCR Possible up To This Point or Beyond (High Ct Values and Not Contagious) Ssummarizes the evidence-to-date on the duration of SARS-CoV-2 Infectivity & when is it Safe to discontinue Isolation: https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1249/5896916 #Timeline #COVID19 #SARSCoV2 #Infectivity #contagiousness #diagnosis #infection #prevention #isolation #precautions

Medical Mask Usage in COVID-19 Medical masks can be used to prevent the spread of respiratory infections. There are 2 main types of medical masks: face masks and N95 respirators. - Face masks fit more loosely and prevent the wearer from spreading large sprays and droplets when coughing or sneezing. - N95 respirators fit more tightly and prevent the wearer from inhaling smaller, airborne infectious particles. N95 respirators are not recommended for use by the general public. Face masks should only be used by - Individuals with symptoms of respiratory infection such as coughing, sneezing, and sometimes fever - Health care workers - Persons taking care of or in close contact with someone with a respiratory infection How do I use a face mask? 1) Wash hands for at least 20 seconds prior to putting on a face mask. 2) Place face mask over nose and mouth. Ensure a tight seal with no gaps and secure elastics or straps. 3) Avoid touching the front of the face mask. If you do, wash hands for at least 20 seconds. 4) Remove the face mask without touching the front. Discard in a closed bin. 5) Wash hands again for at least 20 seconds. Dr. Angel N Desai @angeldesaimd #Medical #Masks #Usage #COVID19 #PatientInfo #Coronavirus

Drug Induced Lupus vs SLE Drug Induced Lupus (DIL): • Epidemiology: -10% of all lupus cases, drug-dependent, 4:1 to 1:1 F:M • Clinical Manifestations: Constitutional symptoms, Arthritis, myalgia, serositis, Kidney & NPSLE rare, Malar rash is rare in DIL, SCLE-DIL (terbinafine, thiazidic, PPI, ACE, calcium-b) • Laboratory Manifestations: - CRP - Usually normal (except with serositis) - Cytopenia - Less common (drug-dependent) • Immunologic Workup: - ANA > 95% (IgG anti-chromatin) - Anti-ENA - Rare (SSA+ for cutaneous DIL), anti-Sm rare - Anti-dsDNA - Rarely positive (common with anti-TNF) - Anti-histone - Positive in >90% - Low complement - Rare - pANCA anti-MPO - Seen with PTU (50%) and minocycline (65-100%) • Prognosis: Usually mild forms with constitutional symptoms • Treatment: Discontinuation of causal drug +++, Hydroxychloroquine, csDMARDs and/or bDMARDs (rare), Topics for cutaneous-DIL • Evolution: Disappearance of manifestations (weeks to months) and of autoantibodies (months to years) Systemic Lupus Erythematosus (SLE): • Epidemiology: 10-180/100,000, Typically Age 20-40, F:M 9:1 • Clinical Manifestations: Malar rash, Photosensitivity, Alopecia, oral ulcers, Lupus nephritis, NPSLE - If present, are evocative of SLE versus DIL • Laboratory Manifestations: - CRP: Usually normal (except with serositis) - Cytopenia: Common • Immunologic Workup: - ANA > - Anti-ENA - Positive in up to 30% - Anti-dsDNA - Positive in 60-80% of cases - Anti-histone - Positive in 60-80% - Low complement - 50-60% - pANCA anti-MPO - Negative • Prognosis: Minor to life-threatening • Treatment: Usual therapeutic management of SLE • Evolution: Chronic disease Dr. Laurent ARNAUD @Lupusreference #druginduced #lupus #sle #comparison #table #rheumatology #diagnosis #management

Systemic Lupus Erythematosus (SLE) - Diagnosis and Management Summary • Epidemiology: 10-180/100,000, Typically Age 20-40, F:M 9:1 • Clinical Manifestations: Malar rash, Photosensitivity, Alopecia, oral ulcers, Lupus nephritis, NPSLE - If present, are evocative of SLE versus DIL • Laboratory Manifestations: - CRP: Usually normal (except with serositis) - Cytopenia: Common • Immunologic Workup: - ANA > - Anti-ENA - Positive in up to 30% - Anti-dsDNA - Positive in 60-80% of cases - Anti-histone - Positive in 60-80% - Low complement - 50-60% - pANCA anti-MPO - Negative • Prognosis: Minor to life-threatening • Treatment: Usual therapeutic management of SLE • Evolution: Chronic disease Dr. Laurent ARNAUD @Lupusreference #SLE #lupus #Systemic #Erythematosus #Diagnosis #Management #Summary #rheumatology