Acute onset, dyspnea, malaise, fever

Key Teaching Points

• This is an example of COVID that is symptomatic, with characteristic laboratory and imaging findings, but not ill enough to require admission. While admission criteria may vary based on provider and/or setting, if the patient is not ill appearing (is conversational), without increased respiratory rate (<20 breaths per minute at rest), and not hypoxic at rest or with ambulation (oxygen saturation at or above 92% on room air) they can likely be monitored as an outpatient. • Some of the characteristic findings of COVID include: low white blood cell count, elevated C-reactive protein, elevated D-dimer (her D-dimer was 0.60 – of note some institutions are using this to initiate empiric anticoagulation, at our institution the D-dimer would have to be very high, >5.0 to do this). Her CXR was clear, however her ultrasound showed characteristic “B-line” artificats. Had a CT of the chest been performed (not indicated as it would not have changed management), it likely would have shown “ground glass opacities” which are characteristic of COVID. While research is ongoing, ultrasound is likely more sensitive than CXR but not as sensitive as CT for changes in the lung in COVID.

Editor’s Notes

• Editor notes: COVID cases that are discharged need follow up by both the primary care physician and the local public health department. Discharge instructions should be clear for return to emergency care, including worsening dyspnea or shortness of breath. Fortunately, this patient appeared well and was discharged.