History and Physical

Examination Of A Covid19
Suspect And Clinical
Question On Rapid- Antigen
Test
 GENERAL DATA

- R.M.
- 38y/o
- Male
- Agoo, La Union
- Married
- Date of admission: November 8,
2020
 “
Percent Reliability: 96%
 CHIEF
COMPLAINT

Difficulty of Breathing
 HISTORY OF
PRESENT ILLNESS
1 week PTA, patient complains of
pain when swallowing and nasal
congestion. He took Benzydamine
hydrochloride (Difflam™) solution
as medication for his sore throat
and applied Vicks vaporub at night
to ease his nasal congestion.
5 days PTA patient started
to have productive cough
with whitish to yellowish
sputum with no
associated fever,
dyspnea, chest pain,
vomiting, and diarrhea.
 HISTORY OF
PRESENT ILLNESS

A few hours PTA, his

3 days PTA, he cough worsened and
experienced loss had difficulty
of smell and breathing, thus
taste. prompted for
admission.
 PAST MEDICAL
HISTORY

(+) HPN; amlodipine 5mg 1 tab OD

 FAMILY HISTORY

- Father is a known hypertensive

- No known history of CAD, cancer, renal

disease, lung disease or DM

- Son tested positive for Covid-19 virus last

Nov 1, 2020
 PERSONAL AND
SOCIAL HISTORY

- Farmer
- Non-smoker
- Occasional alcohol drinker
- Patient lives with his wife and
son who helps him tend their
farm
 REVIEW OF
SYSTEMS

HEENT:
GENERAL: Head (-) headache,
NECK:
Febrile, no weight dizziness and/or
lightheadedness No swollen gland,
change, (+) fatigue lumps and/or
Eyes (-) blurring or
double vision stiffness in the
Ears (-) vertigo, neck observed
SKIN: tinnitus or infection
(-) rashes, (-) Nose (+) nasal
BREAST:
stuffiness
itching
Throat (+) sore throat No lumps, pain, or
nipple discharges
 REVIEW OF
SYSTEMS
PERIPHERAL
RESPIRATORY: VASCULAR:
(+) dyspnea , GASTROINTESTINAL: (-) varicose veins
(+) productive cough, With good appetite (-) swelling of legs
(-) No wheezing and and bowel movement,
hemoptysis and feet
no heartburn and
indigestion
CARDIOVASCULAR: (-) jaundice, URINARY:
(+) hypertension, (-) gallbladder or liver (-) hematuria,
(-) orthopnea, problem (-) polyuria,
(-) chest pain or (-) nocturia
palpitation (-) urinary infection
 REVIEW OF
SYSTEMS
GENITAL:
(-) Hernias NEUROLOGIC:
(-) discharge from or No changes in mood,
sores on the penis attention, or speech (+)
(-) testicular pain or loss of sense of taste
masses and smell
(- ) scrotal pain or ENDOCRINE:
swelling No heat or cold
MUSCULOSKELETAL: intolerance
(-) Muscle or joint pain (-) excessive
HEMATOLOGIC: sweating
(-) arthritis
(-) Anemia (-) excessive thirst or
(-) gout
(-) easy bruising or hunger
(-) backache
bleeding
 PHYSICAL
EXAMINATION

SKIN:
GENERAL SURVEY:
palms cold and moist, but color
awake, conscious, coherent,
good. No cutaneous lesions. Nails
weak looking, in respiratory
without clubbing and cyanosis
distress

VITAL SIGNS:
BP: 130/90mmHg
CR: 95bpm
Temperature: 37.9°C
Respiratory rate: 26 breaths/min
Weight: 65 kg
Height: 165 cm
 PHYSICAL
EXAMINATION

HEENT:
Head: The skull is normocephalic/atraumatic, no scalp lesions.
Eyes: Anicteric sclera, pink palpebral conjunctiva. Pupils equally
round and reactive to light and accommodations, normally
aligned eyes and eyelids and normal movement of extraocular
muscles and no noted discharge.
Ears: Normally set ears, normal auditory acuity, no vertigo, no
tinnitus and no noted signs of infection.
With nasal flaring, no sinusitis was noted.
Throat: no neck vein engorgement, no cervical lymphadenopathy,
no swollen glands, lumps or stuffiness observed.
 PHYSICAL
EXAMINATION

CARDIOVASCULAR:
THORAX & LUNGS: no heaves and thrills,
symmetric with lagging of left PMI at 5th ICS LMCL,
hemithorax on inspiration, (+) distinct heart sounds,
ICS retractions; increased regular rhythm, normal
tactile fremitus; left lower lung rate, no murmur
field with dullness ; increased
breath sounds, (+)bronchial BREAST:
breath sounds, (+) rales no masses, nipples
without discharge
 PHYSICAL
EXAMINATION

ABDOMEN:
EXTREMITIES:
flat, soft, normoactive bowel
warm and without edema.
sounds, no bruits, no tenderness,
Calves supple, nontender
no mass/distention
PERIPHERAL VASCULAR:
GENITALIA: full and equal pulses, pink
external genitalia without lesions, nailbeds, (-)peripheral edema
no palpable mass

MUSCULOSKELETAL:
RECTAL: No joint deformities. Good range of
good sphincter tone, motion in hands, wrists, elbows,
(-)rectal vault masses shoulders, spine, knees, ankles.
 PHYSICAL
EXAMINATION

NEUROLOGIC:
Mental Status: Tense but alert and cooperative. Thought coherent.
Oriented to person, place and time
Cranial Nerves: I- anosmia; VII and IX- ageusia; II- VI, VIII, X-XII
intact
Motor: Good muscle bulk and tone. Strength 5/5 throughout
Cerebellar: Rapid alternating movements (RAMs), point-to-point
movements intact. Gait stable, fluid
Sensory: Pinprick, light touch, position sense and vibration
intact. Romberg negative.
Reflexes: 2+ and symmetric. (-)Babinski
 WORKING
DIAGNOSIS

CAP MR to consider Covid-19,

Uncontrolled Hypertension
 DIFFERENTIAL
DIAGNOSIS
Covid CAP Flu Strep CHF PTB
FEVER / / / / / /
DYSPNEA / / / /
ANOSMIA
AND / /
AGEUSIA
RALES / / /
SORE
/ /
THROAT
 DIFFERENTIAL
DIAGNOSIS
Covid CAP Flu Strep CHF PTB

COUGH dry and

/ / /
(PRODUCTIVE) productive

LUNG
/ / resonant /
DULLNESS

TACTILE
inc inc
FREMITUS

FATIGUE / /
 CLINICAL QUESTION
PICO MODEL
CLINICAL QUESTION:
Among patients who present acute respiratory symptoms and/or fever that
had recent exposure to Covid-19 positive individuals(P), how accurate is the
Rapid antigen Detection test (I), compared to Reverse transcription
Polymerase chain reaction (C), in diagnosing SARS-CoV-2 in respiratory
samples (O)?
P (patients who present acute respiratory symptoms
and/or fever that had recent exposure to Covid-19
positive individuals)
I (Rapid antigen Detection Test (RDT) )
C (Reverse transcription polymerase chain reaction
(RT-PCR) test.)
O(SARS-CoV-2 diagnosis in respiratory samples)
 CLINICAL QUESTION
PICO MODEL

TYPE OF CLINICAL QUESTION:

DIAGNOSIS

BEST STUDY DESIGN:

SYSTEMATIC REVIEW/ META ANALYSIS OF
CONTROLLED TRIAL
RAPID ANTIGEN TESTING (RDT)
⊡ detects the presence of viral
proteins (antigens) expressed by the
COVID-19 virus in a sample from
the respiratory tract of a person.
⊡ If the target antigen is present in
sufficient concentrations in the
sample, it will bind to specific
antibodies fixed to a paper strip
enclosed in a plastic casing and
generate a visually detectable
signal, typically within 30 minutes.
REVERSE TRANSCRIPTASE POLYMERASE CHAIN
REACTION  (RT-PCR)
⊡ A sample is collected from the
parts of the body where the
COVID-19 virus gathers, such as a
person’s nose or throat. The
sample is treated and extract only
the RNA present. This extracted
RNA is a mix of the person’s own
genetic material and, if present,
the virus’s RNA.
⊡ highly sensitive and specific and
can deliver a reliable diagnosis in
as little as 3hrs
⊡ It continues to be the most
accurate method available for the
detection of the COVID-19 virus.
RAPID ANTIGEN TESTING REVERSE TRANSCRIPTASE
(RDT) POLYMERASE CHAIN
⊡ The antigen(s) detected REACTION  (RT-PCR)
are expressed only when ⊡ However, real time RT–
the virus is actively PCR cannot be used to
replicating; therefore, detect past infections,
such tests are best used which is important for
to identify acute or early understanding the
infection. development and spread
of the virus, as viruses are
only present in the body
for a specific window of
time
EVALUATION OF ARTICLES
ON DIAGNOSIS
 CLINICAL QUESTION RESEARCH QUESTION

Among 127 SARS-Cov-2 respiratory

Amon patients who present
acute respiratory symptoms
P
and/or fever that had recent
Appraisin exposure to Covid-19 positive
individuals
samples, age range from 0 to >/=
60yrs with a median age of 38years
m>f SARS-COV-2 suspects with
symptoms of cough and fever, recent
travel to high risk area, amounting
days 0 to >/=8 of beginning of the

g symptoms

Directness I

How accurate is the rapid how accurate is the novel antigen-

antigen detection test based rapid detection test RDT)

C
Compared to reverse
in comparison to the real-time
transcription polymerase chain
reverse-transcription PCR (RT-PCR
reaction

O
in the diagnosis, isolation and
In diagnosing SARS-COV2 in
detection of SARS-COV-2 in
respiratory samples
respiratory samples
Appraising Directness
Does the study provide a direct enough answer to your clinical question?

• YES;

Did the study evaluate the kind of patients you are interested in?

• Yes, the study had a median age of 38 years old and samples from male are greater than female. The
patient is also a 38 year old male.

Is the test in the study exactly the one you want?

Yes, the patient is a COVID 19 suspect and the study evaluates RDT nad RT PCR which are both diagnostic
tests for COVID 19

Is the disease which is being diagnosed the same?

yes
Appraising Validity
A. Was the reference standard an acceptable one?
• RT-PCR was used as the reference standard.
• Yes, the reference standard that is RT-PCR in this journal is
accepted by scientists and medical staff as a robust and well
documented technique. it is the best diagnostic tool for Sars-Cov2
as of now
B. Was the reference standard interpreted independently from the test
in question?
• Yes, Patients in the study underwent both RT-PCR and RDT regradless
if they were positive or negative. The technician performing the RDT
was blinded to the RT PCR results. Diagnostic accuracy was
determined in comparison to SARS-CoV-2 real-time (RT)-PCR.

Porte, L., Legarraga, P., Vollrath, V., Aguilera, X., Munita, J. M., Araos, R., ... & Weitzel, T. (2020). Evaluation of novel antigen-based rapid detection test for the diagnosis
of SARS-CoV-2 in respiratory samples. International Journal of Infectious Diseases. p. 329
Appraising Results
A. What were the likelihood ratios of the various test results?
 ALL SAMPLES
Test result Disease present Disease absent Row total
Positive 77 0 77
Negative 5 45 50
Column total 82 45  

There are four traditional ways of expressing how correct a test is:
 
Sensitivity- . X 100 = 93.9%

Specificity - %

Positive likelihood ratio (LR+) = = = infinite

Negative likelihood ratio (LR-) = 0.061

• The positive likelihood ratio in this case is infinite. A true positive test result implies, with absolute certainty, that the
person has the disease. A positive test result would imply it's infinitely more likely the person has the COVID 19
than not.
• Negative likelihood ratio (LR-) of 0.06 means that a negative test result is 0.06 more likely to occur in a patient
without COVID19 than in a patient with COVID19
 Samples - MALE
Test result Disease present Disease absent Row total
Positive 43 0 43
Negative 1 24 25
Column total 44 24  

Sensitivity- 97.7%
Specificity- 100%
LR+= infinite
LR-= 0.02
• Positive likelihood ratio (LR+) of infinity means A ,positive test result would imply it's infinitely more likely the
person has the COVID 19 than not.

• Negative likelihood ratio (LR-) of 0.02 means that the probability of negative result is less likely to occur in a
male patient with COVID19 than in a male patient without COVID19
 Samples - FEMALE
Test result Disease present Disease absent Row total
Positive 34 0 34
Negative 4 21 25
Column total 38 21  

Sensitivity- 89.5%
Specificity- 100%
LR+= infinity
LR-= 0.11
• Positive likelihood ratio (LR+) of infinity means A positive test result would imply it's infinitely more likely the
person has the COVID 19 than not.
• Negative likelihood ratio (LR-) of 0.11 means that the probability of a negative result is more likely to occur in
a female patient without COVID19 than in a female patient with COVID19
 SAMPLES – DAYS POST SYMPTOM ONSET (0-7)
Test result Disease present Disease absent Row total

Positive 72 0 72

Negative 4 42 46

Column total 76 42  

Sensitivity- 94.7%
Specificity- 100%
LR+= infinite
LR-= 0.05
• Positive likelihood ratio (LR+) of infinity means A positive test result would imply it's infinitely more likely
the person has the COVID 19 than not.
• Negative likelihood ratio (LR-) of 0.05 means that a negative result is less likely to occur in a patient with
COVID19 than in a patient without COVID19
 SAMPLES – DAYS POST SYMPTOM ONSET (8-12)
Test result Disease present Disease absent Row total
Positive 4 0 4
Negative 1 3 4
Column total 5 3  

Sensitivity- 80%
Specificity- 100%
LR+= infinity
LR-= 0.20
• Positive likelihood ratio (LR+) of infinity means A positive test result would imply it's infinitely more
likely the person has the COVID 19 than not.
• Negative likelihood ratio (LR-) of 0.20 means that a negative result is more likely to occur in a patient
without COVID19 than in a patient with COVID19
Assessing Applicability
A. Biologic issues affecting applicability

Race
The study was performed on 127 Chileans
Sex
The viral replication is highest in the pharynx during first days of clinical disease and
declines afterwards. This decline in viral load is more pronounced in female patients.

Pathology:
-antigen tests from upper respiratory swabs is more sensitive in the initial phase of
symptomatic infection.
-samples obtained during the first week of the symptoms and with high viral loads were
more specific and sensitive, sensitivity is reduced with low viral loads
B. What are the socioeconomic issues affecting applicability?

• The research was conducted in Chile where socioeconomic

conditions might be different from the Philippines.
• The fluorescence immunochromatographic SARS-CoV-2 antigen test
(Bioeasy Biotechnolog Co., Shenzhen, China) used in the study is
not included among the list of FDA Philippines approved test kits.
• The study was performed Late summer in Chile where there is a low
circulation of other frequent respiratory viruses; therefore the
performance of the RDT might change in different epidemiologic
conditions.
Individualizing results
• To determine the impact that the test (and its results) might have on our patient’s probability
of having a disease. The main source of an individual’s baseline probability of having a
disease is pre-test probability. Pre-test probability is a percentage given for a diagnostic
test in a patient based on his history and physical examination.
Based on History and Physical Examination of the patient, we have given a 65% pre test probability

The patient is in the

testing range so tests
are required
Using the Baye’s nomogram, we can
Estimate the post-test probability of a
disease given the test results.
• The patient had a positive test
result:
LR+ = infinite
Pre test probability: 80%
Est. Post-test probability: 100%
• The patient had a negative test result
LR- = 0.06
Pre test probability = 80%
Est. Post test probability = 17%
• After arriving at a post-test probability of disease, we can now make a clinical decision.

Initially our pre test probability was at 80% putting us into the testing
range, after the test, the post test probability is now at 100% moving
us out of the testing range and now into the therapeutic range. We can
now stop testing and begin treatment of the patient
 MEMBERS
SUBGROUP 4 SUBGROUP 5
⊡ Ceñidoza, Daryl Anne Idos ⊡ Abraham, Shanon
⊡ Dobaria, Devang Arvindbhai ⊡ Adedoja, Maria Emilia
⊡ Kunadiya Pratixa Jitendrakumar ⊡ Babia, Riddhi
⊡ Ladumor, Sumit Babubhai ⊡ Bhavika Kirplani
⊡ Lutrania, Karen Grace Lictao ⊡ Baraiya, Atul
⊡ Magwilang Ajvine Guitelen ⊡ Bankwhot Nuhu
⊡ Mandalupa, Mark Anthony Arellano ⊡ Baskaran, Sam
⊡ Mangati, Gerina Girlie Mae Barry ⊡ Plete, Apollo
⊡ Patel, Manav Pareshkumar ⊡ Quemi, Juan
⊡ Patel, Pujan Ravindra ⊡ Shylaja Selvaraju