"...it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of light, it was the season of darkness, it was the spring of hope, it was the winter of despair."

A couple stories of what COVID-19 coronavirus has looked like for me (with clinical details changed). I saw two separate patients who were both "COVID rule-outs." Our tests have been taking a while to come back (another topic of great angst), so we have many patients who are in isolation, awaiting the results of their test.

The first, an elderly gentleman with a longstanding cardiac history, is sent by his primary care physician with low-grade fever and shortness of breath. In the emergency department, his oxygen levels are low, and I am called in consultation. When I looked at his clinical picture, my first gestalt is that he does not have coronavirus - he has two separate processes, a urinary tract infection and congestive heart failure. The coronavirus testing - while necessary given the degree of community prevalence - created a lot of angst for the patient, his family, and our staff. Even transporting him from the emergency department to the intensive care unit required a parade lead by security who cleared the path, followed by a fully attired (bunny suit) nurse, respiratory therapist, and transporter, caboosed by our environmental services staff to clean the route. But when I told him I thought coronavirus was unlikely, the tension in his face melted. Fortunately, my clinical gestalt was correct, his test came back negative, he improved with antibiotics and diuretics, and he left intensive care two days later.

The second, a young gentleman, immunocompromised from melanoma treatment, had traveled three weeks earlier. Since then, he has been fighting malaise, fever, chills, and a persistent dry cough. His chest X-ray suggested the "ground-glass" worrisome for coronavirus. (Radiologists love similes with unfamiliar objects. What's ground-glass? What's crazy-paving? What's a snowstorm? How being Californian has sheltered me). Even before we learned the results of his test, his lungs were failing. Because our suspicion was so high, we were prepared when he began to decompensate.

What do these stories suggest to me? Despite our inability to test widely and the delays in receiving results of the tests, clinical judgment still has a role. In pediatrics, we learn the mantra "not all wheezing is asthma," and here, not all fever and shortness of breath is coronavirus. Although we treat all our rule-outs with caution, isolation, and personal protection, their probabilities can differ widely, and we have to remain vigilant for other processes that we may overlook in our anxiety about COVID. On the other hand, some presentations are so concerning for coronavirus that the test is only confirmation. In these situations, what can we do but face this disease head-on, with courage and resolve.