What is the best course of action for a patient in their 40s with no comorbidities, presenting with chills, diarrhea, fatigue, and headache for 3 days, who tested positive for COVID-19 at home, has normal vitals, a normal physical exam, and is able to tolerate oral (PO) fluids?

Management of Mild COVID-19 in Low-Risk Outpatient

This patient should be discharged home with supportive care instructions, symptom monitoring guidance, and isolation precautions—no antiviral therapy is indicated given their age, lack of comorbidities, and stable clinical status. 1

Immediate Disposition

Discharge from urgent care is appropriate for this patient who presents with:

• Normal vital signs indicating hemodynamic stability 2
• Ability to tolerate oral fluids, confirming adequate hydration 2
• No respiratory distress or hypoxemia 1
• Age in 40s with no comorbidities, placing them at low risk for progression to severe disease 1, 3

Antiviral Therapy Decision

Do not prescribe nirmatrelvir/ritonavir (Paxlovid) or other antivirals for this patient because:

• Antivirals are indicated only for patients at high risk for progression to severe COVID-19, including hospitalization or death 1, 3
• This patient lacks high-risk features: they are in their 40s with no comorbidities 3
• Paxlovid must be initiated within 5 days of symptom onset (this patient is on day 3), but the indication itself is not met 3
• The risk-benefit calculation does not favor antiviral use in low-risk patients, particularly given significant drug-drug interactions with ritonavir 3

Supportive Care Instructions

Provide the following discharge guidance:

Symptomatic management:

• Acetaminophen or NSAIDs for fever, headache, and myalgias 4
• Maintain adequate oral hydration to replace fluid losses from diarrhea 2
• Rest and avoid strenuous activity during acute illness 4

Gastrointestinal symptoms monitoring:

• The patient's diarrhea is a recognized manifestation of COVID-19, occurring in 15-37% of patients 2
• GI symptoms may persist or precede respiratory symptoms by several days 2
• Patients with GI symptoms may experience illness duration of 1 week or longer (33% vs 22% without GI symptoms) 2

Red Flag Symptoms Requiring Re-evaluation

Instruct the patient to return immediately or call 911 if they develop:

• Shortness of breath or difficulty breathing 1, 5
• Persistent chest pain or pressure 5
• New confusion or inability to stay awake 5
• Bluish lips or face indicating hypoxemia 1
• Inability to tolerate oral fluids or worsening diarrhea leading to dehydration 2
• Persistent fever >3 days despite antipyretics 4

Isolation and Infection Control

Provide clear isolation instructions:

• Isolate at home for at least 5 days from symptom onset 1
• Patient can end isolation after day 5 if fever-free for 24 hours without antipyretics and symptoms are improving 1
• Wear a mask around others for 10 days total 1
• Avoid contact with immunocompromised individuals and high-risk contacts 2

Follow-up Monitoring

Arrange appropriate follow-up:

• Telephone follow-up in 48-72 hours to assess symptom progression 2
• Monitor for development of respiratory symptoms, as GI symptoms may precede typical COVID-19 manifestations 2
• Be aware that fatigue, headache, and other symptoms may persist for weeks to months in some patients (post-acute COVID-19 syndrome) 6
• No routine laboratory testing or imaging is needed for this stable outpatient 2

Common Pitfalls to Avoid

• Do not prescribe antibiotics unless there is clear evidence of bacterial superinfection, which is not present in this case 1
• Do not order stool testing for COVID-19 diagnosis or monitoring—there is inadequate evidence to support this practice 2
• Do not use hydroxychloroquine/chloroquine with azithromycin or lopinavir-ritonavir—these combinations are not recommended 1, 4
• Do not assume all symptoms will resolve quickly—counsel patients that some may experience prolonged symptoms lasting weeks to months 6