What is the appropriate outpatient management for a 41-year-old woman with three days of high-grade fever, chills, sore throat, vomiting, dizziness, and confirmed COVID-19 infection?

Management of COVID-19 Positive Patient with High-Grade Fever, Vomiting, and Dizziness

This patient requires urgent evaluation for dehydration and potential clinical deterioration, with consideration for hospital-based assessment rather than routine outpatient management, given the combination of persistent vomiting for 3 days, dizziness, and high-grade fever.

Immediate Assessment and Triage

Assess clinical stability urgently to determine if outpatient management is appropriate or if hospital evaluation is needed:

• Evaluate hydration status: 3 days of vomiting with dizziness strongly suggests dehydration or orthostatic hypotension, which may require IV fluid resuscitation 1
• Check vital signs: Monitor oxygen saturation (should be >90-96%), respiratory rate, heart rate, and blood pressure 1, 2
• Assess for warning signs of deterioration: Increased work of breathing, inability to maintain oral hydration, worsening respiratory symptoms, or persistent high fever despite antipyretics 1

Decision Point: Outpatient vs. Hospital Care

If the patient cannot maintain adequate oral hydration due to persistent vomiting, hospital evaluation is necessary 1. The dizziness combined with 3 days of vomiting represents a red flag that outpatient management may be insufficient.

If clinically stable with adequate hydration: Proceed with outpatient management with close monitoring 3

Outpatient Management (Only if Clinically Stable)

Antiviral Therapy

Consider PAXLOVID (nirmatrelvir-ritonavir) if within 5 days of symptom onset and patient has risk factors for severe disease:

• Dosing: 300 mg nirmatrelvir (two 150 mg tablets) with 100 mg ritonavir (one 100 mg tablet) taken together orally twice daily for 5 days 4
• Timing: Must be initiated within 5 days of symptom onset 4
• Critical consideration: Review ALL medications for drug-drug interactions with ritonavir (strong CYP3A inhibitor) before prescribing 4
• Can be taken with or without food 4

Symptomatic Management

For fever control (102°F/38.9°C):

• Ibuprofen 200 mg orally every 4-6 hours (maximum 4 times in 24 hours) 5
• Alternative: Acetaminophen for pain and fever control 1

For vomiting and nausea:

• Anti-emetics are indicated given 3 days of persistent vomiting 1
• Monitor QTc interval if combining with other medications 1
• Aggressive oral rehydration is essential 1

For sore throat with bacterial pharyngitis consideration:

• The combination of fever, chills, and sore throat raises concern for bacterial superinfection 5
• If white plaques present on tonsils or clinical suspicion of bacterial pharyngitis: Consider azithromycin as first-line therapy 5
• Alternative antibiotics: Amoxicillin or fluoroquinolones if azithromycin contraindicated 5

Monitoring Requirements

Close outpatient monitoring is mandatory 3:

• Daily telephone or telemedicine follow-up for the first 48-72 hours 5, 3
• Monitor for: Worsening respiratory symptoms, inability to maintain hydration, new fever patterns, signs of secondary bacterial infection 1
• Reassess within 48-72 hours if antibiotics started 5

Red Flags Requiring Hospital Evaluation

Immediate escalation of care is needed if 1:

• Worsening respiratory status (increased work of breathing, decreasing oxygen saturation)
• Inability to maintain adequate oral hydration despite anti-emetics
• Development of new symptoms suggesting clinical deterioration
• Persistent dizziness suggesting significant dehydration or orthostatic hypotension

Isolation and Infection Control

Home isolation with strict precautions 3:

• Complete 5-day treatment course with continued isolation per public health recommendations 4
• Patient must be monitored for compliance with isolation rules 3
• If isolation rules are jeopardized, alternative monitored isolation may be required 3

Common Pitfalls to Avoid

• Do not underestimate dehydration: 3 days of vomiting with dizziness is concerning and may require IV hydration 1
• Do not miss bacterial superinfection: Monitor for signs of secondary bacterial infection, particularly with persistent fever and sore throat 1, 5
• Do not delay PAXLOVID: If indicated, must be started within 5 days of symptom onset 4
• Do not ignore drug interactions: Ritonavir has significant drug-drug interactions that can be life-threatening 4
• Do not use antibiotics empirically without clinical indication: Avoid unnecessary broad-spectrum antibiotics without evidence of bacterial infection 1