Female
Assignment Instructions:
JL is a 65-year-old female seen in the clinic today. She presents with fatigue, brain fog,
sore throat and temperature of 99.1. She reports that symptoms began three days ago with
a sore throat and have progressively worsened. She also mentions loss of appetite.
Oxygen sat 97%, respiratory rate 17, bp 122/73. Her rapid COVID-19 antigen test is
positive. Chest x-ray is clear, no signs of pneumonia. Current medication includes
atorvastatin 40 mg po daily. What treatment plan would you implement for JL (include
complete medication order)? What patient education and monitoring would you provide?
, Introduction and Case Summary
JL is a 65-year-old woman presenting with mild COVID-19 symptoms including fatigue,
sore throat, low-grade fever (99.1°F), and brain fog. Her vital signs are stable, oxygen
saturation is 97%, and her chest x-ray shows no signs of pneumonia. The positive rapid
antigen test confirms COVID-19 infection. Given her age and comorbid medication use
(atorvastatin 40 mg daily), JL is at increased risk for disease progression. The goal of
treatment is to prevent severe illness, minimize symptom duration, and reduce viral
transmission.
Assessment and Diagnosis
The clinical presentation is consistent with mild COVID-19 infection according to CDC
and NIH definitions. Mild cases are characterized by the presence of respiratory
symptoms without hypoxia (SpO₂ ≥ 94%) or evidence of pneumonia. JL’s risk factors,
including her age (>65 years), increase her eligibility for early outpatient antiviral therapy
(CDC, 2024). A comprehensive assessment should include medication review for
potential drug interactions, particularly concerning statins and antiviral agents such as
nirmatrelvir/ritonavir (Paxlovid).
Treatment Plan and Medication Orders
The primary treatment goal for JL is to reduce viral replication and prevent
hospitalization. According to current CDC and IDSA guidelines (2024), outpatient
treatment for mild to moderate COVID-19 in high-risk adults should include antiviral
therapy if started within 5 days of symptom onset.