Yale Medicine physicians describe the recovery path they’ve seen for patients experiencing ‘mild to moderate’ forms of the disease.
Unless you or someone you know has been infected with the coronavirus, it may be hard to imagine what it’s like to have COVID-19—and recover from it.
Does it feel like the flu? Is it intense, to the point where you feel like you are fighting for your life? Or is the more common experience one where you have few or no symptoms at all?
The truth is COVID-19 can be some or all of the above. But the majority of cases—an estimated 80%—are mild.
“I would say the number of mild cases may be even higher than 80%, as most states are not screening the general population,” says Andre Sofair, MD, MHS, a Yale Medicine internal medicine physician who has been taking care of patients with mild to moderate COVID-19 at Yale New Haven Hospital. “The average length of stay, based on my experience, is five or six days for patients in the hospital who are not in the ICU. There are some who recover very quickly and get out sooner, and others who end up in the hospital for two weeks-plus.”
Matthew Ellman, MD, director of Yale Internal Medicine Associates, says his practice is taking care of many patients who have not required hospitalization, as well as those who have been hospitalized and returned home.
“Eighty to 85% of our patients who are infected do not need to be hospitalized, but they do require monitoring and medical care, most of which is now taking place with telehealth,” Dr. Ellman says. He says it’s typical for these patients to have a telehealth appointment, either on phone or video, at least every other day for 10 to 14 days from the onset of symptoms.
What is a mild case of COVID-19 like?
Many of those infected with the coronavirus show no symptoms and wouldn’t know they have it unless they were tested, Dr. Ellman notes. “And there are some people with very mild symptoms, who may feel like they have a sore throat, some nasal congestion, a little cough, some achy muscles, and maybe a low-grade fever,” he says.
Symptoms, which can also include shortness of breath, chills, and headache, may appear two to 14 days after virus exposure.
“A loss of sense of smell or taste is also a good clue that you have COVID and not another cold virus,” Dr. Ellman says. “Patients have told me it comes on very abruptly—that one hour they are fine, and the next they can’t smell or taste a thing.”
Some patients, particularly those who are younger and don’t have many or any underlying medical conditions, may feel unwell for a few days or up to a week before they begin to improve, Dr. Ellman says. “But even if they only had mild symptoms and feel normal quickly, we tell them they need to remain isolated, not return to public or work for at least 14 days from the onset of symptoms, and remain fever-free without any medication for three days,” he adds.
Dr. Ellman says some of his patients feel much better before the two-week mark, but that the majority have cold- and flu-like symptoms—though mild—that linger for two weeks or longer.
Drs. Ellman and Sofair both say they have been seeing COVID-19 patients who experience gastrointestinal symptoms, including diarrhea and vomiting. Dr. Ellman says physicians in his practice have encountered some cases of what’s called “COVID toe”—chilblain-like lesions that can occur on the tops of the toes and fingers. It has been reported in some COVID-19 cases, though it is not yet on the CDC’s list of symptoms.
What is a ‘mild to moderate’ case of COVID-19 like?
Patients with mild to moderate symptoms tend to have more respiratory problems and a fever, Dr. Ellman says. “A lot of them describe nighttime fevers and sweats and have a significant cough that can be unsettling. They may also have shortness of breath or a feeling of chest pressure or heaviness,” he adds. “They may feel extremely wiped out. To get up and get a glass of water requires a big effort.”
Some of these patients will recover at home, but it may take longer than the milder cases, Dr. Ellman says. One of his patients, for instance, is a physician in his early 60s; it’s been a month since his symptoms started, and he’s fever-free but still fatigued and coughing.
“I have definitely seen people feel very sick for several weeks, and it can take a while for their strength and stamina to come back,” he adds.
A key point for people with COVID-19 illness occurs between days six and 10 (from the onset of symptoms). At this point, some begin to do better while others who have been feeling terrible continue to feel just as bad. Others may improve slightly for a few days, but then their condition takes a turn for the worse. “Because of this, we closely monitor our patients until at least 10 days out from the onset of symptoms,” Dr. Ellman says. “Even if they have recovered enough, we still check in with them at day 14.”
Dr. Sofair agrees that the first seven to 10 days of illness is usually predictive of which way the virus will go. “If you make it past the two-week window, you are usually OK and start to recover, but during that seven to 14 days is when the illness could take a turn,” he says. “Some of that is related to the virus itself and some of it is the body’s immune system response, which can cause inflammation of the lungs and other organs, including the kidneys and liver.”
What is a ‘moderate to severe’ case of COVID-19 like?
The primary reason people with COVID-19 end up requiring hospitalization is due to respiratory problems, namely low oxygen levels, says Lauren Ferrante, MD, MHS, a Yale Medicine pulmonologist and critical care specialist.
But she says that experiencing the need for oxygen doesn’t mean you’ll become critically ill. “Most COVID-19 patients don’t need ventilators, and most people don’t end up in the ICU,” she notes. Rather, most can be taken care of on the general floor and given oxygen that flows through a tube into their nostrils. “These patients may have respiratory symptoms, particularly with exertion, but overall do well with oxygen. They are alert and often talking to their families on FaceTime.”
Often, the patients who become dangerously ill have other risk factors, including obesity, diabetes, heart or lung disease, cancer, other immune problems, or are over 65, Dr. Sofair says.
These patients may end up in the ICU, requiring higher amounts of oxygen and possibly a ventilator. The sickest may end up with other problems too, notes Dr. Ferrante. “When patients are critically ill, their other organs may start to shut down,” she says.
What does recovery from COVID-19 look like?
Given the spectrum of disease severity, recovery can vary widely.
Acknowledging that “we are still learning,” Dr. Ellman observes that patients who’ve had mild symptoms typically return to their regular lives quickly. “I usually tell patients to be aware of how they are feeling and to listen to their bodies and don’t just get out there and do everything you normally would,” he says. “There can be some lingering effects, including a lack of energy.”
Recovery for hospitalized patients tends to look different, with much depending on a patient’s health status prior to hospital admission, Dr. Sofair says.
“We have had a good number of patients who, by the time they leave the hospital, are back to a good level of functioning,” he says. “And even those with severe heart disease or diabetes may make a good recovery after four or six days in the hospital.”
To avoid losing physical function, Dr. Ferrante advises recovering COVID patients to—if they are able—get out of bed and sit in a chair, walk around their room, and do leg exercises. “If people come into the hospital and spend too much time sitting or lying in bed, they will have more trouble functioning after they go home,” she says.
An estimated 30 to 40% of patients continue to face health challenges after being discharged from the hospital. (To help with these residual symptoms, which are mostly but not exclusively pulmonary, Yale Medicine is in the process of opening a post-COVID clinic.)
The best strategy, of course, is to prevent COVID-19 infection altogether, so doctors encourage people to continue practicing social distancing to avoid exposure. But if you believe you are infected, Dr. Sofair says the most important message he can share is to get yourself tested as soon as possible and, if the result is positive, consult your doctor.
“Generally speaking, most patients can be managed outside of the hospital,” Dr. Sofair says. “But if you start to get sicker, early treatment can prevent complications. If you do need to be admitted to the hospital, that does not mean you will get really sick. Only a minority of patients end up in the ICU. We have had many good outcomes, and our doctors and nurses now have experience treating this.”