The coronavirus disease 2019 (COVID-19) pandemic is now established on the African continent, with cases rapidly increasing in Malawi (1742 confirmed cases and 19 deaths as of 5 July 20201). Clinicians require guidelines, deliverable in the Malawi context, to effectively and safely treat patients for the best possible outcome. In Malawi, key public messages around social distancing, hand washing and shielding for at-risk individuals have been widely distributed by the Ministry of Health. However, it has not been possible to implement strict lockdown measures in Malawi due to the risk of widespread economic disruption, hunger, worsened food insecurity, risk of violence and mass political rallies2. Testing rates are low such that the number of confirmed cases in Malawi is likely to significantly under-represent the actual number of cases. As the epidemic unfolds, it is vital that doctors implement standardised case management guidelines to improve survival for patients who require hospital admission. The majority of patients hospitalised with COVID-19 require medical-ward level care, including provision of adequate oxygen3. Increased oxygen provision has been a major focus of COVID-19 preparedness activities in Malawi4. We report a case of a 46-year-old male who was admitted to Queen Elizabeth Central Hospital on 17 June 2020, complaining of exertional dyspnoea after a 10-day history of dry cough and fevers. Patient consent was obtained for this case report. Other than obesity, he had no other significant medical problems and was HIV seronegative. He was a lifelong non-smoker and consumed 30–40 units of alcohol per week. Shortness of breath had appeared over a period of 2 days accompanied by pleuritic chest pain upon coughing. There was no recent foreign travel or contact with COVID-19 suspects. He was strongly suspected of COVID-19 disease due to reported symptoms of fever, dry cough and worsening shortness of breath and was admitted directly to a hospital ward specifically created for the isolation and treatment of such patients. Staff received the patient wearing appropriate personal protective equipment (PPE: gloves, gown, visor and N95 mask) in line with international guidance5. He was transported into an isolation ward in the hospital by a family member and walked into the bespoke high dependency area. This ward was designed specifically for COVID-19 care delivery including PPE donning and doffing areas and infection control and prevention movement and cleaning measures. Negative pressure facilities were not available. Subsequently, family members were not permitted to visit the patient. This area included provision of piped oxygen and continuous monitoring equipment. The patient was clearly dyspnoeic upon arrival with a respiratory rate of 30 breaths/min and unable to speak in full sentences; accessory muscle use was not observed. His oxygen saturations were immediately measured in advance of further medical history and examination and demonstrated SpO2 of 68% and heart rate (HR) 110 beats/min (bpm) without supplemental oxygen. The patient was immediately treated with oxygen (15 L non-rebreather reservoir bag FiO2 ∼0.6) with improvement in SpO2 to 92% and HR 98 bpm. The patient had a normal blood pressure, 138/86 mmHg. The patient was orientated in time and place and did not demonstrate signs of confusion during the admission. The patient was afebrile but reported subjective fevers prior to admission.