How to manage a patient with severe symptoms including sore throat, shortness of breath, and high fever, who requests limited diagnostic workup due to cost?

Management of Patient with Severe Symptoms Suggestive of Respiratory Infection

Given this patient's constellation of symptoms including high fever, shortness of breath, myalgia, and sore throat, a comprehensive evaluation for both COVID-19 and other respiratory infections is necessary, despite the patient's request for limited testing due to cost concerns.

Clinical Assessment

The patient presents with concerning symptoms that require thorough evaluation:

• Fever of 103.0°F (39.4°C) for 2 days
• Sore throat (ST)
• Swollen glands
• Shortness of breath (SOB)
• Headache (HA)
• Weakness
• Body aches (BA)
• Joint, neck, and back pain
• Myalgia for the past couple of days

Red Flags in Presentation

• High fever (>102°F) for multiple days
• Shortness of breath
• Systemic symptoms (weakness, body aches)

Diagnostic Approach

While the patient only wants testing for strep throat due to cost concerns, the presentation warrants a more comprehensive evaluation due to:

1. Pneumonia risk assessment: The patient meets criteria for suspected pneumonia with acute cough, dyspnea, and fever >4 days 1. These symptoms significantly increase mortality risk if untreated.

2. COVID-19 consideration: The symptom profile (fever >38.5°C, breathing difficulties, myalgia) is consistent with possible COVID-19 infection 1. During pandemic conditions, COVID-19 screening is recommended for patients with these symptoms.

3. Severity indicators: The presence of systemic symptoms (altered mental status, dyspnea, and weakness) are significant predictors of severe sepsis development (OR = 2.24-4.29) 2.

Recommended Testing

Based on the clinical presentation and evidence-based guidelines:

1. Strep throat testing: Perform rapid strep test as requested by patient

2. Additional essential testing:

   • COVID-19 screening via RT-PCR nasopharyngeal swab 1
   • Chest imaging (options in order of preference):
     • Chest X-ray (if available) 1
     • Lung ultrasound (if skilled provider available) 1
   • Basic laboratory tests:
     • Complete blood count with differential to assess for leukocytosis and left shift 3
     • C-reactive protein if available (values >50 mg/mL suggest pneumonia) 1

Management Approach

1. If pneumonia is suspected (based on focal chest signs, dyspnea, tachypnea, or fever >4 days):

   • Initiate appropriate antibiotic therapy
   • Consider hospital admission if severe symptoms persist

2. If COVID-19 is suspected:

   • Implement appropriate isolation protocols
   • Provide supportive care
   • Consider antiviral therapy if appropriate

3. Cost-sensitive approach:

   • Explain to patient that while strep testing alone is insufficient given the severity of symptoms
   • Focus on the most high-yield, cost-effective tests first
   • Emphasize that untreated pneumonia or severe COVID-19 would ultimately result in much higher costs and potential mortality

Patient Communication

When discussing with the patient about the need for additional testing beyond strep:

• Explain that systemic symptoms (fever >102°F, shortness of breath, widespread pain) indicate a potentially serious infection
• Discuss how early diagnosis and treatment of pneumonia or COVID-19 significantly reduces hospitalization risk and improves outcomes
• Explore financial assistance options or payment plans if available

Follow-up Recommendations

• Close follow-up within 24-48 hours if outpatient management is chosen
• Clear return precautions for worsening shortness of breath, persistent high fever, or altered mental status
• Consider telehealth follow-up to minimize additional costs if appropriate