What is the recommended workup and management for a 58-year-old female presenting to the emergency room (ER) with 11 days of flu-like symptoms and lethargy for the last 3 days?

Management of a 58-Year-Old Female with Flu-Like Symptoms and Lethargy

A 58-year-old female with 11 days of flu-like symptoms and 3 days of lethargy requires comprehensive assessment for potential influenza complications, with immediate evaluation of vital signs, respiratory status, and hydration status to guide appropriate treatment decisions.

Initial Assessment and Workup

Vital Signs and Clinical Evaluation

• Monitor temperature, respiratory rate, pulse, blood pressure, mental status, and oxygen saturation 1
• Assess for signs of respiratory distress, dehydration, and altered mental status
• Calculate CURB-65 score to determine pneumonia severity if respiratory symptoms present

Laboratory and Diagnostic Testing

• Complete blood count with differential
• Basic metabolic panel to assess renal function and electrolyte status
• If respiratory symptoms present:
  • Chest X-ray to evaluate for pneumonia
  • Blood cultures (if severe illness suspected)
  • Sputum Gram stain and culture if productive cough present 1

Risk Stratification

• Assess for unstable clinical factors that would necessitate hospitalization:
  • Temperature >37.8°C
  • Heart rate >100/min
  • Respiratory rate >24/min
  • Systolic blood pressure <90 mmHg
  • Oxygen saturation <90%
  • Inability to maintain oral intake
  • Abnormal mental status 1, 2

Management Recommendations

Antiviral Considerations

• Antiviral treatment with oseltamivir is typically only recommended if:

  • Symptoms started within the last 2 days
  • Patient has fever >38°C
  • Patient has acute influenza-like illness 1

• However, given the patient's age (58) and prolonged symptoms with lethargy, consider antiviral treatment despite symptom duration >48 hours, as hospitalized patients who are severely ill may benefit from delayed antiviral treatment 1

  • Standard dosing: Oseltamivir 75 mg every 12 hours for 5 days (adjust for renal function if needed) 1

Antibiotic Considerations

• If no evidence of pneumonia and patient is otherwise healthy, antibiotics are not routinely required 1

• Consider antibiotics if:

  • Patient has worsening symptoms (recrudescent fever or increasing dyspnoea)
  • Lower respiratory symptoms are present
  • Patient has risk factors for complications 1

• If antibiotics indicated:

  • For non-severe illness: Oral co-amoxiclav or tetracycline
  • Alternative options: Macrolide (clarithromycin or erythromycin) or respiratory fluoroquinolone 1

Supportive Care

• Ensure adequate hydration - IV fluids if unable to maintain oral intake
• Oxygen therapy if hypoxic (aim for SaO2 ≥92%)
• Antipyretics for fever management
• Nutritional support for prolonged illness 1, 2

Hospitalization Criteria

• Consider hospital admission if two or more of the following unstable clinical factors are present:

  • Temperature >37.8°C
  • Heart rate >100/min
  • Respiratory rate >24/min
  • Systolic blood pressure <90 mmHg
  • Oxygen saturation <90%
  • Inability to maintain oral intake
  • Abnormal mental status 1, 2

• The presence of lethargy for 3 days is particularly concerning and may indicate:

  • Dehydration
  • Pneumonia or other complications
  • Potential neurological complications of influenza 3

Monitoring and Follow-up

• If hospitalized:

  • Monitor vital signs at least twice daily
  • Use Early Warning Score system for tracking clinical status 1
  • Review 24 hours prior to discharge to ensure stability

• If managed as outpatient:

  • Clear instructions for when to seek immediate medical attention
  • Follow-up within 24-48 hours to assess clinical improvement
  • Consider follow-up clinical review for any patient with significant complications 1

Special Considerations

• Lethargy after 11 days of symptoms raises concern for complications such as:

  • Secondary bacterial pneumonia
  • Dehydration
  • Potential neurological complications of influenza
  • Other viral or bacterial co-infections 4

• The prolonged duration of symptoms (11 days) is atypical for uncomplicated influenza, which typically resolves within 7 days, suggesting possible complications requiring thorough evaluation 5, 6