Next Steps for a 64-Year-Old Female Patient with Stable Vitals, Normal Blood Work, and Negative COVID-19, Flu, and RSV Tests
The next step for this 64-year-old female patient with stable vitals, normal blood work, and negative COVID-19, flu, and RSV tests is to conduct a focused cardiopulmonary evaluation to determine the underlying cause of her symptoms.
Initial Assessment
Since the patient has stable vitals and normal blood work, with negative tests for common respiratory viruses, a systematic approach is needed to identify the cause of her presentation:
Recommended Diagnostic Workup:
Cardiopulmonary Evaluation 1:
- ECG to assess for cardiac abnormalities
- Chest imaging (X-ray and/or CT) to evaluate for pneumonia or other pulmonary pathology
- Echocardiogram to assess cardiac function
- Ambulatory rhythm monitor if palpitations or irregular heartbeat is reported
Additional Laboratory Testing 1:
- Procalcitonin level to help determine if bacterial infection is present
- Sputum and blood cultures if bacterial pneumonia is suspected, particularly if there are concerns for multidrug-resistant pathogens
- C-reactive protein to assess inflammation
Clinical Decision Making
If Respiratory Symptoms Are Present:
Consider empiric antibiotics if community-acquired pneumonia (CAP) is suspected despite negative COVID-19, flu, and RSV tests 1
- For low-risk patients: β-lactam (ampicillin-sulbactam, ceftriaxone, or cefotaxime) plus either a macrolide (azithromycin or clarithromycin) or doxycycline
- For high-risk patients: β-lactam plus macrolide or β-lactam plus fluoroquinolone
Important consideration: A low procalcitonin value early in the course of illness may guide withholding or early stopping of antibiotics, especially in patients with less severe disease 1
If Cardiovascular Symptoms Are Present:
- Cardiology consultation is recommended if there are 1:
- Abnormal cardiac test results
- Persistent cardiopulmonary symptoms not otherwise explained
- Known cardiovascular disease with new or worsening symptoms
If Tachycardia or Exercise Intolerance Is Present:
- Perform a 10-minute active stand test to assess for orthostatic hypotension or postural orthostatic tachycardia syndrome (POTS) 1
Special Considerations
Age-related factors: At 64 years old, this patient is at increased risk for cardiovascular disease, which may become clinically evident during or after an acute illness 1
Antibiotic stewardship: Despite empiric use of antibiotics in some COVID-19 patients during the pandemic, there is no justifiable rationale for antimicrobial use in patients without evidence of bacterial infection 2, 3
Post-acute sequelae: Consider evaluation for post-acute sequelae if the patient has recently recovered from COVID-19 but has persistent symptoms 1
Pitfalls to Avoid
Overuse of antibiotics: Do not prescribe antibiotics empirically without evidence of bacterial infection, as this contributes to antimicrobial resistance 2, 3
Missing non-infectious causes: Don't focus exclusively on infectious etiologies; consider cardiac, pulmonary, or systemic conditions that may present with similar symptoms
Incomplete evaluation: Ensure comprehensive assessment before attributing symptoms to a specific cause or discharging the patient
Ignoring age-related risks: Remember that this 64-year-old patient has increased risk factors for cardiovascular disease that may require specific attention
By following this systematic approach, you can determine the underlying cause of this patient's presentation and develop an appropriate treatment plan based on the specific diagnosis identified through the evaluation.