What should be done next for an elderly patient with fever, malaise, cough, nausea, vomiting, hypotension, and tachycardia?

Management of Elderly Patient with Sepsis

For an elderly patient from an ALF presenting with fever, malaise, cough, nausea, vomiting, hypotension (BP 85/40), and tachycardia (HR 120), the next step after initial fluid bolus should be to place a central line and start norepinephrine (option C).

Rationale for Vasopressor Therapy

• The patient is presenting with clear signs of septic shock: fever (101.5°F), hypotension (85/40 mmHg), and tachycardia (120 bpm) 1
• According to the American College of Cardiology, if hypotension persists after two fluid boluses, vasopressor therapy with norepinephrine should be initiated, which requires central line placement 1
• The patient's blood pressure of 85/40 mmHg indicates shock, which requires immediate intervention to prevent organ damage and death 1

Why This Takes Priority Over Other Options

• While influenza testing and droplet precautions (option A) are important, especially during influenza season, they do not address the immediate life-threatening hypotension which requires vasopressor support 1
• Metronidazole 500mg TID (option B) targets anaerobic bacteria and is not appropriate first-line therapy for suspected influenza or community-acquired pneumonia 1
• Loperamide (option D) is contraindicated in patients with suspected infectious diarrhea and would not address the patient's primary issues of respiratory symptoms and hemodynamic instability 1

Clinical Presentation Analysis

• The constellation of fever, malaise, cough, nausea, and vomiting in an elderly patient from an assisted living facility during winter (January) strongly suggests sepsis, likely from influenza or secondary bacterial pneumonia 1
• Elderly patients from long-term care facilities are at high risk for influenza complications and secondary bacterial pneumonia 1
• The presentation of infection in elderly patients may be atypical, with fewer classic symptoms and more functional decline 1

Additional Immediate Management Steps

• After initiating vasopressors, place the patient in droplet precautions and perform influenza testing, as recommended by the American Geriatrics Society and CDC 1, 2
• Rapid influenza diagnostic testing has high specificity (98%) and sensitivity (94%) compared to laboratory methods, enabling faster decision-making regarding isolation and treatment 3
• Obtain complete blood count, comprehensive metabolic panel, lactate, blood cultures, and chest radiography 1
• Monitor oxygen saturation, as levels <90% predict short-term mortality and respiratory failure 1

Common Pitfalls to Avoid

• Do not delay vasopressor therapy while waiting for additional fluid boluses if the patient remains hypotensive after initial fluid resuscitation 1
• Do not overlook the need for droplet precautions after addressing the hemodynamic instability, as nosocomial influenza can lead to significant morbidity and increased healthcare costs 4
• Do not assume that gastrointestinal symptoms (nausea and vomiting) indicate primary gastrointestinal infection; these can be manifestations of systemic infection including influenza 5
• Do not miss the opportunity for early antiviral therapy, which is most beneficial when started within 24 hours of symptom onset 5