What is the best course of action for an elderly patient presenting with a sore throat, productive cough, nausea, shortness of breath (SOB), sweating, and lethargy, without fever, and with negative tests for influenza (flu), COVID-19, respiratory syncytial virus (RSV), and streptococcal (strep) infection, over the past 5 days?

Management of Elderly Patient with Respiratory Symptoms and Negative Viral Testing

This elderly patient requires urgent chest imaging (chest X-ray or CT scan) and empiric antibiotic therapy for community-acquired pneumonia, as the constellation of productive cough, shortness of breath, sweating, and lethargy over 5 days—despite negative viral tests—strongly suggests bacterial pneumonia, which carries significant mortality risk in the elderly. 1

Immediate Diagnostic Workup

Chest Imaging is Critical

• Obtain chest X-ray or CT scan immediately to evaluate for pneumonia, as shortness of breath with productive cough and systemic symptoms (sweating, lethargy, nausea) in an elderly patient suggests lower respiratory tract infection 2, 1
• The absence of fever does not rule out serious bacterial infection, particularly in elderly patients who may have blunted fever responses 3, 4
• Chest imaging will help differentiate pneumonia from other serious conditions and guide antibiotic selection 2

Laboratory Testing

• Obtain complete blood count with differential, looking for leukocytosis or lymphopenia 2
• Check inflammatory markers including C-reactive protein, procalcitonin if available 2
• Assess renal function and electrolytes given nausea and potential dehydration 2
• Consider blood cultures if patient appears systemically ill 2

Empiric Antibiotic Therapy

Start Antibiotics Immediately

• Initiate empiric antibiotics for community-acquired pneumonia without waiting for culture results, as bacterial pneumonia is the most likely diagnosis given productive cough, dyspnea, and systemic symptoms 2, 5
• Appropriate regimens include:
  • Amoxicillin plus azithromycin 2, 5
  • Fluoroquinolone monotherapy (levofloxacin or moxifloxacin) 2
  • Azithromycin alone may be considered for less severe presentations 2, 5

Rationale for Empiric Treatment

• Bacterial co-infection or secondary bacterial pneumonia occurs in approximately 40% of viral respiratory infections requiring hospitalization 2
• Waiting for clinical deterioration before starting antibiotics causes preventable harm, particularly in elderly patients 2
• The productive cough suggests bacterial involvement, as viral infections typically cause dry cough 1, 6

Evaluation for Life-Threatening Complications

Rule Out Severe Pharyngeal Infections

Given the sore throat component, evaluate for dangerous complications 2, 3:

• Assess for peritonsillar abscess: Look for unilateral tonsillar swelling, uvular deviation, trismus, "hot potato voice" 3, 4
• Evaluate for retropharyngeal abscess: Check for neck stiffness, neck tenderness or swelling, drooling 3, 4
• Consider Lemierre syndrome: Particularly important in severe pharyngitis with systemic symptoms; caused by Fusobacterium necrophorum and can progress to life-threatening septic thrombophlebitis 2, 3
• Physical examination should specifically assess for drooling, difficulty swallowing, neck tenderness/swelling, and tonsillar asymmetry 3, 4

COVID-19 Considerations Despite Negative Test

Repeat Testing May Be Warranted

• Consider repeat COVID-19 RT-PCR testing if symptoms persist or worsen, as false negatives are common, particularly with timing of sample collection relative to symptom onset 1
• The sensitivity of nasopharyngeal RT-PCR ranges only 60-78% 1
• This patient's symptom profile (sore throat, productive cough, nausea, shortness of breath, sweating, lethargy) overlaps significantly with COVID-19 presentations 1, 6, 7

Atypical COVID-19 Presentations

• Approximately 13.6% of COVID-19 patients present without respiratory symptoms at hospital admission 7
• Absence of fever does not exclude COVID-19, as not all patients develop fever 1, 7
• Gastrointestinal symptoms (nausea) occur in COVID-19 and may precede respiratory symptoms 2, 1

Monitoring and Follow-Up

Close Observation Required

• Re-evaluate within 24-48 hours or sooner if symptoms worsen 1
• Monitor for progression to severe disease, particularly:
  • Respiratory rate ≥30 breaths/min 1
  • Oxygen saturation ≤93% 1
  • Worsening dyspnea or new chest pain 1
  • Development of fever >38.5°C 1

Symptomatic Management

• Provide analgesic therapy with acetaminophen or ibuprofen for sore throat pain 2, 3
• Ensure adequate hydration given nausea 2
• Supplemental oxygen if hypoxemic 1

Critical Clinical Pitfalls to Avoid

Do Not Delay Treatment

• Do not wait for culture results or clinical deterioration before starting antibiotics in an elderly patient with signs of lower respiratory tract infection 2
• The principle of "do no harm" in this pandemic era means preventing deterioration through early empiric treatment 2

Do Not Dismiss Absence of Fever

• Elderly patients and those with serious infections may not mount a fever response 3, 4
• The absence of fever does not rule out bacterial pneumonia, peritonsillar abscess, or other serious infections 3, 4

Do Not Ignore the Sore Throat

• While focusing on pneumonia, ensure severe pharyngeal complications are excluded, as these can be life-threatening and require different management (surgical drainage for abscesses) 2, 3

Consider Co-Infection

• Co-infection with multiple pathogens is possible and can worsen outcomes 1, 8
• Bacterial superinfection can occur even with negative initial viral testing 2