What is the best course of action for an elderly male patient with a history of compensated condition, presenting with fever, vomiting, and hypoxemia, who refuses to have his vital signs taken?

Management of Elderly Male with Fever, Vomiting, Hypoxemia, and Refusal of Vital Signs

This patient requires immediate pulse oximetry and chest radiography to rule out pneumonia, followed by empiric broad-spectrum antibiotics and transfer to an acute care facility if hypoxemia is confirmed, regardless of the patient's initial refusal of vital signs. 1

Immediate Priority: Document Hypoxemia Despite Refusal

• Pulse oximetry is non-invasive and should be performed immediately even when patients refuse traditional vital signs, as oxygen saturation <90% is a critical predictor of mortality and need for hospitalization in elderly patients with suspected infection 1
• The documented O2 saturation of 92% already indicates hypoxemia and warrants urgent evaluation for pneumonia, as oxygen saturation <94% has 80% sensitivity and 91% specificity for pneumonia diagnosis in febrile nursing home residents 1
• Fever (100.2°F) combined with hypoxemia (92%) and vomiting constitutes a high-risk presentation requiring immediate intervention, as bacteremia mortality rates in elderly patients reach 20-35%, with 50% of deaths occurring within 24 hours of diagnosis 1

Clinical Assessment Without Full Vital Signs

• Focus on respiratory rate assessment, as rates >25 breaths/min combined with O2 saturation <90% predict impending respiratory failure requiring ICU admission 1
• Nonspecific symptoms including vomiting, lethargy, and confusion are frequently the presenting signs of bacteremia in elderly patients, occurring even before classic sepsis criteria are met 1
• The patient's refusal of vital signs does not eliminate the need for critical diagnostic testing—chest radiography and pulse oximetry should proceed as these are essential for diagnosis and disposition decisions 1

Diagnostic Workup

• Obtain portable chest radiograph immediately to identify pneumonia infiltrates, as 75-90% of chest radiographs show evidence of acute pneumonia when obtained for suspected LTCF-acquired pneumonia 1
• Chest radiography is mandatory when hypoxemia is documented or suspected, to exclude multi-lobe infiltrates, large pleural effusions, congestive heart failure, or mass lesions 1
• Perform sepsis screening with blood cultures before antibiotics if feasible, as bacteremia occurs in approximately 6% of LTCF infections, with urinary tract (55%) and respiratory tract (10%) being the most common sources 1

Immediate Treatment Interventions

• Start empiric broad-spectrum antibiotics immediately without waiting for culture results, as mortality is highest in bacteremic pneumonia (50%) and early treatment is critical 1
• Administer supplemental oxygen to maintain SpO2 >90%, as hypoxemia (PaO2 <60 mmHg or SpO2 <90%) is a major indicator in the Pneumonia Prognosis Index for short-term mortality 1
• Consider IV fluid resuscitation given the vomiting episode, as dehydration combined with infection increases risk of hypotension and organ dysfunction 1

Disposition Decision

• Transfer to acute care facility is indicated based on hypoxemia alone (O2 sat 92%), as this meets criteria for hospital admission regardless of other risk factors 1
• The combination of fever, hypoxemia, and gastrointestinal symptoms (vomiting) places this patient at high risk for complications including respiratory failure, bacteremia, and death 1
• Oxygen saturation <90% was added as a sole indicator for hospital admission in PSI risk classes I-III as a "margin of safety" in clinical trials, and this patient's 92% saturation approaches that threshold 1

Common Pitfalls to Avoid

• Do not delay treatment while attempting to obtain full vital signs from a refusing patient—pulse oximetry and respiratory rate can be assessed with minimal cooperation and provide critical prognostic information 1
• Do not assume the patient is stable based on relatively preserved mental status, as elderly patients with bacteremia frequently present with nonspecific symptoms and can deteriorate rapidly 1
• Do not withhold chest radiography due to patient refusal of other assessments—portable radiography is essential for diagnosis and can be performed with minimal patient cooperation 1
• Avoid attributing symptoms solely to a benign cause (e.g., viral gastroenteritis) when hypoxemia is present, as this combination suggests serious bacterial infection requiring immediate intervention 1