[##]-year-old
[male/female] presents with [fever/body aches/upper respiratory symptoms] with
history and exam consistent with [seasonal] influenza.
Initial considerations in this
patient included influenza, bacterial and viral etiologies of upper respiratory
infection (URI), bronchitis, pneumonia, sinusitis, toxic exposure, sepsis,
meningitis, encephalitis, and other pulmonary or cardiac etiologies among
others.
Patient presented with symptoms
suggestive of influenza during appropriate season. Patient noted to
[not] have significant risk factors for complications from influenza
[specifically age less than 2 years/age greater than 65 years/pregnancy through
to 2 weeks after delivery/chronic pulmonary (including asthma), cardiovascular
(except hypertension), renal, hepatic, hematological (including sickle cell
disease), neurologic, neuromuscular, or metabolic disorders (including diabetes
mellitus)/immunosuppression, including that caused by medications or
HIV/persons younger than 19 years of age who are receiving long-term aspirin
therapy/American Indians and Alaska Natives/extreme obesity (BMI ≥40 kg/m2)/patients
in nursing homes or chronic care facilities]. A chest
x-ray was obtained in the evaluation of this patient and was notable for
[right/left/upper/middle/bilateral/multifocal consolidation(s) with/without
associated effusion]. Labs were obtained and were notable for [leukocytosis with a
leftward shift/etc.]. Patient was noted to have evidence of [fever/tachycardia/tachypnea/etc.]
on presentation [with/without significant improvement] after treatment with [IV
fluids/anti-pyretics/antibiotics]. Blood cultures [were/were not] obtained due to planned
admission. Confirmatory
testing for influenza obtained in patient felt to require admission and noted
to be [negative/positive].
Influenza felt to be likely cause
of symptoms with antiviral treatment initiated in the ED [with Oseltamavir
(Tamiflu)/Zanamivir (Relenza)/Peramivir (Rapivab) and empiric antibiotic coverage
due to evidence of sepsis]. Patient felt to not be appropriate for
outpatient treatment based on [evidence of sepsis, absence of good social
support]. We discussed planned
admission with the patient who demonstrates understanding and agreement with
this plan. We discussed case with Dr. [NAME] who evaluated the patient
and agrees with need for admission to [general floor/telemetry unit/step-down
unit/ICU].
Note: This is based on the 2018
recommendations for treatment of seasonal influenza from the Infectious Disease
Society of America (IDSA).
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