MDM - Influenza (Discharge)

[##]-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].  Confirmatory testing for influenza felt [not to be indicated as the results were unlikely to change management/obtained in patient felt to be high risk and noted to be negative/positive].  No evidence of pneumonia on history or exam [and no evidence of consolidations on chest x-ray]. 

Influenza felt to be likely cause of symptoms in patient presenting [within 48 hours of onset of symptoms/over 48 hours from onset of symptoms] with antiviral treatment felt to be [indicated after discussion of potential benefits and risks with the patient/indicated in patient with risk factors for complications/indicated in patient with household contacts who are high risk for complications/indicated in a healthcare worker caring for high risk individuals].  Prior to discharge, we discussed return precautions, specifically for symptoms suggestive of bacterial co-infection or worsening illness, and recommended follow up with primary care provider within [2-3 days/1-2 weeks], and the patient demonstrated understanding and agreement with this plan.

Note: This is based on the 2018 recommendations for treatment of seasonal influenza from the Infectious Disease Society of America (IDSA).

https://rebelem.com/idsa-guideline-on-seasonal-influenza-management-2018/
https://www.idsociety.org/practice-guideline/influenza/