MDM - Influenza (Admit)

[##]-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).

https://rebelem.com/idsa-guideline-on-seasonal-influenza-management-2018/

https://www.idsociety.org/practice-guideline/influenza/

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/

Discharge instructions - Bronchitis

As discussed in the Emergency Department prior to discharge, you have been diagnosed with bronchitis.  Bronchitis is an infection that causes a cough.  It happens when the tubes that carry air into the lungs, called the "bronchi," get infected.  Usually, bronchitis happens after a person gets a cold or the flu.  The viruses that cause the cold or flu infect the bronchi and irritate them.

People often wonder if taking antibiotics will help with their bronchitis.  But the answer is no, because it is usually caused by a virus.  Antibiotics kill bacteria, not viruses.

Bronchitis can also happen when a person gets an infection called "whooping cough," but this is much less common.  Whooping cough is caused by bacteria that can infect the bronchi.  Most people get vaccines that prevent whooping cough, but the vaccine doesn't always work.  Your doctor will be able to tell if you have whooping cough by doing an exam and listening to way your cough sounds.

The most common symptoms of bronchitis are a nagging cough that can last up to a few weeks, coughing up mucus that is clear, yellow, or green, and normal cold or flu symptoms, like a stuffy nose, sore throat, or headache.  People with bronchitis do not usually get a fever.

Bronchitis almost always goes away on its own, although it can take a few weeks.  To feel better, you can treat your cold and flu symptoms.  Different treatments you can try include getting lots of rest and drinking plenty of liquids, drinking hot tea, sucking on cough drops or hard candy, taking over-the-counter cough and cold medicines, breathing in warm, moist air, such as in the shower, over a kettle, or from a humidifier, and taking a pain-relieving medicine if you have cold or flu symptoms like headache, muscle aches, or joint pain.

You may also have been prescribed an inhaler containing a medication called Albuterol.  To use the inhaler, breathe out, put your lips on the inhaler and then breathe in gradually and fully as you press the button on the inhaler.

It's also important to avoid smoking or being around others who smoke. This can make your cough worse.

Return to the Emergency Department for difficulty breathing, persistent or worsening wheezing or cough, new or worsening fever (≥38.0 °C or 100.4 °F), worsening chest tightness, or any new or concerning symptoms.

MDM - Croup

[##-month/year-old male/female] with history and exam consistent with likely croup.

Initial consideration in this patient included croup, pneumonia, allergic reaction, bacterial tracheitis, pharyngitis, pneumonia, bronchitis, epiglottitis, retropharyngeal abscess (RPA), peritonsillar abscess (PTA), diphtheria, foreign body obstruction, and esophageal pathology among others. 

Patient presented with [mother/father/parents] with report of [dry/barking] cough consistent with croup in patient within the expected age (3 months to approximately 5 years old).  Patient [with/without measured/reported] fever and associated [upper respiratory symptoms].  Patient noted to have a Westley Croup Score of [0-17] consistent with [mild/moderate/severe] illness.  Doubt pneumonia given absence of productive cough or abnormal lung sounds.  Chest x-ray [felt to not be indicated at this time/obtained and noted to be unremarkable].  No evidence of acute otitis media noted on exam.  No evidence of significant pharyngeal erythema, exudate, or other findings suggestive of significant pharyngitis on ED evaluation. 

Doubt bacterial tracheitis in otherwise well-appearing child without findings suggestive of purulent sputum, respiratory distress, or other suggestive findings.  Improvement noted with treatment with [Decadron/racemic epinephrine/Acetaminophen/Ibuprofen] in the ED prior to discharge.  Patient noted to be tolerating fluids by mouth prior to discharge with no evidence of stridor, cyanosis or respiratory distress at time of discharge.

Prior to discharge, we discussed return precautions, specifically for evidence of worsening infection or bacterial tracheitis, treatment [with Decadron/Acetaminophen/Ibuprofen], and follow up with primary care doctor within [2-3 days/1 week] for further evaluation, and the patient's [mother/father/parents] demonstrated understanding and agreement.

https://www.mdcalc.com/westley-croup-score