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/

MDM - Acute Bronchitis

[##]-year-old [male/female] with history and exam consistent with acute bronchitis of likely [viral/bacterial] etiology.

Initial consideration in this patient included bronchitis, pneumonia, influenza, allergic rhinitis, upper respiratory infections (URI), pulmonary embolism (PE), and reactive airway diseases (asthma, chronic bronchitis) among others. 

Patient presented with cough [productive of sputum] and [reported/evidence of] wheezing consistent with bronchitis.  Patient’s lung sounds were [notable for expiratory wheezing/noted to be normal].  Patient noted to [have/have no] evidence of fever or other systemic infectious symptoms.  A chest x-ray [was/was not] obtained [and noted to have no evidence of consolidations suggestive of pneumonia or other acute abnormality/due to absence of abnormal lung sounds or other evidence suggestive of pneumonia or other acute intrathoracic pathology].  The patient [reported/denied] a history of obstructive lung disease (asthma or COPD).  Patient [reported/denied] a history of tobacco use [and we discussed smoking cessation prior to discharge with the patient noted to be pre-contemplative/contemplative/expressing desire to quit at this time].  Patient noted to have [mild/some/significant] improvement after treatment with [specify] in the ED prior to discharge.

We discussed return precautions, specifically for evidence of worsening difficulty breathing, treatment with [bronchodilators/steroids], and follow up with primary care doctor within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement with this plan.

Discharge Instructions - Influenza

As discussed in the Emergency Department prior to discharge, you have been diagnosed with influenza or the flu.  The flu is an infection that can cause fever, cough, body aches, and other symptoms.  The most common type of flu is the "seasonal" flu, of which there are different forms of seasonal flu, for example, "type A" and "type B."  Besides seasonal flu, there is also the "swine" flu, which caused a worldwide outbreak ("pandemic") in 2009 and 2010, and the bird flu.  Bird flu (also known as "avian flu") is a severe form of the flu that is caused by a type of flu virus that first infected birds.

All forms of the flu can cause fever (temperature higher than 100ºF or 37.8ºC), extreme tiredness or fatigue, headache or body aches, cough, sore throat, and runny nose.  Flu symptoms can come on very suddenly.

All forms of the flu are caused by viruses.  Antibiotics provide no benefit in the treatment of viral infections.  Most patients get better within a week or two without complications.  An antiviral medication called Oseltamivir (Tamiflu) may have been prescribed to you based on how long you have had symptoms and your risk factors.  This medication is usually reserved for patients who are at a higher risk from influenza such as people 65 or older, very young children, pregnant women, and people with certain other medical problems.

It is important that you stay home, rest, and drink plenty of fluids.  You can take over-the-counter medications for pain such as Ibuprofen (also known as Advil or Motrin) or Naproxen (also known as Aleve).  You can also take Acetaminophen (also known as Tylenol) to relieve fever and body aches.

Return to the Emergency Department if you have trouble breathing or are short of breath, feel pain or pressure in your chest or belly, get suddenly dizzy, feel confused, have severe vomiting, or any new or concerning symptoms.

Discharge Instructions - Acute Otitis Media

As discussed in the Emergency Department prior to discharge, you have been diagnosed with an ear infection, specifically of the inner ear called otitis media.  This type of infection is usually caused by bacteria growing inside the inner ear canal.  The inner ear is drained by a tube that leads from the ear to the back of the throat.  When we get a cold or a viral infection, this tube can become blocked off (due to inflammation and swelling of the tube), drainage can’t occur properly, and this creates an environment for bacteria to grow.  Children tend to have more ear infections because their ear tubes are smaller and more horizontal, making them more easily blocked and less able to drain.

If you were prescribed antibiotics, fill the prescription and start the medication as soon as possible.  Make sure you take your antibiotics as directed for the whole course (don’t stop early).  There should be a significant improvement within 2 days of taking the antibiotics.

You can take Acetaminophen (also known as Tylenol) or Ibuprofen (also known as Advil or Motrin) for the pain.  If the fever hasn’t come down one hour after giving one of these medications, you can try the other medication.  While it is very safe to try both, it is important to make sure that you take (or give your child) the right dose of each, as instructed on each box.

Try to avoid taking any flights while there is ongoing pain.

Return to the Emergency Department for ongoing fever (≥38.0 °C or 100.4 °F) after 2 days of antibiotics use, more fluid coming out of the ear, seizure, feeling drowsy, confused, or lethargic, neck stiffness, or any new or concerning symptoms.

Lethargy is an extreme form of tiredness when a person is only minimally responsive.  An example of a lethargic child is a child who is lying still and does not make eye contact with you when you speak to them.

Discharge Instructions - Croup

As discussed in the Emergency Department prior to discharge, your child has been diagnosed with croup.  Croup (also known as laryngotracheobronchitis) is characterized by a barky (or dry) cough and a fever.  It is most commonly due to a viral infection, so antibiotics have no role in treating this illness.  It usually lasts five to seven days.  The cough is typically worst on day two and is worse in the nighttime.

In the Emergency Department, your child may have been given a prescription for a single dose of a steroid medication, such as Dexamethasone or Prednisolone.  This medication will help the croup to go away faster.

It is important to keep your child hydrated.  You can use formula or breast milk if they are less than one year of age, or Pedialyte, flat ginger-ale, or water if they are over one year of age.

If your child has a fever, you can help him or her feel better by treating the fever with Acetaminophen (also known as Tylenol) or Ibuprofen (also known as Advil or Motrin).  If your child does not appear to be getting better an hour after giving one of these medications, you can try the other medication.

For example, if your child is not better one hour after taking Ibuprofen, you can give your child Acetaminophen.  While it is very safe to try both, it is important to make sure that you give your child the right dose of each, according to their weight, as instructed on each box.  Avoid using any over-the-counter cold medications at the same time: these medications often have several medicines in them, including Acetaminophen or Ibuprofen, so you could end up giving too much of one or the other if you add cold medications.

There are also some simple home treatments that you can try, including:

    -Using steam or cool mist to help your child to breathe easier

    -Putting a humidifier in your child’s room

    -Opening up the window in your child’s room to allow in the cool night air

Often croup improves on the way to the Emergency Department, because the child was exposed to the cool night air on the way in.

Return to the Emergency Department for dehydration or signs of dehydration (producing fewer wet diapers or peeing less; dry mouth with no visible spit bubbles; no tears made when crying), if you child develops lethargy (an extreme form of tiredness when a child is only minimally responsive - an example of a lethargic child is a child who is lying still and does not make eye contact with you when you speak to them), if your child is making a high pitched breathing sound even at rest, if your child is having difficulty breathing, or for any new or concerning symptoms.

Discharge Instructions - Bronchiolitis

As discussed in the Emergency Department prior to discharge, your child has been diagnosed with bronchiolitis.  Bronchiolitis is an infection that affects a part of the lungs called the “bronchioles.”  The bronchioles are the small, branching tubes that carry air in and out of the lungs.  When these tubes get infected, they get swollen and filled with mucus, which can make it harder to breath.

Bronchiolitis usually affects children younger than 2 years of age.  In most patients, bronchiolitis goes away on its own, but some children need to be seen by a doctor.  The most common cause of bronchiolitis is a viral infection called respiratory syncytial virus or RSV.

Most children with bronchiolitis have a stuffy or runny nose, a mild cough, fever (≥38.0 °C or 100.4 °F), and decreased appetite.  Some will have more severe symptoms, like breathing fast, trouble breathing, pauses in breathing (apnea), wheezing (a whistling sound with exhalation), a severe cough, and trouble eating or drinking leading to dehydration.

Bronchiolitis is most commonly due to a viral infection, so antibiotics do not provide any benefits.  In general, treatment is focused on making sure your child is getting enough oxygen.  One way to help with this is to suction your child’s nose, since RSV commonly causes significant mucus production and runny nose.  Using a humidifier can also be beneficial.  It is also important to make sure your child is getting enough fluids to prevent dehydration.  This can be accomplished by giving your child small amounts of fluid more frequently throughout the day.

Return to the Emergency Department if your child develops stops breathing even briefly, has a very hard time breathing, starts to turn blue (cyanosis) or pale, starts grunting, looks like he/she is getting tired of having to work so hard to breath, or has any new or concerning symptoms.

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