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With influenza season upon us, I wanted to take a new angle in the Standard of Care project this month. We’re not going to judge someone else’s care, we are all going to judge each other’s care.

A 50-year-old man comes into the emergency department with fever up to 103 degrees, chills, runny nose, a harsh cough, and general malaise for the past two days. He began having a dull/burning chest pain with his cough the day of presentation which is what prompted him to come to the emergency department. The only time he gets the chest pain is when he coughs.

The patient smokes a little less than a pack of cigarettes per day. He has a history of mild hypertension which is well-controlled on medications. There is a moderate amount of influenza in your community at the time the patient is seeking care. The patient says that he doesn’t have insurance and is going to have to pay out of pocket for any tests that you order or any medications that you give to him, so he asks you not to do anything that isn’t absolutely necessary.

His physical examination shows a fever of 102.4 degrees, pulse oximeter reading of 97% on room air, nasal congestion, and pharyngitis. His lung sounds are clear and equal bilaterally. His heart examination is unremarkable. There are no other abnormalities.

We all know that the standard of care can’t be based on what one expert would do in a given situation, but I would like to see whether there is a consensus on the management of this patient. Assume that anything not mentioned in the scenario is “normal” or would not meaningfully contribute to your decision about how to manage this patient.
Your department has “rapid influenza” testing available.

What is the minimum amount of testing and/or treatment that should be done in order to meet the standard of care? Keep in mind that if the patient has a “bad outcome,” several other experts will be reviewing your chart to determine whether or not YOU met the standard of care.

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Comments   

# Director of Emergency ServicesDavid Pietrasiuk MD 2009-01-06 00:21
PA & Lat CXR, Rapid influenza test,
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# My approachWalter Simmons, M.D., MPH, FACEP 2009-01-06 06:08
PA and Lat CXR, Rapid Influenza, antipyretic of choice, oral fluids, tincture of time (2 - 3 hours) and reassess. If doing well, send home with instructions regarding cold/flu, hydration, antipyretics, appropriate OTC meds (considering HTN), when to return, smoking cessation. If not doing well address admission vs. further evaluation including full blood work.
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# Attending PhysicianMax Baumgardner, DO 2009-01-06 07:39
CXR, motrin / tylenol, evaluation for 1-2 hours and reassement including recheck of vitals.
Ensure adequate follow up as needed
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# Fluless in SeatleAdan 2009-01-07 07:00
CXR, rapid flu test, APAP every 6 hrs, fluid, smoking cessation, anti-tussive if dry cough (tessalon?) expectorants if phlegm (mucinex?), basic hygiene education. Instructions to return to clinic or if not possible, to the ER.
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# Michael Nerenberg MD 2009-01-07 18:31
Tylenol, ekg, cxr. No rapid flu as is too late to treat anyway, even if you believe in Relenza or whatever. Watch an hour or two and see how he feels.
Brief talk about smoking. Long talk about when to come back, with specific info on post flu pneumonia, dob, etc.
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# MDJeffrey Stalnaker 2009-01-10 20:45
As an internist & emergency physician I find it interesting how patients are handled in the ED vs the office. There is little chance this patient would be kept in the office for 2 hours, & if so, he would likely feel worse than when he came in. Likewise, if this patient requires a long talk about when to come back, what do most of the others require? Assuming his blood pressure is normal, is it practical to discuss hypertension concerns with decongestants? With a negative CXR, the only real risk here may be the chest pain. Do you assume it's related to the cough, or head down a different road?
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# My work-upAndy Su 2009-01-14 04:56
I believe that standard of care is a very fuzzy concept. If I saw two patients with the exact same presentation, I don't know if I would always order the same tests. I certainly try my best to be consistent but we're talking about medicine.

For this patient, however, I would probably order
Tylenol & Motrin
EKG
Cardiac Monitor
Pulse Ox
CXR (PA & Lateral)
Rapid influenza (even if it's too late to treat, it can be helpful diagnostically.)
Rapid strep
Troponin I
D-Dimer (maybe)
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# My Typical work upDKow 2009-01-19 14:24
Rapid Flu to make diagnosis if present.
CXR P/A & Lateral
EKG for baseline even though I would not be considering this to be cardiac. Given his history and if there are complications, this would be nice to have to compare a future EKG to.
Tylenol/NSAID and Fluids.
Discuss complications of flu, be aware of problems of decongestants with HTN and warn him of this.
Treat Pneumonia if present.
Home with follow up with PMD in 2-3 days and return if worse or changes in symptoms or if chest pain becomes constant or not just associated with cough.
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# Attending ED PhysicianGregory 2009-01-20 00:38
Two dictums from medical school come to mind: 1)It's all in the History and 2)If it won't change what you're going to do, why order the test?

By this man's Hx, he is suffering from an acute viral URI/Bronchitis. Whether it's Influenza or another viral culprit seems inconsequential as I would not treat him with an antiviral at this point. What would knowing his influenza status do for me/him (other than from a public health stand point)? Prognostication ? He is certainly at risk for morbidity with ANY virus given his smoking Hx and age.

What we do need to do is rule out a bacterial process like pneumonia, so a PA/LAT CXR seems prudent. As for the chest pain, it certainly sounds non-cardiac. An ECG is cheap and non-invasive, but remember it's negative predictive value is not fantastic.

At the end of the day, I would order Motrin an ECG and a CXR. Counsel the pt on smoking cessation, cardiac CP symptoms, dyspnea and supportive care and try to arrange for close follow up. If we can assume that his vital signs are unremarkable with the exception of his Temp, I see no utility to observe this pt for any prolonged period of time. He feels sick because he is. Although Motrin may help a little, sitting in my ED for 2 or more hours won't. As long as he is tolerating po fluids and understands what symptoms or changes should prompt him to return to the ED, he can go.
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# Martin 2009-01-20 18:15
Do the influenza test. The patient and doctor always are more comfortable when there is a definitive diagnosis.
I would also do a CXR and ECG ( a smoking middle aged man with HTN) and try not to fall into a trap of limiting essential tests because the patient is paying out of pocket. This could result in significant adverse consequences for both parties.
Evaluating the patient after 2 hours is also acceptable. What is the rush to get him out of the department ?
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# Cold in El PasoJose Crespo 2009-01-20 20:12
I see it all the time, I would get 3 basics; EKG,Chest Xray, forget the influnza test. Send him home if above is normal and have him take tylenol for the fever, poly-tussin DHC and make sure he pushes fluids, fluids and more fluids. follow up at clinic or ED in 3-5 days if not better
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# ED PhysicianWilliam Hardman, M.D. 2009-01-21 03:21
Why are all the physicians showing fever phobia? There no evidence the fever is causing discomfort, and may even be beneficial for the course of the disease. No testing, wxcept maybe a CXR if patient wants it after talking with him.
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# MDAThomas 2009-01-21 15:06
Chest xray because he is a smoker. Tylenol or motrin for pain in his chest. Antibiotics if the chest xray shows an infiltrate. Why get an ECG when he has reproducible pain with coughing. Why get a troponin. One ECG and one troponin tell you very little about a person with intermittent short lived chest pain like this fellow is having.
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# pa-cbrian w badger 2009-01-21 15:07
i find this quandry interesting...i t forces the practitioner to THINK about the cost of the work-up..someth ing we should be doing anyway, all the time...anyway, where i have worked, this pt would be a fast-track patient; he would have some tylenol while waiting for the flu test (in my area, we treat positive flu's up to 3 days out); no cxr/ekg given all the pertinent negatives; good pt education on discharge (treatment/foll ow-up/etc.)
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# Joseph Martinez 2009-01-22 22:35
No testing required. We are clinicians after all and clinically this patient has influenza or other viral illness that does not require anything except supportive care/treatment. That should be the standard of care. Realistically, if you order anything based on this patient scenario, it is because of patient desires or malpractice concerns. Warn to return if symptoms worsen! Have patient follow-up with his primary doc in 2-3 days.
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# PA-CJimi Akingbade 2009-01-23 21:14
I haven't heard anyone mention CBC, lytes, IVF bolus in this pt who does not have much oral intake. I would give a couple liters NSS, tylenol and motrin, tussive, likely course of zithromax since he's a smoker, has much higher likelihood of bacterial bronchitis or secondary infection. No one has mentioned antibiotics here but in reality most would give it in this scenario even with negative CXR.
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# EM physicianEM 2009-01-24 15:38
I am very much in favor of the influenza test. If positive it would help avoid some of the other more expensive diagnostic tests, and help reassure the patient and physician of an accurate diagnosis. Although it is lower down on my differential, the patient's risk factors for legionella are concerning.
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# He has a virusCO EP 2009-01-30 01:41
History, history, history (and physical). He has a viral illness. Influenza testing won't change anything I do. I would get a CXR due to his smoking history and treat with abx (doxycycline - because it's cheap) for any suspicious abnl. A complication of this illness could be a COPD exacerbation (presumed COPD from smoking history), if symptoms persist. I would give good instructions for return for persistent fever, productive cough, etc.

Acetaminophen in the Dept, provide with Albuterol MDI and instruction on how to use it. Recommend OTC acetaminophen, ibuprofen, mucolytics, and brief smoking cessation discussion. No need to observe any longer than it would take for the CXR and acetaminophen.
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# Dan Mayer 2009-02-27 18:00
I would treat for the flu symptomatically and without anti viral agents, but would add specifically to the discharge instructions that he should return immediately if he became short of breath.
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