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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