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January 2013: Respiratory

A 28-year-old female second mate reports to the clinic with complaints of sore throat and nasal congestion for 2 days. This morning she woke up poorly rested and with body aches. She also notes a non-productive cough since last night that she associates with her post-nasal drip. Symptoms seem to be progressively worsening so she decided to take ibuprofen and pseudoephedrine.

She denies headaches, facial pressure, or vision changes. She has been working but feels like she needs to go to sleep and has no energy. Last night she woke up during the middle of the night very cold while the room temperature was 78 degrees. She is on day 15 of her 21-day hitch.

  • Past Medical History: Depression, anxiety, hypothyroidism
  • Past Surgical History: C-Section x2
  • Current Medications: Multivitamin, birth control, citalopram 40mg/day, levothyroxine 200mcg/day
  • Allergies: NKDA
  • Immunization Status: Up to date including annual flu vaccine
  • Social History: Social drinker, smokes 1½ a pack a day
  • Family History: Mother with breast cancer; father with unspecified mental illness


  • Temp 102
  • Pulse 120
  • Respiration 18
  • BP 108/70
  • POx 99% on Room Air

Physical Exam

  • General: A&Ox3, Ill appearing but NAD
  • HEENT: PERRLA, EOMI; TM’s appear normal with normal light reflex; nares with yellow rhinorrhea and mild congestion; throat with erythema but no tonsil exudate, mucus membranes appear moist, sinuses are non-tender to palpation
  • Neck: soft and supple, trachea is midline, shotty cervical lymphadenopathy appreciated
  • Cardio: tachycardic, regular rhythm, no murmurs appreciated
  • Lung: clear to auscultation bilaterally
  • Abdomen: soft non-tender, non-distended, normal bowel sounds
  • Extremities: no clubbing, cyanosis or edema
  • Neuro: Grossly Intact

Lab Work

  • Rapid Flu = negative for influenza A, positive for influenza B

How would you approach this patient?

Differential Diagnosis

  • Common cold/viral illness
  • Influenza
  • Allergic rhinitis

Diagnosis: Influenza



  • Strict isolation until afebrile for at least 24 hrs and/or have completed antiviral medications
  • Symptomatic control of fever and body aches with acetaminophen or ibuprofen
  • Symptomatic control of cough with cough suppressant
  • Maintain adequate hydration status
  • Administer oseltamivir (Tamiflu) 75mg po bid for five days (should be started within 48 hrs of symptom onset) OR zamamivir (Relenza) 10mg PO BID for five days


In this case, the patient tested positive for influenza B via the Rapid Flu test. Be aware, this test has a high false negative rate and therefore a negative result on this test does not rule out influenza A or B. In addition, this patient did receive the flu vaccine. The 2012-2013 flu season vaccine protects against influenza A (strains H1N1 and H3N2) as well as influenza B. The viruses selected for inclusion in the seasonal flu vaccines are updated annually based on information collected by the CDC and WHO.

Clinically, if you suspect that your patient has the flu it should be treated as such. Your clinical suspicion for influenza should be raised if your patient presents with fever, cough and body aches during flu season. Patients typically have severe complaints, but lack significant findings on physical exam. Flu season typically begins in October and can run as late as May.  Peak months of activity are December to February.

Once influenza is suspected, isolation is mandatory to avoid the spread of the illness among the general population. Patient should remain in isolation for 3-5 days or until they no longer have a fever for at least 24 hours. Once the diagnosis of influenza has been confirmed, medical services along with worksite management must work together to mitigate spread and unwarranted concern.  Any other workers suspected of infection should be isolated and tested immediately, particularly those individuals working and living in close quarters with the patient.

Symptomatic control is the mainstay of treatment, but antiviral medications can be administered to reduce the duration and severity of the illness in most cases. This applies to normal healthy adults. Patients with pre-existing chronic conditions and/or at the extremes of ages would need to be handled on an individual basis and closely monitored for potential complications such as pneumonia.

Return to Work:

  • Symptoms must be well controlled
  • Afebrile for 24 hrs
  • Able to drink and maintain adequate hydration
  • Patient feels fully capable of job functions