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January 2015: Respiratory

A 32 year old male cook presents to you with complaints of headache, coughing, body aches, chills, and fatigue for two days. The coughing has been non-productive, occurs throughout the day and night and is causing some associated sore throat.  Headaches are more frequent than usual and ibuprofen is not helping.

Headaches are described as a dull ache and are located behind his eyes and on the sides of his head. He has been working but feels like he needs to go to sleep and has no energy. Last night he woke up during the middle of the night with his whole body shaking despite the temperature in his room being 75 degrees. He is on day 7 of his 21-day hitch.

Past Medical History: Unremarkable
Past Surgical History: Tonsils removed at age 12
Current Medications: Multivitamin
Allergies: NKDA
Immunization Status: Up to date
Social History: Social drinking, smokes ½ a pack a day
Family History: Mother with emphysema; father with CAD

Vitals

  • Temp 101.2
  • Pulse 92
  • Respiration 18
  • BP 132/87
  • PO 97% 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 clear rhinorrhea and mild congestion; throat with erythema but no tonsil exudate, mucus membranes appear moist, sinuses are non-tender to percussion
  • Neck: soft and supple, trachea is midline, shotty cervical lymphadenopathy appreciated
  • Cardio: regular rate, 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 = positive for influenza A, negative for influenza B

 

How would you approach this patient?

 

Diagnosis: Influenza

Discussion

In this case, the patient tested positive for influenza via the Rapid Flu test. However this test has a high false negative rate. Therefore a negative result on this test does not rule out influenza A or B. 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.

Treatment

  • 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)

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
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