Flu-like Symptoms

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of ‍flu-like symptoms

Symptoms include:

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍cough, ‍non-productiveproductive of ‍clearcolored phlegm

‍sore throat

‍runny or stuffy nose

‍body or muscle aches

‍headache, ‍diffuse, ‍persistentintermittent, ‍pressurethrobbing, ‍mild

‍fatigue

‍shortness of breath

‍chest pain, ‍retrosternal, ‍aching, ‍on exertionat restwith deep breath, ‍mild

‍vomiting, ‍ episodes ‍per day, ‍, ‍hematemesis



Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective



Contributing factors:

‍similar symptoms in close contacts

‍exposure to flu

‍incomplete vaccination

‍recent travel

‍smoking

‍elderly or very young age

no history of: ‍influenza, ‍asthma, ‍chronic heart disease, ‍chronic lung disease, ‍immunodeficiency, ‍diabetes, ‍pregnancy





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Eyes: conjunctiva/sclera ‍normal, lids/lashes ‍normal

Ears: tympanic membranes ‍normal ‍, auditory canal ‍ on ‍rightleft, hearing ‍intact

Nose: ‍clear, discharge ‍clear, ‍

Throat: ‍normal, ‍erythema, ‍exudate, ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Skin: ‍rashlesions on ‍





ASSESSMENT:

‍Influenza ‍likelysuspectedpossible

DDx: influenza, viral upper respiratory infection, COVID-19, common cold, bacterial pharyngitis, bronchitis, pneumonia, sinusitis, gastroenteritis, mononucleosis, adenovirus infection, RSV infection, pertussis, legionnaires' disease, malaria, rickettsial diseases, hantavirus, medication-induced symptoms, systemic lupus erythematosus, thyroiditis, sepsis, toxic shock syndrome





PLAN:

Investigations:

- Blood work: ‍CBC, ‍CRP, ‍electrolytes, ‍creatinine, ‍glucose

- Throat swab

- Influenza test

- Covid test

- Chest X-ray

Treatments:

- ‍Acetaminophen as needed

- ‍Ibuprofen as needed

- ‍Anti-viral medications

- Over-the-counter cold and flu remedies

- Encourage hydration

- Rest and sleep

- Avoid contact with others

Further care:

- Follow-up in ‍ ‍hoursdays

- Return if symptoms persist for more than a week, if new symptoms develop, or if condition worsens

- Referral to ER if severe headache, stiff neck, or other signs of serious illness occur