A 78-year-old woman comes to the urgent care center due to the abrupt onset of fever, sore throat, a nonproductive cough, and muscle pain that began yesterday morning. Several of her social friends have been sick, including one who was hospitalized with influenza. The patient received an influenza vaccine 2 months ago and has no history of influenza infection. Medical history includes hypertension, coronary artery disease, and ischemic cardiomyopathy with a left ventricular ejection fraction of 35%. She is a lifetime nonsmoker.
Temperature is 38.3 C (100.9 F), blood pressure is 122/76 mm Hg, pulse is 95/min, and respirations are 14/min. Oxygen saturation is 98% on room air. The patient appears uncomfortable but is in no acute distress. No pharyngeal erythema or tonsillar exudates are present, and there is no cervical lymphadenopathy. Auscultation of the lungs reveals no abnormalities.
Rapid influenza antigen test is negative, and chest x-ray reveals no infiltrates. The patient asks to go home.
Which of the following is the most reasonable next step in management of this patient?

Question

A 78-year-old woman comes to the urgent care center due to the abrupt onset of fever, sore throat, a nonproductive cough, and muscle pain that began yesterday morning.  Several of her social friends have been sick, including one who was hospitalized with influenza.  The patient received an influenza vaccine 2 months ago and has no history of influenza infection.  Medical history includes hypertension, coronary artery disease, and ischemic cardiomyopathy with a left ventricular ejection fraction of 35%.  She is a lifetime nonsmoker.
Temperature is 38.3 C (100.9 F), blood pressure is 122/76 mm Hg, pulse is 95/min, and respirations are 14/min.  Oxygen saturation is 98% on room air.  The patient appears uncomfortable but is in no acute distress.  No pharyngeal erythema or tonsillar exudates are present, and there is no cervical lymphadenopathy.  Auscultation of the lungs reveals no abnormalities.
Rapid influenza antigen test is negative, and chest x-ray reveals no infiltrates.  The patient asks to go home.
Which of the following is the most reasonable next step in management of this patient?

Quizplus · Accepted Answer

This patient who had exposure to an individual with influenza now has acute fever, sore throat, cough, and malaise, raising strong suspicion for influenza infection. Rapid influenza antigen testing cannot be used to rule out infection due to high false-negative rates (pooled sensitivity is only ~65%). Similarly, a history of influenza vaccination does not eliminate the risk of infection; vaccination is protective in only 45%-60% of older individuals, and outbreaks commonly occur even in highly vaccinated populations (eg, assisted living, nursing home). Patients who have influenza symptoms for <48 hours should receive antiviral therapy with oseltamivir or zanamivir to reduce symptom duration and, potentially, the likelihood of influenza-related complications (eg, secondary pneumonia). Antiviral therapy, regardless of symptom duration, is recommended for patients who require hospitalization, have severe or progressive illness, or are at high risk of complications. high risk (Choice A) Although the diagnosis of influenza can be confirmed by reverse transcription PCR or viral culture (the latter takes 48-72 for results and is used less commonly), antiviral treatment should not be delayed for confirmatory testing. (Choice B) This patient with a cough and no tonsillar exudates or cervical lymphadenopathy has only 1 of the Centor criteria (fever), indicating no need for rapid streptococcal antigen testing due to a low likelihood of streptococcal infection. Centor criteria (Choice C) This patient with a normal chest x-ray and a nonproductive cough is unlikely to have community-acquired pneumonia; treatment with azithromycin is not indicated at this time. (Choice E) Symptomatic treatment is indicated for low-risk patients who have had influenza symptoms >48 hours. This patient has had symptoms <48 hours and also has risk factors (ie, advanced age, cardiac disease) for influenza complications; she should receive antiviral therapy. Educational objective: Antiviral treatment (eg, oseltamivir) is recommended for patients with <48 hours of influenza-like symptoms. Those who require hospitalization, have severe or progressive illness, or are at high risk of complications should also receive antiviral therapy regardless of symptom duration. Negative rapid influenza antigen testing or a history of influenza vaccination does not rule out influenza infection. __________ References: Antiviral agents for the treatment and chemoprophylaxis of influenza --- recommendations of the Advisory Committee on Immunization Practices (ACIP). (http://www.ncbi.nlm.nih.gov/pubmed/21248682) Seasonal influenza in adults and children--diagnosis, treatment, chemoprophylaxis, and institutional outbreak management: clinical practice guidelines of the Infectious Diseases Society of America. (http://www.ncbi.nlm.nih.gov/pubmed/19281331)

A 78-Year-Old Woman Comes to the Urgent Care Center Due