A 47-year-old man comes to the office in mid-January due to persistent high-grade fever, headache, and severe myalgias that began abruptly 4 days ago. The patient also has sore throat, nonproductive cough, and mild nasal congestion but no shortness of breath or chest pain. It has been 5 years since his last appointment, and he is not up to date on health maintenance or immunizations. The patient has no chronic medical problems, takes no medications, and has no known drug allergies. Temperature is 38.5 C (101.3 F), blood pressure is 135/80 mm Hg, pulse is 88/min, and respirations are 16/min. Oxygen saturation is 98% on room air. Physical examination shows a mildly erythematous oropharynx with normal tonsils. No significant cervical lymphadenopathy is present. Breath sounds are clear and equal bilaterally with no dullness to percussion or egophony. Heart sounds are normal. Which of the following is the most appropriate next step in management of this patient?

Question

A 47-year-old man comes to the office in mid-January due to persistent high-grade fever, headache, and severe myalgias that began abruptly 4 days ago.  The patient also has sore throat, nonproductive cough, and mild nasal congestion but no shortness of breath or chest pain.  It has been >5 years since his last appointment, and he is not up to date on health maintenance or immunizations.  The patient has no chronic medical problems, takes no medications, and has no known drug allergies.  Temperature is 38.5 C (101.3 F), blood pressure is 135/80 mm Hg, pulse is 88/min, and respirations are 16/min.  Oxygen saturation is 98% on room air.  Physical examination shows a mildly erythematous oropharynx with normal tonsils.  No significant cervical lymphadenopathy is present.  Breath sounds are clear and equal bilaterally with no dullness to percussion or egophony.  Heart sounds are normal.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d27f_f29f_bc81_21807e4c2a49_MD0003_00 Influenza is a seasonal respiratory infection with peak prevalence in January and February. Approximately 1-5 days after inoculation, patients abruptly develop systemic (fever, malaise, myalgias, headache) and upper/lower respiratory (rhinorrhea, sore throat, nonproductive cough) symptoms. Physical examination and laboratory studies are often normal but may show pharyngeal erythema (without exudates) and mild alterations in leukocyte count (low early, high late). For adults with suspected or confirmed influenza, treatment is as follows: Those with no risk factors for influenza complications do not require diagnostic testing and are generally treated symptomatically. Those with risk factors (eg, age ≥65, chronic medical problems, pregnancy) for influenza complications should receive antiviral therapy (eg, oseltamivir), regardless of symptom duration. Antivirals can also be considered in those without risk factors who come to the office within 48 hours (not 4 days) of symptom onset as treatment may reduce symptom duration (Choice D). (Choice A) Patients who are moderately or severely ill should not be given the influenza vaccine until symptoms abate. (Choice B) Streptococcal pharyngitis is characterized by sore throat with tonsillar exudate, cervical adenitis, and fever. Headache, myalgias, cough, and rhinorrhea are more characteristic of a viral infection (eg, influenza). A rapid streptococcal antigen test would not be useful and is not indicated in this patient with only a single Centor criterion (fever). (Choice C) Azithromycin may be prescribed for community-acquired pneumonia in areas with low rates of Streptococcus pneumoniae macrolide resistance. Although atypical pneumonias (eg, Mycoplasma pneumoniae) share many symptoms with influenza and can be treated with azithromycin, the abrupt onset of symptoms makes influenza far more likely. Educational objective: Patients with influenza abruptly develop systemic (fever, malaise, myalgia, headache) and upper/lower respiratory (rhinorrhea, sore throat, nonproductive cough) symptoms. In the absence of risk factors (eg, age ≥65, chronic medical conditions) for influenza complications, most adults do not require testing and are treated symptomatically. References: Influenza. (http://www.ncbi.nlm.nih.gov/pubmed/23809717) Does this patient have influenza? (http://www.ncbi.nlm.nih.gov/pubmed/15728170)

A 47-Year-Old Man Comes to the Office in Mid-January Due