What is the appropriate History of Present Illness (HPI) assessment, plan, and physical exam for a patient presenting with influenza-like symptoms, and what treatment should be prescribed?

From the Guidelines

For a patient presenting with cold/flu symptoms, I would recommend symptomatic treatment and consider antiviral therapy if the patient meets specific criteria, as outlined in the most recent and highest quality study 1. The patient's history of present illness (HPI) should include the duration and severity of symptoms, such as nasal congestion, rhinorrhea, sore throat, nonproductive cough, generalized malaise, and fever.

• Symptoms began gradually and have progressively worsened
• Patient denies shortness of breath, chest pain, vomiting, or diarrhea
• No known sick contacts The physical exam should include:
• Vital signs: Temperature, HR, RR, BP, O2 sat
• General: Alert, mildly fatigued appearing
• HEENT: Nasal mucosa erythematous with clear discharge, oropharynx mildly erythematous without exudates, tympanic membranes clear bilaterally
• Neck: No lymphadenopathy
• Lungs: Clear to auscultation bilaterally, no wheezes or rales
• Heart: Regular rate and rhythm, no murmurs The assessment would be acute viral upper respiratory infection (common cold/influenza-like illness), and the plan would include symptomatic treatment with acetaminophen 650mg every 6 hours as needed for fever/pain, guaifenesin 400mg every 4 hours for cough, and saline nasal spray as needed, as well as increased fluid intake, rest, and humidified air 1. Antiviral therapy (oseltamivir 75mg twice daily for 5 days) would be appropriate if influenza is confirmed by rapid testing and symptoms began within 48 hours, as recommended by the Infectious Diseases Society of America/American Thoracic Society consensus guidelines 1.
• The patient should be advised to return if symptoms worsen, persist beyond 10 days, or if they develop high fever, productive cough, shortness of breath, or severe headache.
• Antibiotics are not indicated as the presentation suggests viral etiology, and this approach targets symptom relief while the viral infection runs its course, typically 7-10 days.

From the FDA Drug Label

Oseltamivir phosphate for oral suspension is indicated for the treatment of acute, uncomplicated illness due to influenza A and B infection in patients 2 weeks of age and older who have been symptomatic for no more than 48 hours. The recommended oral dosage of oseltamivir phosphate for oral suspension for treatment of influenza in adults and adolescents 13 years and older is 75 mg twice daily (12.5 mL of oral suspension twice daily) for 5 days.

To write an HPI assessment and plan for a patient presenting with cold flu symptoms, consider the following:

• History of Present Illness (HPI):
  • Onset and duration of symptoms
  • Character of symptoms (e.g. fever, cough, sore throat, body aches)
  • Severity of symptoms
  • Any factors that exacerbate or relieve symptoms
• Physical Exam:
  • Vital signs (temperature, blood pressure, heart rate, respiratory rate)
  • Head and neck exam (e.g. throat, ears, sinuses)
  • Lung exam (e.g. breath sounds, wheezing)
  • Abdominal exam (if applicable)
• Plan:
  • If the patient has been symptomatic for no more than 48 hours, consider prescribing oseltamivir phosphate for oral suspension at a dose of 75 mg twice daily for 5 days for adults and adolescents 13 years and older, as indicated in the drug label 2.
  • Provide guidance on symptom management, such as rest, hydration, and over-the-counter medications for fever and pain relief.
  • Consider recommending annual influenza vaccination to prevent future illness. Note: The patient's age, weight, and renal function should be taken into account when determining the appropriate dosage of oseltamivir phosphate for oral suspension.

From the Research

HPI Assessment

• The patient presents with cold flu symptoms, including nasal congestion, rhinorrhea, sore throat, cough, general malaise, and/or low-grade fever 3
• The patient's symptoms are likely self-limited, and informing them about the nature of the common cold can help manage expectations and limit unnecessary treatments 3
• A thorough medical history should be taken to rule out any underlying conditions that may be exacerbating the symptoms

Plan

• Treatment options with proven effectiveness for cold symptoms in adults include over-the-counter analgesics, zinc, nasal decongestants with or without antihistamines, and ipratropium for cough 3
• A combination of paracetamol and pseudoephedrine may be effective in relieving nasal congestion and pain-related symptoms 4
• However, the use of pseudoephedrine should be carefully considered due to its potential for misuse and risks 5

Physical Exam

• Vital signs should be taken, including temperature, blood pressure, and pulse
• A thorough head and neck exam should be performed to assess for any signs of infection or other underlying conditions
• The patient's nasal passages and sinuses should be examined for any signs of congestion or infection

Prescription

• Based on the patient's symptoms and medical history, a prescription for a combination of paracetamol and pseudoephedrine may be considered, along with other treatments such as zinc or ipratropium for cough 4, 3
• However, the patient should be closely monitored for any signs of adverse effects or misuse of pseudoephedrine 5
• Alternative treatments, such as nasal saline irrigation or topical application of ointment containing camphor, menthol, and eucalyptus oils, may also be considered 3