Write a dictation note for a 68-year-old male presenting to the emergency department with cough, nasal congestion, sore throat, fever, influenza A positive, hypotension, tachycardia, leukocytosis, and possible sepsis.

Emergency Department Dictation Note

Chief Complaint

68-year-old male presenting with cough, cold-like symptoms, hypotension, and leukocytosis.

History of Present Illness

This patient presents with influenza A infection complicated by hypotension and leukocytosis, indicating possible sepsis or severe secondary bacterial pneumonia requiring immediate hospital admission and aggressive treatment. 1

The patient developed upper respiratory symptoms including cough and cold-like symptoms, with confirmed influenza A by rapid testing. He now presents with hemodynamic instability manifested by hypotension, which combined with leukocytosis represents signs of septicaemia and meets criteria for hospital admission. 1

Key clinical features documented:

• Cough (primary respiratory symptom) 2
• Cold-like symptoms (likely including nasal congestion, constitutional symptoms) 1
• Influenza A positive (confirmed viral pathogen) 3
• Hypotension (critical indicator requiring immediate hospital admission) 1
• Leukocytosis (suggests possible bacterial superinfection or severe inflammatory response) 4, 5

Assessment and Clinical Reasoning

Sepsis is characterized by fever or hypothermia, tachycardia, tachypnea, and either leukocytosis or leukopenia in the setting of infection, with hypotension indicating severe sepsis and potential organ dysfunction. 4, 5 This patient's hypotension combined with leukocytosis and confirmed influenza A infection meets criteria for severe sepsis requiring immediate intervention. 1

The presence of leukocytosis in influenza is atypical, as influenza typically causes leukopenia or normal white blood cell counts. 1 Elevated white blood cell count in the setting of influenza strongly suggests secondary bacterial pneumonia, most commonly caused by Streptococcus pneumoniae, Staphylococcus aureus, or Haemophilus influenzae. 1, 2

Critical indicators for hospital admission present: 1

• Hypotension (signs of septicaemia)
• Leukocytosis (suggesting bacterial superinfection)
• Age 68 years (elderly at high risk for complications)

Diagnostic Workup Initiated

Immediate investigations performed per guidelines for severely ill patients: 1

• Full blood count with differential 1
• Urea, creatinine, and electrolytes 1
• Liver enzymes 1
• Blood culture (obtained before antibiotic administration) 1
• Chest X-ray (to evaluate for pneumonia in hypoxic or severely ill patient) 1, 6
• Pulse oximetry 1
• Nasopharyngeal aspirate or nose/throat swabs for viral confirmation 1

Treatment Plan

Immediate Management

1. Antiviral Therapy

• Oseltamivir 75 mg orally twice daily initiated immediately 3
• Oseltamivir is the antiviral agent of choice for influenza A and may be used in severely ill hospitalized patients even if symptomatic for more than 48 hours 1, 3

2. Empiric Antibiotic Therapy Combination antibiotic therapy initiated immediately to cover Streptococcus pneumoniae, Staphylococcus aureus (including MRSA consideration), and Haemophilus influenzae: 1

• For severe pneumonia complicating influenza, combination therapy is mandatory 1
• Recommended regimen addresses pneumococcal and staphylococcal coverage with consideration for MRSA given severity 1
• Duration: 10 days for severe, microbiologically undefined pneumonia, extended to 14-21 days if Staphylococcus aureus confirmed 1

3. Supportive Care

• Intravenous fluid resuscitation for hypotension 1
• Oxygen therapy as needed to maintain SaO2 >92% 1
• Continuous hemodynamic monitoring 1

Monitoring Parameters

Reassessment criteria for treatment failure: 1

• If non-response to combination therapy after 48-72 hours, consider adding antibiotics effective against MRSA 1
• Monitor for development of multiple organ failure, which strongly predicts mortality 5

Disposition

Hospital admission to monitored bed with consideration for ICU-level care given hypotension and severe sepsis presentation. 1

Clinical Pitfalls Avoided

• Did not delay antibiotic administration waiting for culture results, as immediate parenteral antibiotics are indicated for severe pneumonia 6
• Recognized that leukocytosis in influenza is atypical and suggests bacterial superinfection, not simply viral infection alone 1, 7
• Did not rely on fever alone as indicator of bacterial infection, as hypotension and leukocytosis are more reliable markers of severe illness 7
• Initiated oseltamivir despite possible >48 hour symptom duration, as benefit may still exist in severely ill hospitalized patients 1, 3