Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint:
Document the patient’s main concerns related to influenza infection. This may include:
Fever (common)
Chills
Myalgia (muscle aches)
Malaise (fatigue)
Headache
Cough (may be dry or productive)
Sore throat
Runny or stuffy nose
History of Present Illness:
Onset and duration of symptoms.
Severity of symptoms (e.g., high fever, debilitating fatigue).
Any history of recent contact with individuals with influenza-like illness.
Vaccination status for influenza (current season).
Past Medical History:
Underlying medical conditions that may increase risk of complications (e.g., chronic lung disease, heart disease, immunodeficiency).
Prior hospitalizations for influenza or other respiratory illnesses.
Family History:
Family members with recent influenza-like illness (uncommon to elicit specific details).
Social History:
Occupation (certain professions have higher exposure risk).
Living situation (crowded living conditions can increase transmission risk).
Physical Examination:
Vital signs (may show fever, tachycardia).
General examination: assess for signs of dehydration, respiratory distress.
Head, Ears, Nose, and Throat (HEENT) examination:
Nasal congestion, rhinorrhea (runny nose)
Pharyngeal erythema (redness in the back of the throat)
Chest examination:
Listen for wheezing or crackles (abnormal lung sounds) that may indicate lower respiratory tract involvement.
Laboratory Tests:
Rapid influenza diagnostic test (RIDT):
Point-of-care test to detect influenza A and B viruses quickly (may not be definitive).
Influenza PCR (polymerase chain reaction):
More sensitive and specific test for influenza virus detection, but results may take longer.
Complete blood count (CBC) (optional):
May show mild leukocytosis (increased white blood cells) in some cases.
Imaging Studies:
Imaging studies are not routinely needed for uncomplicated influenza.
Chest X-ray (may be considered if suspicion for pneumonia).
Diagnosis:
Influenza virus infection (confirmed or suspected based on clinical presentation and testing).
Specify the influenza type if identified by testing (e.g., influenza A infection).
Staging (not applicable):
Influenza infection does not have stages.
Treatment Plan:
Treatment for uncomplicated influenza focuses on symptom management and supportive care.
Antiviral medications (oseltamivir, zanamivir) are most effective when started within 48 hours of symptom onset. They may shorten illness duration and lessen symptom severity.
Supportive measures include:
Rest
Increased fluids to prevent dehydration
Over-the-counter medications for fever, cough, and muscle aches (acetaminophen, ibuprofen)
Prognosis:
Reassure the patient that most healthy individuals recover from influenza within a week to two weeks.
Advise on potential complications (e.g., pneumonia, especially in high-risk individuals).
Patient Education:
Importance of rest and staying home to prevent further spread of the virus.
Proper hand hygiene and cough etiquette to minimize transmission.
Hydration and maintaining good nutrition to support recovery.
When to seek additional medical attention (e.g., worsening symptoms, difficulty breathing, high fever persisting for more than 3 days).
Importance of annual influenza vaccination for prevention (advise based on season).