When a patient presents with a chief complaint of upper respiratory Infection symptoms (fevers, cough, runny nose,) the first thing we do, like all chief complaints, is start with a critical differential diagnosis.
Fever and Cough:
Cellulitis (or other soft tissue infection)
So for our algorithm we consider how to evaluate each of these critical diagnosis before anchoring on viral uri. That does not mean you have to LP everyone. It just means that you have to evaluate your patient for each of the diagnoses on your critical differentials.
So here is the algorithm
Q1: Does the patient have a wild card? Are they immunosuppressed, i.e. AIDS, chemo patient who could be neutropenic, transplant patient, or a pt on rheum medications? Is your patient very old or very young? Does the patient have cardiac (CHF) or pulmonary (COPD) disease? These are all patients that have an increased risk of mortality and as a result may require a more extensive work up. For more on wild cards, review our lecture on the topic (https://www.blog.numose.com/emed-basics/wildcard).
If the answer is yes then you should expand your work up esp if the patient is febrile.
Consider ordering the following
Make sure to do a careful focused physical exam looking for clinical features consistent with diagnoses on your critical differential. For example, carefully evaluate your patient for ams and meningitis. Check to see if your patient has a new murmur consistent with endocarditis. If your patient has tachycardia out of proportion to fever, evidence of elevated jvd, crackles in the lungs, and lower extremity edema consider myocarditis.
If the answer to Q1 is no then you can lower your guard. The next question to ask is how long the symptoms have been present and if the cough is productive. There are multiple differing guidelines and rules that try to guide if your patient should get a chest xray. In general it seems to be a moving target. If the patient has had symptoms for > 1-2 weeks and the cough has become increasingly more productive than a chest xray may be warranted. If the time frame is less than that and there are no wild cards or red flags then most likely your patient has an acute viral upper respiratory infection and can be d/ced home with no work up.
The Idea being that not everyone who presents with flu like symptoms needs an xray on day 2 of the illness.
But wait, what about an Influenza swab
For this healthy population a Influenza swab is not helpful. If the pt presents within 72 hours and the swab is positive tamiflu would not necessarily need to be prescribed especially since the efficacy of the medication is starting to come in doubt. These healthy patients should also be able to recover from the flu with basic symptomatic management. Unless your ID department is trying to track how many influenza cases your department is seeing, avoid this test in the patient without any wild cards as it won’t change your management of the patient.
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