This week, I had an extremely important appointment to attend; therefore, I placed the address into the GPS system of my vehicle. After approximately ten minutes, I felt uncomfortable with the directions and stopped at the side of the road. My intuition was telling me that I was going in the wrong direction. I placed the address again and now had a new set of directions, which seemed logical. In about fifteen minutes, I saw a change in direction and once again trusted my intuition and made the change yet one more time, and I knew it was now correct. Sometimes, we have tossed away logic and intuition in favor of technology, and the result can be upending, to say the least. In the practice of medicine, we have certain recommendations and guidelines that have been delivered by organizations such as the CDC. Yet, our experience, clinical judgment, and intuition will sometimes create an entirely different diagnosis and, therefore, a different clinical approach. Which one do we use Is it safer to utilize our experience, education, and intuition when approaching a patient rather than depend solely on technology Both have a place, but good clinical judgment will be married to our experience. Many new clinicians are missing this important part of the puzzle and have become accustomed to the easy way, only using guidelines. They can readily miss the diagnosis, create a dangerous situation for their patients, and come headlong into litigation for failure to diagnose. Having a good history and knowing the facts are always important to expand our differential diagnosis. The purpose of this missive is to remind clinicians that with the new season of Autumn, we will see the dreaded tripledemic, and I endeavor to give certain facts that may be a helpful reminder for both the old and the new.
We are entering the season of Influenza, COVID-19, and RSV. The big questions relate to our ability to listen to our patients and pinpoint certain signs and symptoms during our exam that can lead us in the correct discussion path in order to deliver the appropriate treatment. We can also use the opportunity to remind our patients that vaccinations are available to lessen the effects of these illnesses; we can remind the patient to utilize other strategies related to our hygiene and methods of lessening transmission, most especially to those who can succumb to these diseases and possibly lose their lives. No one wants to live with the knowledge that they may have been responsible for the death of their grandparents or others who have compromised immune systems, including pregnant women.
What are the most common signs of Influenza? The patient may present with a cough, sore throat, runny nose, nasal congestion, body aches, headaches, and extreme fatigue. Many have sinus infections, bronchitis, pneumonia, and ear infections due to flu-related complications. In an average year, thousands of people in the United States die from flu. Always entertain the differential diagnosis; this is the season to review these diseases and become the experts our patients think we are. How does this differ from a cold? A cold usually has some symptoms, such as sneezing, sore throat, cough, and a runny nose. A cold is annoying, but not debilitating. How do we treat patients with influenza? We suggest they rest, drink plenty of fluids, and take pain relievers such as OTC Tylenol or Aleve and Advil. Remember to check their medications and history to prevent bleeding in patients with A-Fib or other conditions for which they have been prescribed blood thinners. Post-exposure medications would be antivirals, not antibiotics, and the suggested medications are Tamiflu, Relenza, Rapived, and Xoflu. “Listen to your intuition. It will tell you everything you need to know.” Anthony J. D’Angelo, The College Blue Book.
We have been told that Covid is now a virus that we can expect annually, and we certainly need to prevent our friends, families, and ourselves from becoming infected. I had Covid two years ago and was hospitalized twice with pulmonary and gastrointestinal effects. Unfortunately, I have yet to regain my sense of taste, which is a major situation when your wife is a good cook. My wife was also hospitalized within weeks of me and has since suffered from the effects of long-term Covid-19 in relation to her memory. Even Covid Celia is smarter than most of her friends but is aware of some cognitive residuals. Covid-19 infection in 2023 looks similar to earlier years but is more forgiving.
What does Covid look like in the patient encounter? The patient presents with fever and chills, cough, shortness of breath, extreme fatigue, muscle or body aches, headache, the new loss of smell or taste, sore throat, congestion or runny nose, nausea and vomiting (particularly in children), diarrhea, upper respiratory infection. Some may develop a more severe lower respiratory tract infection which can become pneumonia, and in addition, conjunctivitis. The Eris variant has a lower rate of loss of taste and smell. The treatment can be Paxoloid in the first forty-eight- hours, Veklury, and Lagevrio. The CDC also suggests isolation, taking precautions, and getting plenty of fluids and rest.
The last culprit I wish to discuss is RSV (Respiratory Syncytial Virus).
In most cases in adults, the symptoms are a mild cough and cold, but some adults, particularly those over 65 or the immunocompromised, can have severe complications; in any given year, 177,000 adults over 65 are hospitalized, and 14,000 die due to their complications.
The symptoms of an RSV patient include a stuffy nose, sneezing, coughing, wheezing, lethargy, decreased appetite, or fever (which is more common in children). A severe infection will have a patient present with S.O.B., difficulty in breathing, and a worsening cough that leads to wheezing, tachycardia, high fever, convulsions, extreme exhaustion, disorientation, and dehydration. You may discover cyanosis in their extremities. These patients need immediate medical attention. If they are home, suggest 911; if they are in your office, do likewise, as oxygenation is paramount. Treatment in the healthy patient is usually OTC Cold preparations and Tylenol or Advil, based on their hematological profile and concurrent drugs. Remember, more severe infection requires oxygen, a steroid course for pulmonary inflammation, and a bronchodilator.
Writing this in October gives me permission to wish you all A Happy Halloween. Unfortunately, trick or treating or home parties, which many parents host, can and will usually spread viruses unless the little revelers are immunized. Children are notorious for not washing their hands in most circumstances; therefore, their little hands are infection vectors. Ask yourself, how can you best protect your family and those you are responsible for?
My summation is a warning to be a real sleuth and not to cherry-pick a diagnosis. What is so frightening for those in primary care, urgent care, and the ER is that there is a tremendous overlapping of the symptoms, and yet they are different illnesses and require different treatments. It is easy, in a rapid medical environment, to miss certain cues, and send the patient out without the appropriate therapy. The patient can then develop a far more severe problem. We will all make errors, unfortunately. The purpose of this missive is to exhort you to sharpen your skills and to make you aware that a missed diagnosis is a patient who becomes sicker and a possible litigation for you. How do you protect yourself, your license, profession, and your loved ones in this chaotic environment? It is only by purchasing a personal liability insurance policy whose job is to protect your interests. Why take chances? Some say it costs too much money. On the contrary, just like other medical items, they are a tax deduction. But the greatest reward you can have from this decision is knowing that regardless of the problem, you will have the security of the best, an AAA Best (Superior) Company in the country that offers excellent legal support through every step of your legal journey. Happy Halloween.
Written For CM&F By: Robert M. Blumm, PA, DFAAPA, PA-C Emeritus
CM&F Clinical Advisor