4-12
fever. Administer bid for 5 days via plastic inhaler (Diskhaler). If patients develop wheezing, discontinue
the drug and be prepared to treat symptoms (see Respiratory: Asthma). Amantadine or
rimantadine shorten duration of symptoms by 50% and are recommended for patients at high risk
for complications from infection. 100 mg bid po for 3-5 days if started within the first 48 hours. Give
symptomatic treatment for cough and nasal symptoms as well.
Patient Education
General: Infections can spread via airborne droplets (cough, sneeze) and contact (contaminated hands,
lips and objects). The usual course of a cold is 6-10 days, and about half that length for uncomplicated
influenza.
Activity: Rest is important to speed recovery. Strenuous activity can delay recovery.
Medication: Aspirin is not recommended, especially in children, due to the risk of Reye’s syndrome – a
life-threatening form of kidney failure.
Prevention: Hand washing can reduce transmission. Vaccination will prevent specific strains of influenza,
but not all influenza. The vaccine cannot cause influenza, but some side effects (myalgia, headache) may
mimic mild influenza or cold symptoms.
No Improvement/Deterioration: Return if symptoms worsen or do not resolved in two weeks, or if fever
over 103°F develops.
Follow-up Actions
Return Evaluation: Evaluate for alternative diagnoses and complications, including secondary bacterial
infection, if still symptomatic after 72 hours of treatment (particularly if in high-risk group).
Evacuation/Consultation criteria: Evacuation not usually necessary, except for moderate to severe influ-
enza. Consult primary care physicians as needed.
Respiratory: Pneumonia
COL Warren Whitlock, MC, USAIntroduction: Pneumonia, an infection of the lungs, is a leading cause of death worldwide. There are three
important principles for successful treatment:
- Accurately assess severity and initiate appropriate treatment-- outpatient or inpatient administration of IV
antibiotics. Hospitalize any patient with more than 2 of the following characteristics: age >65, immunosup
pression due to chronic disease, significantly altered vital signs (temp >102°F, tachypnea, hypotension)
or mental status changes, lab or x-ray findings as below. Mortality for these patients can be 10-25%
versus < 1% for other patients. - Avoid delays in treatment, which can negatively affect the patient outcome.
- Treat appropriate organisms: typical (bacterial) and atypical (mycoplasma, chlamydia, legionella, viruses)
organisms
Subjective: Symptoms
Fever (over 101°F), rigors (shaking chills), malaise, shortness of breath, cough (productive and non-
productive), occasional myalgias, chest pain– generally pleuritic (rarely upper abdominal).
Focused History: Quality: Do you cough up anything? What color is it? (Colored sputum is a good indicator
of bacterial infection.) Does coughing or deep breathing make your chest hurt? (Chest pain of pneumonia
characteristically worsens with cough or deep breathing.) Where does it hurt? (If located over rales, unilateral
rhonchi, or a pleural friction rub, indicates probable “lobar” or whole lobe pneumonia.) Do you have fever or
shaking chills? (Atypical pneumonia can present with low-grade fever but typical pneumonia classically presents
with high, spiking fevers that follow rigors or shaking chills.) Do you have any trouble breathing? (Shortness
of breath or difculty breathing is typical.) When is the cough worse? (Post-nasal drip cough is worse at night.)
Duration: When did the symptoms start? (Typical pneumonia develops suddenly and patient presents within
hours. Atypical [viral, mycoplasma, etc.] usually begins with a prodrome of low-grade fever and malaise for
several days.) Alleviating or Aggravating Factors: Is the pain better in certain positions? (Chest pain that