Dysuria / Flu “answers”

A 30s M presents with 3-4 days of suprapubic pain with dysuria. He denies discharge, GU lesions, or testicular pain. His review of systems is notable for nausea, and no vomiting / diarrhea. He has no pmh, psh, and his appetite has been fine. His vitals are normal (afebrile). On exam, he has mild suprapubic tenderness and no cvat. He has a wbc of 14 and his chem, LFTs are normal. His urinanalysis is shown. What do we do next?

—

Like much of medicine, there are no simple answers. If you asked ten doctors, you are likely to get ten different answers. There are counterpoints to all of my answers.

I would get a cxr. A patient with a normal O2 sat and clear lungs do not need a cxr because they don’t have pneumonia. That’s true about 99.99% of the time, but a rare patient may have pneumonia despite normal findings. Many providers will get a cxr on anyone with a fever. When the ED is busy, I tend to get more testing because I don’t have much time for each patient. The common serious complication of the flu is pneumonia, and a cxr is an easy, low-risk screening tool.

I would not give iv fluids. If a patient walks into the ED, he is tolerating sufficient oral intake even if he may be a bit dehydrated. IV fluids make most patients with viral syndromes feel better, but it is far from a necessity.

I would not send a flu swab. You don’t need a lab test to know if someone has the flu. A simple guideline is to flu test everyone that is getting admitted to the hospital (with viral symptoms). The rapid flu test is insensitive and the pcr test is more reliable though it takes longer. Occasionally, I would do a flu test out of curiosity, usually outside the “flu season” to see if the flu is starting, or to see if a patient is dying from the flu. The flu does not know there is a season and can occur at any time.

I would not do a sepsis bundle for a patient that seems to have a viral illness. By guidelines and CMS requirements, this patient is a candidate for the sepsis protocol, but that does not make it the right thing to do. The provider is balancing doing what is right and being potentially ding’d by missing a septic patient. Think about the impact of a sepsis bundle for every flu patient in the midst of a flu epidemic which has already overburdened the ED. There are many negative aspects of the CMS requirements – unnecessary testing (leading to unnecessary admissions, treatment, e.g. false positive blood cultures), unnecessary abx (causing more abx resistance, c dif), unnecessary fluids (causing chf or worse), and so on.

I would not give tamiflu. The controversy behind tamiflu is well-documented. I do not believe that it helps at all. I give anti-virals to patients that are dying (different anti-virals depending on the prevalent strain / sensitivities, this may include amantadine).

I would put the pt in “isolation”. Patients with the flu are contagious. It is not possible to isolate twenty flu patients in any ED. Isolation means asking the patient to wear a surgical mask. Isolation is incomplete because patients go to the bathroom, touch the stretchers, and go to the cafeteria. We don’t wipe down the crime scene every time a flu patient goes to the common bathroom. Do ambulances get wiped down after transporting a flu patient? Don’t get me started on state mandates on health care workers and the flu. It’s ridiculous to mandate a nurse who does not have the flu to wear a mask, but a patient that actually has the flu is not legally required to wear a mask. Containment rarely works for contagious disease; think “Outbreak”, “Resident Evil”, “World War Z”, and mrsa.