1. Pandemic Influenza Triage Tools Educational Program Module II Triage Game Patient Triage by Clinicians

2. Triage Game: Case Studies Assume pandemic is declared Review patient information Using PITA – Rate Level 1 - 5

3. Case Study 1 Patient Case: 59-year-old male Influenza Symptoms: 100.7° temperature. Cough and aching all over Chief Complaint: Cough, body aches and fever for two days Past Medical History: Hypertension, insulin-dependent diabetes, CHF, arthritis Vital Signs: SpO2 – 91% (room air), Temperature – 100.7°, Heart Rate – 108, Respiratory Rate – 28, Blood Pressure – 170/102 Appearance: Awake, alert, with diaphoresis and increased work of breathing and some nasal flaring PITA Score:

4. Case Study 1 continued Patient Case: 59-year-old male Influenza Symptoms: 100.7° temperature. Cough and aching all over Chief Complaint: Cough, body aches and fever for two days Past Medical History: Hypertension, insulin-dependent diabetes, CHF, arthritis Vital Signs: SpO2 – 91% (room air), Temperature – 100.7°, Heart Rate – 108, Respiratory Rate – 28, Blood Pressure – 170/102 Appearance: Awake, alert, with diaphoresis and increased work of breathing and some nasal flaring PITA Score: 2

5. Case Study 2 Patient Case: 55-year-old female Influenza Symptoms: 101.6° temperature, cough, aches and pains, tolerating oral fluids Chief Complaint: Sneezing, nasal congestion, cough, and generalized muscle aches and pains Past Medical History: Hypertension Vital Signs: SpO2 – 98% (room air), Temperature – 101.6°, Heart Rate – 70, Respiratory Rate – 16, Blood Pressure – 158/92 Appearance: All within normal limits PITA Score:

6. Case Study 2 continued Patient Case: 55-year-old female Influenza Symptoms: 101.6° temperature, cough, aches and pains, tolerating oral fluids Chief Complaint: Sneezing, nasal congestion, cough, and generalized muscle aches and pains Past Medical History: Hypertension Vital Signs: SpO2 – 98% (room air), Temperature – 101.6°, Heart Rate – 70, Respiratory Rate – 16, Blood Pressure – 158/92 Appearance: All within normal limits PITA Score: 5

7. Case Study 3 Patient Case: 43-year-old male Influenza Symptoms: 102.6° temperature, cough, vomiting, diarrhea Chief Complaint: Two-day history of fever and cough, with vomiting and diarrhea for the past 12 hours. All attempts to take fluids/anti-pyretics results in vomiting them back up Past Medical History: None Vital Signs: SpO2 – 98% (room air), Temperature – 102.6°, Heart Rate – 120, Respiratory Rate – 20, Blood Pressure – 108/74 Appearance: Awake and alert, with dry mucous membranes and hot, dry skin PITA Score:

8. Case Study 3 continued Patient Case: 43-year-old male Influenza Symptoms: 102.6° temperature, cough, vomiting, diarrhea Chief Complaint: Two-day history of fever and cough, with vomiting and diarrhea for the past 12 hours. Attempts to take fluids/anti-pyretics results in vomiting them back up Past Medical History: None Vital Signs: SpO2 – 98% (room air), Temperature – 102.6°, Heart Rate – 120, Respiratory Rate – 20, Blood Pressure – 108/74 Appearance: Awake and alert, with dry mucous membranes and hot, dry skin PITA Score: 3

9. Case Study 4 Patient Case: 35-year-old female Influenza Symptoms: 103° temperature, cough, achiness all over Chief Complaint: Cough and fever for a few days last week. Got better, but developed high fever (up to 104°) today with cough and shortness of breath. Aches all over. Tolerating fluids well Past Medical History: None Vital Signs: SpO2 – 96% (room air), Temperature – 103°, Heart Rate – 103, Respiratory Rate – 20, Blood Pressure – 126/80 Appearance: Awake, alert, with frequent productive cough (green sputum) PITA Score:

10. Case Study 4 continued Patient Case: 35-year-old female Influenza Symptoms: 103° temperature, cough, achiness all over Chief Complaint: Cough and fever for a few days last week. Got better, but developed high fever (up to 104°) today with cough and shortness of breath. Aches all over. Tolerating fluids well Past Medical History: None Vital Signs: SpO2 – 96% (room air), Temperature – 103°, Heart Rate – 103, Respiratory Rate – 20, Blood Pressure – 126/80 Appearance: Awake, alert, with frequent productive cough (green sputum) PITA Score: 3

11. Case Study 5 Patient Case: 80-year-old male, nursing home resident Influenza Symptoms: 102° temperature, dry cough, headache, severe muscle aches/pains Chief Complaint: Sudden onset of flu-like symptoms, including fever, cough, chest discomfort, and worsening respiratory distress Past Medical History: Congestive heart failure Vital Signs: SpO2 – 89% (room air), Temperature – 102°, Heart Rate – 122, Respiratory Rate – 28, Blood Pressure – 96/52 Appearance: Lethargic, pale, and in severe respiratory distress with retractions. Sitting in a tripod position PITA Score:

12. Case Study 5 continued Patient Case: 80-year-old male, nursing home resident Influenza Symptoms: 102° temperature, dry cough, headache, severe muscle aches/pains Chief Complaint: Sudden onset of flu-like symptoms, including fever, cough, chest discomfort, and worsening respiratory distress. Past Medical History: Congestive heart failure Vital Signs: SpO2 – 89% (room air), Temperature – 102°, Heart Rate – 122, Respiratory Rate – 28, Blood Pressure – 96/52 Appearance: Lethargic, pale and in severe respiratory distress with retractions. Sitting in a tripod position PITA Score: 1

13. Case Study 6 Patient Case: 38-year-old female Influenza Symptoms: 101.9° temperature, labored breathing Chief Complaint: Fever, cough, chest and joint pain Past Medical History: Sickle cell anemia, splenectomy Vital Signs: SpO2 – 90% (room air), Temperature – 101.9°, Heart Rate – 138, Respiratory Rate – 42, Blood Pressure – 126/72 Appearance: Writhing in pain, unable to speak complete sentences, use of accessory muscles of breathing. Grunting PITA Score:

14. Case Study 6 continued Patient Case: 38-year-old female Influenza Symptoms: 101.9° temperature, labored breathing Chief Complaint: Fever, cough, chest and joint pain Past Medical History: Sickle cell anemia, splenectomy Vital Signs: SpO2 – 90% (room air), Temperature – 101.9°, Heart Rate – 138, Respiratory Rate – 42, Blood Pressure – 126/72 Appearance: Writhing in pain, unable to speak complete sentences, use of accessory muscles of breathing. Grunting PITA Score: 1

15. Case Study 7 Patient Case: 7-year-old male Influenza Symptoms: 102.7° temperature, sore throat Chief Complaint: Patient's throat hurts. Hasn't been eating or drinking much for two days. Decreased urine output. Brother has the flu. Family is living in a domestic violence shelter and has no money or access to antipyretics Past Medical History: None. Immunizations are up to date Vital Signs: SpO2 – 98% (room air), Temperature – 102.7°, Heart Rate – 118, Respiratory Rate – 22 Appearance: Awake and alert. Hot, dry skin and dry lips PITA Score:

16. Case Study 7 continued Patient Case: 7-year-old male Influenza Symptoms: 102.7° temperature, sore throat Chief Complaint: Patient's throat hurts. Hasn't been eating or drinking much for 2 days. Decreased urine output. Brother has the flu. Family is living in a domestic violence shelter and has no money or access to anti-pyretics Past Medical History: None. Immunizations are up to date Vital Signs: SpO2 – 98% (room air), Temperature – 102.7°, Heart Rate – 118, Respiratory Rate – 22 Appearance: Awake and alert. Hot, dry skin and dry lips PITA Score: 4

17. Case Study 8 Patient Case: 29-year-old female Influenza Symptoms: 101° temperature, cough, wheezing, and shortness of breath Chief Complaint: Cough and fever for two days with increasing shortness of breath and wheezing. Has been taking Albuterol inhaler several times a day Past Medical History: Asthma (uses inhaler daily year-round) Vital Signs: SpO2 – 93% (room air), Temperature – 101, Heart Rate – 106, Respiratory Rate – 20, Blood Pressure – 108/70 Appearance: Awake and alert. Increased work of breathing and mild retractions PITA Score:

18. Case Study 8 continued Patient Case: 29-year-old female Influenza Symptoms: 101° temperature, cough, wheezing, and shortness of breath Chief Complaint: Cough and fever for two days with increasing shortness of breath and wheezing. Has been taking Albuterol inhaler several times a day Past Medical History: Asthma (uses inhaler daily year-round) Vital Signs: SpO2 – 93% (room air), Temperature – 101, Heart Rate – 106, Respiratory Rate – 20, Blood Pressure – 108/70 Appearance: Awake and alert. Increased work of breathing and mild retractions PITA Score: 2

19. Case Study 9 Patient Case: 18-month-old female Influenza Symptoms: 101.2° temperature, cough, wheezing Chief Complaint: Patient became ill two days ago with a productive cough and temperature up to 102°. Patient's older sibling has been home with the flu for several days. Patient began wheezing this morning Past Medical History: None. Fully immunized (including flu) Vital Signs: SpO2 – 96% (room air), Temperature – 101.2 °, Heart Rate – 112, Respiratory Rate – 24 Appearance: Awake and alert. Frequent cough with occasional audible wheezing noted. Drinking juice during triage. Respirations nonlabored. Skin colored pink PITA Score:

20. Case Study 9 continued Patient Case: 18-month-old female Influenza Symptoms: 101.2° temperature, cough, wheezing Chief Complaint: Patient became ill two days ago with a productive cough and temperature up to 102 °. Patient's older sibling has been home with the flu for several days. Patient began wheezing this morning Past Medical History: None. Fully immunized (including flu) Vital Signs: SpO2 – 96% (room air), Temperature – 101.2 °, Heart Rate – 112, Respiratory Rate – 24 Appearance: Awake and alert. Frequent cough with occasional audible wheezing noted. Drinking juice during triage. Respirations non-labored. Skin colored pink PITA Score: 3

21. Case Study 10 Patient Case: 22-year-old female Influenza Symptoms: 101.6° temperature, aches all over Chief Complaint: Works as a nanny and one of the children she cares for was diagnosed with influenza yesterday Past Medical History: No past medical history Vital Signs: SpO2 – 100% (room air), Temperature – 101.6°, Heart Rate – 80, Respiratory Rate – 16, Blood Pressure – 98/60 Appearance: All within normal limits PITA Score:

22. Case Study 10 continued Patient Case: 22-year-old female Influenza Symptoms: 101.6° temperature, aches all over Chief Complaint: Works as a nanny and one of the children she cares for was diagnosed with influenza yesterday Past Medical History: No past medical history Vital Signs: SpO2 – 100% (room air), Temperature – 101.6°, Heart Rate – 80, Respiratory Rate – 16, Blood Pressure – 98/60 Appearance: All within normal limits PITA Score: 5

23. Case Study 11 Patient Case: 25-year-old male Influenza Symptoms: 103.2 ° temperature, sore throat, body aches, able to keep fluids down Chief Complaint: "I should have listened to my mother," reports a 25-year-old male. "She told me to get a flu shot but I was too busy. Now I think I have it. My throat is sore and I ache all over." Past Medical History: None Vital Signs: Heart Rate – 104, Respiratory Rate – 20, SpO2 – 100% (room air), BP – 110/75 Appearance: Dry mucous membranes, hurts to swallow but able to take fluids, no respiratory distress PITA Score:

24. Case Study 11 continued Patient Case: 25-year-old male Influenza Symptoms: 103.2° temperature, sore throat, body aches, able to keep fluids down Chief Complaint: "I should have listened to my mother," reports a 25-year-old male. "She told me to get a flu shot but I was too busy. Now I think I have it. My throat is sore and I ache all over." Past Medical History: None Vital Signs: Heart Rate – 104, Respiratory Rate – 20, SpO2 – 100% (room air), BP – 110/75 Appearance: Dry mucous membranes, hurts to swallow but able to take fluids, no respiratory distress PITA Score: 4

25. Case Study 12 Patient Case: 50-year-old homeless male Influenza Symptoms: 102° temperature. Productive cough Chief Complaint: Patient dropped off by police who found patient sleeping in a barrel in a park in 30° weather. Patient smokes and has been coughing "for a few days" Past Medical History: Depression Vital Signs: SpO2 – 97% (room air), Temperature – 102 °, Heart Rate – 98, Respiratory Rate – 16, Blood Pressure – 140/76 Appearance: Awake and alert. Mucous membranes dry. Drinking juice and hungrily eating crackers PITA Score:

26. Case Study 12 continued Patient Case: 50-year-old homeless male Influenza Symptoms: 102° temperature. Productive cough Chief Complaint: Patient dropped off by police who found patient sleeping in a barrel in a park in 30° weather. Patient smokes and has been coughing "for a few days" Past Medical History: Depression Vital Signs: SpO2 – 97% (room air), Temperature – 102 °, Heart Rate – 98, Respiratory Rate – 16, Blood Pressure – 140/76 Appearance: Awake and alert. Mucous membranes dry. Drinking juice and hungrily eating crackers PITA Score: 4

27. Case Study 13 Patient Case: 2-month-old infant girl Influenza Symptoms: 101.7° temperature and cough Chief Complaint: Flu-like symptoms over the last three days with nasal congestion and cough with thick mucous. Mother reports not being able to wake baby. EMS noted she was "floppy" when they arrived Past Medical History: None Vital Signs: SpO2 – 92% (on 100% oxygen by mask), Temperature – 101.7° rectal, Heart Rate – 220, Respiratory Rate – 22 Appearance: Responds to pain with weak cry. Bluish color to skin. Retractions PITA Score:

28. Case Study 13 continued Patient Case: 2-month-old infant girl Influenza Symptoms: 101.7° temperature and cough Chief Complaint: Flu-like symptoms over the last three days with nasal congestion and cough with thick mucous. Mother reports not being able to wake baby. EMS noted she was "floppy" when they arrived Past Medical History: None Vital Signs: SpO2 – 92% (on 100% oxygen by mask), Temperature – 101.7° rectal, Heart Rate – 220, Respiratory Rate – 22 Appearance: Responds to pain with weak cry. Bluish color to skin. Retractions PITA Score: 1

29. Case Study 14 Patient Case: 68-year-old female Influenza Symptoms: 101° temperature, cough, and vomiting Chief Complaint: Patient is recovering at home from deep vein thrombosis. Nurse came to draw blood for an INR level. Told nurse that she has had a fever and cough for two days. Vomiting for 24 hours. Past Medical History: Hip replacement two months ago Vital Signs: SpO2 – 99% (room air), Temperature – 101°, Heart Rate – 83, Respiratory Rate – 16, Blood Pressure – 152/75 Appearance: Awake and alert. No respiratory distress noted. Lips dry and cracked. PITA Score:

30. Case Study 14 continued Patient Case: 68-year-old female Influenza Symptoms: 101° temperature, cough, and vomiting Chief Complaint: Patient is recovering at home from deep vein thrombosis. Nurse came to draw blood for an INR level. Told nurse that she has had a fever and cough for two days. Vomiting for 24 hours. Past Medical History: Hip replacement two months ago Vital Signs: SpO2 – 99% (room air), Temperature – 101°, Heart Rate – 83, Respiratory Rate – 16, Blood Pressure – 152/75 Appearance: Awake and alert. No respiratory distress noted. Lips dry and cracked PITA Score: 4

31. Case Study 15 Patient Case: 70-year-old female Influenza Symptoms: 100.7° temperature, cough Chief Complaint: Patient has had dry cough for two weeks. Worried she might have the flu because she volunteers in an elementary school Past Medical History: Post-menopausal but no meds or comorbidities Vital Signs: SpO2 – 99% (room air), Temperature – 100.7°, Heart Rate – 63, Respiratory Rate – 16, Blood pressure – 104/66 Appearance: Awake and alert. Active, fit older adult, yoga teacher. No respiratory distress, lungs clear PITA Score:

32. Case Study 15 continued Patient Case: 70-year-old female Influenza Symptoms: 100.7° temperature, cough Chief Complaint: Patient has had dry cough for two weeks. Worried she might have the flu because she volunteers in an elementary school Past Medical History: Post-menopausal but no meds or comorbidities Vital Signs: SpO2 – 99% (room air), Temperature – 100.7°, Heart Rate – 63, Respiratory Rate – 16, Blood pressure – 104/66 Appearance: Awake and alert. Active, fit older adult, yoga teacher. No respiratory distress, lungs clear. PITA Score: 5

33. Case Study 16 Patient Case: 30-day-old infant Influenza Symptoms: 101° temperature, cough, unable to nurse Chief Complaint: Emergency Medical Services (EMS) calls in to report they are en route with a 30-day-old infant with respiratory difficulty. The mother reported that her other two children have been sick with flu-like symptoms. She also thinks he stopped breathing for a few seconds Past Medical History: None Vital Signs: SpO2 – 88% (room air), Heart Rate – 92, Respiratory Rate – 56 Appearance: Increased respiratory effort, pale, decreased responsiveness PITA Score:

34. Case Study 16 continued Patient Case: 30-day-old infant Influenza Symptoms: 101° temperature, cough, unable to nurse Chief Complaint: Emergency Medical Services (EMS) calls in to report they are en route with a 30-day-old infant with respiratory difficulty. The mother reported that her other two children have been sick with flu-like symptoms. She also thinks he stopped breathing for a few seconds Past Medical History: None Vital Signs: SpO2 – 88% (room air), Heart Rate – 92, Respiratory Rate – 56 Appearance: Increased respiratory effort, pale, decreased responsiveness PITA Score: 1

35. Case Study 17 Patient Case: 28-year-old female Influenza Symptoms: 98.6° temperature, no symptoms, able to tolerate fluids Chief Complaint: "I'm getting married next Saturday and I can't get sick," says a worried 28-year-old female. "They closed my office because just about everyone has the flu. I had my flu shot but is there anything else you can do?" Past Medical History: No past medical history Vital Signs: Heart Rate – 60, Respiratory Rate – 16, SpO2 – 100% (room air), Blood Pressure – 125/65 Appearance: All within normal limits PITA Score:

36. Case Study 17 continued Patient Case: 28-year-old female Influenza Symptoms: 98.6° temperature, no symptoms, able to tolerate fluids Chief Complaint: "I'm getting married next Saturday and I can't get sick," says a worried 28-year-old female. "They closed my office because just about everyone has the flu. I had my flu shot but is there anything else you can do?" Past Medical History: No past medical history Vital Signs: Heart Rate – 60, Respiratory Rate – 16, SpO2 – 100% (room air), Blood Pressure – 125/65 Appearance: All within normal limits PITA Score: 5

37. Case Study 18 Patient Case: 2-year-old male Influenza Symptoms: 101° temperature rectal, vomiting, diarrhea, dry cough Chief Complaint: "This poor little guy got the flu from my other kids. He's had it worse than any of them with the vomiting and diarrhea," reports the mother, while the child fussing in her arms Past Medical History: None, immunizations are up to date; child has received the seasonal influenza vaccination Vital Signs: Heart Rate – 110, Respiratory Rate – 28, SpO2 – 99% (room air) Appearance: Awake, alert, cranky child. Lips are dry and cracked and last wet diaper was a few hours ago PITA Score:

38. Case Study 18 continued Patient Case: 2-year-old male Influenza Symptoms: 101° temperature rectal, vomiting, diarrhea, dry cough Chief Complaint: "This poor little guy got the flu from my other kids. He's had it worse than any of them with the vomiting and diarrhea," reports the mother, while the child is fussing in her arms Past Medical History: None, immunizations are up to date; child has received the seasonal influenza vaccination Vital Signs: Heart Rate – 110, Respiratory Rate – 28, SpO2 – 99% (room air) Appearance: Awake, alert, cranky child. Lips are dry and cracked and last wet diaper was a few hours ago PITA Score: 3

39. Case Study 19 Patient Case: 24-year-old male Influenza Symptoms: 102.2° temperature, cough shortness of breath Chief Complaint: Increasing cough and shortness of breath over last week Past Medical History: Cystic fibrosis, double lung transplant seven months ago Vital Signs: Heart Rate – 116, Respiratory Rate – 28, SpO2 – 90% (baseline is 94%), Blood Pressure – 112/72 Appearance: Awake, alert, increased work of breathing PITA Score:

40. Case Study 19 continued Patient Case: 24-year-old male Influenza Symptoms: 102.2° temperature, cough, shortness of breath Chief Complaint: Increasing cough and shortness of breath over last week Past Medical History: Cystic fibrosis, double lung transplant seven months ago Vital Signs: Heart Rate – 116, Respiratory Rate – 28, SpO2 – 90% (baseline is 94%), Blood Pressure – 112/72 Appearance: Awake, alert, increased work of breathing PITA Score: 2

41. Case Study 20 Patient Case: 48-year-old female Influenza Symptoms: 98.6° temperature, no symptoms, able to tolerate fluids Chief Complaint: Works in a school full of kids who are home with the flu. Tried twice to get the pandemic flu shot but told not high risk and can't get it. Requesting a pandemic flu shot or Tamiflu prescription in case she gets sick. No acute complaints Past Medical History: No past medical history Vital Signs: SpO2 – 100% (room air), Temperature – 98.6°, Heart Rate – 70, Respiratory Rate – 18, Blood Pressure – 112/60 Appearance: All within normal limits PITA Score:

42. Case Study 20 continued Patient Case: 48-year-old female Influenza Symptoms: 98.6° temperature, no symptoms, able to tolerate fluids Chief Complaint: Works in a school full of kids who are home with the flu. Tried twice to get the pandemic flu shot but told not high risk and can't get it. Requesting a pandemic flu shot or Tamiflu prescription in case she gets sick. No acute complaints Past Medical History: No past medical history Vital Signs: SpO2 – 100% (room air), Temperature – 98.6°, Heart Rate – 70, Respiratory Rate – 18, Blood Pressure – 112/60 Appearance: All within normal limits PITA Score: 5

43. Case Study 21 Patient Case: 27-year-old female Influenza Symptoms: 104° temperature, difficulty breathing Chief Complaint: Fever of 104°. Was sick with cough for past two days. Bluish discoloration of lips and skin. Family reports new onset seizures (multiple back-to-back grand mal) with progressive difficulty breathing. Actively seizing upon arrival to ED. Does not respond to verbal stimuli Past Medical History: None known Vital Signs: SpO2 – 90% (on 100% oxygen via non-rebreather mask), Temperature – 104°, Heart Rate – 120, Respiratory Rate – 34, Blood pressure – 98/58 Appearance: Actively seizing, respirations labored, skin hot and damp PITA Score:

44. Case Study 21 continued Patient Case: 27-year-old female Influenza Symptoms: 104° temperature, difficulty breathing Chief Complaint: Fever of 104°. Was sick with cough for past two days. Bluish discoloration of lips and skin. Report of new onset seizures (multiple back-to-back grand mal) with progressive difficulty breathing. Actively seizing upon arrival to ED. Does not respond to verbal stimuli Past Medical History: None known Vital Signs: SpO2 – 90% (on 100% oxygen via non-rebreather mask), Temperature – 104°, Heart Rate – 120, Respiratory Rate – 34, Blood Pressure – 98/58 Appearance: Actively seizing, respirations labored, skin hot and damp PITA Score: 1

45. Case Study 22 Patient Case: 52-year-old male Influenza Symptoms: 102.9° temperature, cough Chief Complaint: Cough and fever. Homeless. Doesn't' have money to buy food, fluids or antipyretics Past Medical History: Schizophrenia Vital Signs: Heart Rate – 96, Respiratory Rate – 20, SpO2 – 97%, Blood Pressure – 155/68 Appearance: Awake, alert, frequent cough, hot dry skin, dry lips PITA Score:

46. Case Study 22 continued Patient Case: 52-year-old male Influenza Symptoms: 102.9° temperature, cough. Chief Complaint: Cough and fever. Homeless. Doesn't have money to buy food, fluids or antipyretics Past Medical History: Schizophrenia Vital Signs: Heart Rate – 96, Respiratory Rate – 20, SpO2 – 97%, Blood Pressure – 155/68 Appearance: Awake, alert, frequent cough, hot to touch, dry lips PITA Score: 4

47. Case Study 23 Patient Case: 36-year-old male Influenza Symptoms: 101° temperature, sore throat and cough Chief Complaint: Cough (green sputum) and fever. Last used inhaler an hour ago Past Medical History: Paraplegia (fall 10 years ago; spinal cord injury), multiple episodes of pneumonia, uses inhaler prn Vital Signs: Heart Rate – 86, Respiratory Rate – 20, SpO2 – 95%, fever up to 103° before taking antipyretic an hour ago. Blood Pressure – 134/67 Appearance: Awake, alert, occasional wheezing PITA Score:

48. Case Study 23 continued Patient Case: 36-year-old male Influenza Symptoms: 101° temperature, sore throat and cough Chief Complaint: Cough (green sputum) and fever. Last used inhaler an hour ago Past Medical History: Paraplegia (fall 10 years ago; spinal cord injury), multiple episodes of pneumonia, uses inhaler prn Vital Signs: Heart Rate – 86, Respiratory Rate – 20, SpO2 – 95%, fever up to 103° before taking antipyretic an hour ago. Blood Pressure – 134/67 Appearance: Awake, alert, occasional wheezing PITA Score: 3

49. Case Study 24 Patient Case: 70-year-old male Influenza Symptoms: Cough, fever Chief Complaint: Coughing up yellow sputum x2 weeks, fever up to 102, increased shortness of breath over baseline Past Medical History: Cirrhosis, hypertension Vital Signs: Temperature – 100°, Heart Rate – 106, Respiratory Rate – 32, SpO2 – 93%, Blood pressure – 172/89 Appearance: Awake, alert, increased work of breathing PITA Score:

50. Case Study 24 continued Patient Case: 70-year-old male Influenza Symptoms: Cough, fever Chief Complaint: Coughing up yellow sputum x2 weeks, fever up to 102, increased shortness of breath over baseline Past Medical History: Cirrhosis, hypertension Vital Signs: Temperature – 100°, Heart Rate – 106, Respiratory Rate – 32, SpO2 – 93%, Blood Pressure – 172/89 Appearance: Awake, alert, increased work of breathing PITA Score: 2

51. Case Study 25 Patient Case: 14-year-old female Influenza Symptoms: Cough Chief Complaint: Patient is from out of town, traveling with school group, was exposed to influenza on the bus. Coughing. History of asthma but doesn't have her inhaler with her Past Medical History: Mild asthma Vital Signs: Temperature – 100°, Heart Rate – 76, Respiratory Rate – 18, SpO2 – 97%, Blood Pressure – 110/72 Appearance: Awake, alert, occasional wheezing noted on auscultation PITA Score:

52. Case Study 25 continued Patient Case: 14-year-old female Influenza Symptoms: Cough Chief Complaint: Patient is from out of town, traveling with school group, was exposed to influenza on the bus. Coughing. History of asthma but doesn't have her inhaler with her Past Medical History: Mild asthma Vital Signs: Temperature – 100°, Heart Rate – 76, Respiratory Rate – 18, SpO2 – 97%, Blood Pressure – 110/72 Appearance: Awake, alert, occasional wheezing noted on auscultation PITA Score: 4

53. Case Study 26 Patient Case: 47-year-old male Influenza Symptoms: Productive cough Chief Complaint: Patient complains of cough with green sputum. Was sick last week with mild cough, got better and then yesterday got a lot worse. Fevers/chills all night (didn't take temp at home) Past Medical History: Kidney disease – on hemodialysis Vital Signs: Temperature – 103°, Heart Rate – 96, Respiratory Rate – 22, SpO2 – 95%, Blood Pressure – 138/78 Appearance: Awake, alert, constant cough PITA Score:

54. Case Study 26 continued Patient Case: 47-year-old male Influenza Symptoms: Productive cough Chief Complaint: Patient complains of cough with green sputum. Was sick last week with mild cough, got better and then yesterday got a lot worse. Fevers/chills all night (didn't take temp at home) Past Medical History: Kidney disease – on hemodialysis Vital Signs: Temperature – 103°, Heart Rate – 96, Respiratory Rate – 22, SpO2 – 95%, Blood Pressure – 138/78 Appearance: Awake, alert, constant cough PITA Score: 3

55. Case Study 27 Patient Case: 6-year-old female Influenza Symptoms: Cough Chief Complaint: Mom states patient has had cough for three days. Can't sleep at night due to coughing. Tolerating fluids well but decreased appetite Past Medical History: None. Did not receive influenza vaccine but is up to date on other immunizations Vital Signs: Temperature – 100°, Heart Rate – 86, Respiratory Rate – 20, SpO2 – 99% Appearance: Awake, alert, mucous membranes moist PITA Score:

56. Case Study 27 continued Patient Case: 6-year-old female Influenza Symptoms: Cough Chief Complaint: Mom states patient has had cough for three days. Can't sleep at night due to coughing. Tolerating fluids well but decreased appetite Past Medical History: None. Did not receive influenza vaccine but is up to date on other immunizations Vital Signs: Temperature – 100°, Heart Rate – 86, Respiratory Rate – 20, SpO2 – 99% Appearance: Awake, alert, mucous membranes moist PITA Score: 5

57. Case Study 28 Patient Case: 48-year-old male Influenza Symptoms: Respiratory distress Chief Complaint: Patient resides in rest home and was found with agonal respirations. Had been sick with cough and fever for a few days Past Medical History: Post-head injury, requires total care Vital Signs: Temperature – 97° rectal, Heart Rate – 44, Respiratory Rate – 8, SpO2 – 77%, Blood Pressure – 70/32 Appearance: Unresponsive, cool, clammy, agonal respirations PITA Score:

58. Case Study 28 continued Patient Case: 48-year-old male Influenza Symptoms: Respiratory distress Chief Complaint: Patient resides in rest home and was found with agonal respirations. Had been sick with cough and fever for a few days Past Medical History: Post-head injury, requires total care Vital Signs: Temperature – 97° rectal, Heart Rate – 44, Respiratory Rate – 8, SpO2 – 77%, Blood Pressure – 70/32 Appearance: Unresponsive, cool, clammy, agonal respirations PITA Score: 1

59. Case Study 29 Patient Case: 8-year-old female Influenza Symptoms: Cough, sore throat and fever Chief Complaint: Productive cough, sore throat and fever up to 103° for two days. Mom is concerned about patient's heavy breathing, which is worse when she lies down Past Medical History: Spina bifida (permanently in wheel chair), pneumonia, indwelling ventriculoperitoneal shunt, multiple surgeries Vital Signs: Temperature – 102.2°, Heart Rate – 110, Respiratory Rate – 30, SpO2 – 93% Appearance: Increased work of breathing with some retractions and nasal flaring PITA Score:

60. Case Study 29 continued Patient Case: 8-year-old female Influenza Symptoms: Cough, sore throat and fever Chief Complaint: Productive cough, sore throat and fever up to 103° for two days. Mom is concerned about patient's heavy breathing, which is worse when she lies down Past Medical History: Spina bifida (permanently in wheel chair), pneumonia, indwelling ventriculoperitoneal shunt, multiple surgeries Vital Signs: Temperature – 102.2°, Heart Rate – 110, Respiratory Rate – 30, SpO2 – 93% Appearance: Increased work of breathing with some retractions and nasal flaring PITA Score: 2

61. Case Study 30 Patient Case: 35-year-old female Influenza Symptoms: Cough with wheezing, fever Chief Complaint: Cough for three days, began wheezing last night, felt feverish but didn't check temperature at home Past Medical History: Eczema Vital Signs: Temperature – 102.1°, Heart Rate – 88, Respiratory Rate – 24, SpO2 – 94%, Blood Pressure – 140/78 Appearance: Wheezing on auscultation, awake, alert, tolerating oral fluids well PITA Score:

62. Case Study 30 continued Patient Case: 35-year-old female Influenza Symptoms: Cough with wheezing, fever Chief Complaint: Cough for three days, began wheezing last night, felt feverish but didn't check temperature at home Past Medical History: Eczema Vital Signs: Temperature – 102.1°, Heart Rate – 88, Respiratory Rate – 24, SpO2 – 94%, Blood Pressure – 140/78 Appearance: Wheezing on auscultation, awake, alert, tolerating oral fluids well PITA Score: 3

63. Case Study 31 Patient Case: 8-month-old female Influenza Symptoms: Cough Chief Complaint: Dad runs in with baby in his arms and screams for help. States child has had cough for two days and now "isn't acting right." He went to check on child after naptime and can't rouse her Past Medical History: None Vital Signs: Temperature – 104° rectal, Heart Rate – 78, Respiratory Rate – 22, SpO2 – 82% Appearance: Decreased responsiveness and poor muscle tone PITA Score:

64. Case Study 31 continued Patient Case: 8-month-old female Influenza Symptoms: Cough Chief Complaint: Dad runs in with baby in his arms and screams for help. States child has had cough for two days and now "isn't acting right." He went to check on child after naptime and can't rouse her Past Medical History: None Vital Signs: Temperature – 104° rectal, Heart Rate – 78, Respiratory Rate – 22, SpO2 – 82% Appearance: Decreased responsiveness and poor muscle tone PITA Score: 1

65. Case Study 32 Patient Case: 29-year-old female Influenza Symptoms: Cough, vomiting Chief Complaint: Arrives with family friend who states that patient has had cough for three days, vomiting multiple times since last night. Lives with her mother (caregiver) who is home sick with influenza. Vomited up Tylenol this morning Past Medical History: Anoxic brain injury at birth Vital Signs: Temperature – 101.8°, Heart Rate – 94, Respiratory Rate – 18, SpO2 – 97%, Blood Pressure – 120/66 Appearance: Mucous membranes dry, decreased urine output in last 12 hours PITA Score:

66. Case Study 32 continued Patient Case: 29-year-old female Influenza Symptoms: Cough, vomiting Chief Complaint: Arrives with family friend who states that patient has had cough for three days, vomiting multiple times since last night. Lives with her mother (caregiver) who is home sick with influenza. Vomited up Tylenol this morning Past Medical History: Anoxic brain injury at birth Vital Signs: Temperature – 101.8°, Heart Rate – 94, Respiratory Rate – 18, SpO2 – 97%, Blood Pressure – 120/66 Appearance: Mucous membranes dry, decreased urine output in last 12 hours PITA Score: 3

67. Case Study 33 Patient Case: 50-year-old male Influenza Symptoms: Cough Chief Complaint: Productive cough for three days. Can't sleep at night due to coughing Past Medical History: None Vital Signs: Temperature – 103°, Heart Rate – 99, Respiratory Rate – 28, SpO2 – 92%, Blood Pressure – 149/68 Appearance: Awake and alert, hot dry skin PITA Score:

68. Case Study 33 continued Patient Case: 50-year-old male Influenza Symptoms: Cough Chief Complaint: Productive cough for three days,. Can't sleep at night due to coughing Past Medical History: None Vital Signs: Temperature – 103°, Heart Rate – 99, Respiratory Rate – 28, SpO2 – 92%, Blood Pressure – 149/68 Appearance: Awake and alert, hot dry skin. PITA Score: 3

69. Case Study 34 Patient Case: 81-year-old male Influenza Symptoms: Cough, shortness of breath Chief Complaint: Cough for a week, with increasing shortness of breath, can't walk more than a few steps Past Medical History: Normally active older adult with hypertension, high cholesterol, prostate cancer 10 years ago Vital Signs: Temperature – 100°, Heart Rate – 116, Respiratory Rate – 28, SpO2 – 92%, Blood Pressure – 146/82 Appearance: Awake and alert, rapid respirations, increased work of breathing PITA Score:

70. Case Study 34 continued Patient Case: 81-year-old male Influenza Symptoms: Cough, shortness of breath Chief Complaint: Cough for a week, with increasing shortness of breath, can't walk more than a few steps Past Medical History: Normally active older adult with hypertension, high cholesterol, prostate cancer 10 years ago Vital Signs: Temperature – 100°, Heart Rate – 116, Respiratory Rate – 28, SpO2 – 92%, Blood Pressure – 146/82 Appearance: Awake and alert, rapid respirations, increased work of breathing PITA Score: 2

71. Case Study 35 Patient Case: 2-month-old male Influenza Symptoms: Respiratory arrest Chief Complaint: Baby stopped breathing and parents called EMS. Patient was apneic when EMS arrived. They are bagging the patient and doing chest compressions Past Medical History: Prematurity (born at 27 weeks gestation), was on ventilator for first weeks of life Vital Signs: Temperature – 101° rectal, Heart Rate – 42, SpO2 – 88% on 100% oxygen via bag/valve/mask Appearance: Cyanotic PITA Score:

72. Case Study 35 continued Patient Case: 2-month-old male Influenza Symptoms: Respiratory arrest Chief Complaint: Baby stopped breathing and parents called EMS. Patient was apneic when EMS arrived. They are bagging the patient and doing chest compressions Past Medical History: Prematurity (born at 27 weeks gestation), was on ventilator for first weeks of life Vital Signs: Temperature – 101° rectal, Heart Rate – 42, SpO2 – 88% on 100% oxygen via bag/valve/mask Appearance: Cyanotic PITA Score: 1

73. Case Study 36 Patient Case: 24-year-old female Influenza Symptoms: Cough, fever Chief Complaint: Cough for two days with fever up to 101.5° Past Medical History: None Vital Signs: Temperature – 101°, Heart Rate – 76, Respiratory Rate – 18, SpO2 – 99%, Blood Pressure – 127/72 Appearance: Awake and alert, tolerating oral fluids well, occasional cough PITA Score:

74. Case Study 36 continued Patient Case: 24-year-old female Influenza Symptoms: Cough, fever Chief Complaint: Cough for two days with fever up to 101.5° Past Medical History: None Vital Signs: Temperature – 101°, Heart Rate – 76, Respiratory Rate – 18, SpO2 – 99%, Blood Pressure – 127/72 Appearance: Awake and alert, tolerating oral fluids well, occasional cough PITA Score: 5

75. Case Study 37 Patient Case: 68-year-old male Influenza Symptoms: Fever, shortness of breath Chief Complaint: Increasing shortness of breath over last three days with fever up to 101.7° Past Medical History: Smoker, COPD, Hypertension, Type II diabetes Vital Signs: Temperature – 100.9°, Heart Rate – 86, Respiratory Rate – 30, SpO2 – 90% (unsure of baseline), Blood Pressure – 147/85 Appearance: Awake and alert, retractions and grunting with respirations, productive cough (green sputum) PITA Score:

76. Case Study 37 continued Patient Case: 68-year-old male Influenza Symptoms: Fever, shortness of breath Chief Complaint: Increasing shortness of breath over last three days with fever up to 101.7° Past Medical History: Smoker, COPD, Hypertension, Type II diabetes Vital Signs: Temperature – 100.9°, Heart Rate – 86, Respiratory Rate – 30, SpO2 – 90% (unsure of baseline), Blood Pressure – 147/85 Appearance: Awake and alert, retractions and grunting with respirations, productive cough (green sputum) PITA Score: 2

77. Case Study 38 Patient Case: 44-year-old female Influenza Symptoms: Cough Chief Complaint: Cough, chills and headaches for three days. Also complains of nausea, vomiting and diarrhea. Has been unable to keep down fluids or antipyretics since yesterday. Last urinated over eight hours ago Past Medical History: Migraines Vital Signs: Temperature – 102°, Heart Rate – 93, Respiratory Rate – 20, SpO2 – 97%, Blood Pressure – 124/65 Appearance: Awake and alert, lips parched, no respiratory distress PITA Score:

78. Case Study 38 continued Patient Case: 44-year-old female Influenza Symptoms: Cough Chief Complaint: Cough, chills and headaches for three days. Also complains of nausea, vomiting and diarrhea. Has been unable to keep down fluids or antipyretics since yesterday. Last urinated over eight hours ago Past Medical History: Migraines Vital Signs: Temperature – 102°, Heart Rate – 93, Respiratory Rate – 20, SpO2 – 97%, Blood Pressure – 124/65 Appearance: Awake and alert, lips parched, no respiratory distress PITA Score: 3

79. Case Study 39 Patient Case: 47-year-old female Influenza Symptoms: Cough and shortness of breath Chief Complaint: Cough and shortness of breath. Family called EMS because she has been unable to breath well for the last 24 hours Past Medical History: HIV Vital Signs: Temperature – 103.2°, Heart Rate – 146, Respiratory Rate – 44, SpO2 – 86%, Blood Pressure – 90/50 Appearance: Severe respiratory distress with extremely labored breathing, cyanosis. Pale with cool, clammy skin. Responds to verbal stimuli by opening eyes PITA Score:

80. Case Study 39 continued Patient Case: 47-year-old female Influenza Symptoms: Cough and shortness of breath Chief Complaint: Cough and shortness of breath. Family called EMS because she has been unable to breath well for the last 24 hours Past Medical History: HIV Vital Signs: Temperature – 103.2°, Heart Rate – 146, Respiratory Rate – 44, SpO2 – 86%, Blood Pressure – 90/50 Appearance: Severe respiratory distress with extremely labored breathing, cyanosis. Pale with cool, clammy skin. Responds to verbal stimuli by opening eyes PITA Score: 1

81. Case Study 40 Patient Case: 16-year-old male Influenza Symptoms: Cough and fever Chief Complaint: Cough and fever for three days. Started wheezing yesterday. Able to tolerate oral fluids Past Medical History: Allergies, ADHD Vital Signs: Temperature – 102.2°, Heart Rate – 90, Respiratory Rate – 20, SpO2 – 95%, Blood Pressure – 120/68 Appearance: Awake, alert, skin warm and dry. Able to speak full sentences. Wheezing noted on auscultation PITA Score:

82. Case Study 40 continued Patient Case: 16-year-old male Influenza Symptoms: Cough and fever Chief Complaint: Cough and fever for three days. Started wheezing yesterday. Able to tolerate oral fluids Past Medical History: Allergies, ADHD Vital Signs: Temperature – 102.2°, Heart Rate – 90, Respiratory Rate – 20, SpO2 – 95%, Blood Pressure – 120/68 Appearance: Awake, alert, skin warm and dry. Able to speak full sentences. Wheezing noted on auscultation PITA Score: 4