Case study

Dr Shah uses remote examination to prescribe with confidence

Dr Bhavini Shah
MBBS MRCGP
GP
 at 
Colindale Medical Centre
 in 
London
Devices used

Background

The Covid-19 pandemic accelerated the transition into digital healthcare. The NHS turned to remote consultations to minimise the risks to patients and staff. Practices started using telephone, video and online consultations to manage patients. This allowed primary care to practice in a new and potentially more efficient manner, but this has also presented challenges. One of the limitations of video consultations is the difficulty with examining patients, which is particularly applicable when managing patients with a sore throat. 

Tonsillitis is a common presentation in primary care and patients often present with a sore throat. It is commonly caused by a virus, especially when associated with symptoms such as a cough and cold. However, in some circumstances, it can be caused by a bacterial infection, which may require antibiotics. Clinical predictors such as the FeverPAIN Score or Centor Criteria help to determine the likelihood of streptococcal infection, but they rely on examination findings.

Case presentation

A 20-year-old male presented with 2-3 day history of sore throat, associated with nasal congestion, productive cough and fever symptoms. The patient:

  • had no breathing problems and was eating and drinking normally
  • had a flatmate with similar symptoms
  • had recently travelled to Italy and had no known contact with Covid-19
  • had no history of bladder or bowel symptoms
  • had no past medical history of note

Learning points

  • Antimicrobial stewardship by following evidence-based prescribing.
  • Less risk of unwanted side effects in patients prescribed antibiotics.
  • During the Covid-19 pandemic, guidelines from The Royal College of Paediatrics and Child Health recommended that the oropharynx of children should be examined with full PPE, including a face visor. By using Arc, clinicians can examine the oropharynx safely.
  • The modification of the FeverPAIN Score to a starting score of 2 in lieu of an examination has led to an increase in antibiotic prescriptions.
  • With visualisation of the oropharynx, the clinician is able to identify conditions such as Quinsies. 
  • Arc reduces the need for face-to-face reviews in practices, the GP workload, use of PPE and risk of Covid-19 transmission.

Outcome

Arc allows assessment of the basic observations which are an essential part of the assessment normally undertaken in primary care. The temperature, pulse and oxygen saturations were within normal limits for this patient. With the view of the oropharynx, I was able to see that there was no tonsillar exudate and inflammation. Auscultation of the chest was also clear. Based on the history and examination findings I calculated the FeverPAIN Score of 1, advised the patient on self-care management with appropriate safety netting and explained that bacterial infection was unlikely.

I was more confident in my management plan as I was able to practice evidence-based medicine. Additionally, the patient was more satisfied with the consultation as I was able to reassure them following a full assessment. In comparison, when using video consultations alone I am unable to visualise the oropharynx clearly or perform basic observations. Often this leaves clinicians in a difficult dilemma where they may either prescribe antibiotics or delayed antibiotics inappropriately or they bring the patient into the GP surgery for review; with a face to face examination of the oropharynx putting the clinician at risk of contracting Covid-19. If presented with a similar case without examination, I would likely have prescribed antibiotics when they weren’t indicated.

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