Case study

Dr Hyams detects early pyelonephritis with remote examination

Dr Abby Hyams
MBChB DRCOG DFFP MRCGP (Distinction)
GP
 at 
Highfield Surgery
 in 
Hemel Hempstead
Devices used

Background

Common presentations to general practice can be complicated if you are unable to examine a patient due to the Covid-19 pandemic. A typical example is a urine tract infection with back pain. Without being able to assess a patient’s blood pressure, temperature and pulse, we run the risk of unnecessary admissions to secondary care. Patient observations are needed to ensure that we are not missing pyelonephritis. As GPs we are skilled at managing risk. In order to safely assess risk, we use the tools available to us. So when those tools aren’t available, for example in a remote consultation, it can lead to increased anxiety and potentially inappropriate referrals. With Arc, the patient can be examined remotely, giving both doctor and patient confidence in the management plan.

Case presentation

A 22-year-old female presented with a one-day history of dysuria. The patient:

  • denied any haematuria but did have foul-smelling urine
  • denied any nausea and did not feel feverish
  • had no significant past medical history and was not taking any medication
  • looked unwell and had a blood pressure of 135/95, a pulse of 123bpm and was afebrile
  • was complaining of bilateral lower back pain and was feeling unwell in herself

Learning points

  • Patients at risk of pyelonephritis need comprehensive assessments in order to identify those who require referral. This can be very difficult where a remote consultation doesn’t provide the opportunity for taking basic observations.  
  • Referring a patient for further assessment without being able to examine them may be inappropriate for the patient, antagonize secondary care colleagues and waste valuable resources. 
  • Arc allows us to see a patient remotely and examine them, which removes a level of uncertainty as to whether to refer as an emergency or to try oral antibiotics first.

Outcome

After reviewing the history, it appeared that the patient had pyelonephritis. It was unclear initially as to whether the patent needed admission, or if a trial of oral antibiotics was appropriate. After examination and noting the tachycardia, I was confident that she needed an assessment in A&E. She agreed to attend immediately for further assessment and likely IV antibiotics.

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