Case study

Dr Hyams prevents a delayed emergency referral with remote examination

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

Background

Remote consultations are being used increasingly in the NHS and especially during the Covid-19 pandemic to assess all patients. This is usually a safe and efficient way of assessing patients without needing to bring them to a GP surgery, to reduce potential Covid exposure. However, there will still be some patients that require examination, and most doctors will be able to recall a case of unexpected examination findings changing their management.

Case presentation

A 49-year-old male presented with a one-year history of feet and leg swelling with orthopnoea. The patient:

  • used to drink excess alcohol but had decreased this over the past 3 weeks
  • had a history of snoring
  • had no significant past medical history
  • was not on any medication

Learning points

  • The importance of baseline observations in a case of oedema and orthopnea.
  • The importance of good history taking alongside examination when unexpected findings are present.
  • Less likely to miss serious conditions when able to examine the patient.
  • Listening to a patient’s chest when they complain of any chest related symptoms is essential.
  • The use of remote consultations and examination equipment with Arc allows examination and clearer assessment than video link alone.

Outcome

This case was immediately concerning and brought up a number of differential diagnoses. Having access to examination equipment allowed me to check the patient’s observations. His blood pressure was 170/134, his oxygen was 93% on air and his heart rate was 111bpm. Auscultation of his chest showed some quiet crepitations with decreased lung sounds in the left base. He was also able to demonstrate the pitting oedema of his ankles using the remote camera.

Using the examination equipment available I was able to assess the patient and appreciate the severity of his condition. Given his high blood pressure with low oxygen in a previously well young male, I felt that it was a matter of urgency to check his renal function and have a chest X-ray and ECG. Knowing that his oxygen saturations were low and his blood pressure was high with a tachycardia, this alerted me to the urgency of the case and I directed him to A&E for assessment. 

If I had not had access to examination equipment I would not have been able to assess the patient. His symptoms were of concern immediately and it was obvious that he needed examination. Without being examined he would have needed to attend a surgery and his emergency management may have been delayed.

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