Case study

Dr Hyams mitigates uncertainty and excludes sepsis with remote examination

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

Background

General practice is full of uncertainty and we are often managing complex sets of symptoms. As we are increasingly doing consultations remotely, this can prove to be more difficult without being able to examine patients. Arc provides access to examination equipment and allows us to assess cases more comprehensively. 

It is common in general practice for a patient to present with a cluster of symptoms which point to one diagnosis, but also show other, atypical, symptoms. Without the appropriate assessment tools, this can be difficult to provide a diagnosis with certainty.

Case presentation

A 24-year-old female presented with a six-day history of headaches and vomiting. The patient:

  • complained of vertigo and a sore throat
  • had pain across both her maxillary and frontal sinuses
  • had been feeling feverish and unwell
  • denied any neurology, visual disturbance, photophobia, neck stiffness or rhinitis
  • had a past history of sinus polyps and depression
  • was taking Sertraline

Learning points

  • In situations where the history does not fit neatly into a diagnostic category, examination is even more essential.
  • Remote examination equipment reduces the need for the patient to attend a surgery, whilst also allowing diagnosis to be accurate.
  • Careful safety netting in remote consultations where there is any uncertainty of diagnosis should be even more thorough.
  • Reassurance for both patient and doctor is an important part of general practice and helps to maintain good communication. Having examination equipment helps us to provide this. It is also important for a doctor’s wellbeing and decreasing stress. 
  • The patient would have had to attend the surgery if there had not been an Arc available. But with Arc, she was examined, treated and advised appropriately online.

Outcome

The patient’s blood pressure was 103/79, her heart rate was 81bpm and her temperature was 36.1C. Her right tympanic membrane was dull but otherwise unremarkable, while her right was dull with a mild sucked in appearance. She did not have any photophobia. I felt that the most likely diagnosis was sinusitis causing systemic symptoms. In view of her systemic symptoms and unusual presentation, I gave her a course of amoxicillin and some stemetil for symptomatic relief. Due to the unusual symptoms, I safety-netted very carefully. Safety netting is even more important in remote consultations as it is easier to miss cues. 

Initially, I was concerned about sepsis or an intracranial pathology. The ability to examine the patient was very reassuring, as I was able to see that her observations were normal and she was afebrile. Being able to examine her ears was also vital in reassuring me of a diagnosis of sinusitis, as the findings supported this.

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