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It seemed obvious that it was meningitis. A 10-year-old girl, previously fit, had woken up that morning with a fever and, as the day had progressed, she had gradually lapsed into a coma. On examination her only positive physical signs were a fever and severe neck stiffness.
We did a lumbar puncture and, to our amazement, it was normal. My registrar suggested doing a chest X-ray. This showed severe right middle lobe pneumonia, the whole lobe being opaque. We went back to the patient and re-examined her chest. Neither of us could detect any abnormality on auscultation. We put her on intravenous Amoxicillin and by the following morning she had regained consciousness.
Hitherto I, a paediatric SHO at the time, had realised that it was possible to miss a small patch of pneumonia on auscultation, but it had never occurred to me that it was possible to miss a whole lobeful. The fact is that auscultation has its limitations and we are foolish if we forget this.
One of the commonest consultations that we have in general practice is with patients with upper respiratory infections who are concerned that the infection has moved to their chests. In the majority of cases these fears are unfounded.
Nevertheless, we diligently listen to their chests before reassuring most of them with as much authority as we can muster. In reality we do not know for sure whether they have a chest infection or not. It is neither practicable nor desirable that all such patients should have chest X-rays. So what are we to do?
In practice we look for other evidence of pneumonia such as a high fever in the absence of any other septic focus, copious purulent sputum production, taccypnoea or reduced oxygen saturation.
If we find such features we tend to prescribe antibiotics in the best unscientific tradition of general practice. This inevitably leads to some antibiotic overprescribing, but to do otherwise would invite more hospital admissions, some avoidable deaths and more litigation.
If you are a GP, next time you reassure a worried patient that they do not have a chest infection, you would do well to have at the back of your mind a quotation from a letter from Oliver Cromwell to the General Assembly of the Church of Scotland: ‘I beseech you, in the bowels of Christ, think it possible that you may be mistaken.’
Tim Cantor is a sessional GP in Kent
I think Dr Cantor hits upon a very relevant point when we look at the level of antibiotic prescribing in general practice. We're not just doing it because the patients persist in asking, or because we want to get them out of the door, we are doing it because the alternative may be an increase in referrals which would cost the health service a great deal more money. This argument needs making when we get bashed for our prescribing patterns.
Thanks for this case.
I'm really interested to know about previous history in the patient presented here. Was she really truly completely well the day before? Did she have any PH of chest infections / pre-term birth / or is she immunocompromised - with such a substantial apparently rapid onset pneumonia? What was her resp rate / intercession etc - could that have been a clue? My biggest question though is about air entry - did she really truly have good air entry in the affected lung? On home visits to sick patients whose chest signs are equivocal, I have been known to give patients 2 puffs salbutamol via spacer - the signs I wasnt sure about almost always get a lot more obvious / or I can hear proper air entry everywhere and am reassured.
Please dont think I'm wanting to argue with the beseeching here - though I think it refers to everything - not just chest infections: its so easy to make a diagnosis, and then only see confirmation of this!
And I think its really interesting and not evaluated properly, the very significant effect that out-of-the-ordinary negative cases have on doctors . For example, if someone has a serious adverse effect on meds I have prescribed , of course I remember it - for ever. But I dont notice eg strokes that didnt happen / were avoided as a result of my prescribing - since they are not so personal and obvious.
But I hope this case isnt a reason to hand antibiotics out to everybody with a maybe chest infection. Isnt this where safetynetting comes in?
Excellent post Tom.
I totally agree-our line of work meas we will non uncommondly come across such atypical presentations etc.
The problem is convincing the public(patients) that what we learn at medical schbut NOT ALL of the time
Valuable reminder for me-thanks!
is it worth taking such big risks with peoples lives, this will change once more gp's land up with litigation, or the gmc, then you will be less experimental with peoples lives, and spend the money where it counts, the health of our patients, and not worrying if it reduces an admission.
I am a GP in Hastings and had a similar case in 6 year old - chest exam clear and she had high temperature
Admission revealed opaque right lung on chest x-ray
You do not mention if you percussed the chest and if so was that normal too?
The same happened to me except that the child was my 7 year old daughter. She got ill very quickly without any chest symptoms or signs other than pyrexia. I got it into myhead that she had meningitis. She was admitted and her initial CXR was normal. There were mutterings about her infection being viral until someone did a second CXR a couple of days later. One dose of antibiotic transformed her.
I am not advocating antibiotics without a diagnosis.
There are cultural differences not only among patients but also among doctors. Let us look at this issue:
If a patient has vague symptoms with no clear quick diagnosis and he/she travels for private treatment;
* An English doctor would diagnose "Virus infection".
They are against giving antibiotics. No swab test is
done. No follow up.
* A French doctor would diagnose "Liver disease". They
drink a lot of delicious French wine.
* A German doctor would diagnose "Low Blood
Pressure". They may have reasons to feel low at times.
* An American doctor would diagnose "Food allergy".
They are prone to allergy to most things.
I do know a case that one English woman age 40 , with a cough, went to an English GP in England, who diagnosed that she had a virus infection and asked her to go to bed. Following week, she saw a Locum English GP, as cough got worse and same diagnosis was given. She went to bed and not to work. The work managers rang her and there was no answer. They rang her mother who rang her but no answer. The mother went to her daughter's flat, as she had a duplicate key, and found her dead. The post mortem showed Lobar Pneumonia, as cause of death. The mother feels aggrieved as the deceased was her only daughter. She did not complain to anyone and keeps crying, even now. The father has gone mad with dementia. However, Asian British doctors are inclined to give antibiotics as they have seen many relatives who died of Pneumonia and TB, in South Asia. Now they are under fire from Care Quality Commission for prescribing more antibiotics than their English colleagues. I noted impartially that some English doctors are good in teaching but weak in learning. May I ask the readers how should we solve this dilemma as avoidable deaths are overtaking life in Britain, where antibiotics are cheap but not available without prescription? How should we save lives?
Dr Bashir Qureshi FRCGP, FRCPCH, FFSRH-RCOG, AFOM-RCP, Hon FRSPH. Author of TRANSCULTURAL MEDICINE; Dealing with patients from different cultures, religions and ethnicities. 1989, 1994.
You always share some new case study from the medical field. It is not easy to understand chest functionality from a common man. I read www.gloucestercitynews.net/.../advantages-of-online-learning.html article for online learning of medical terms. Your experience teach us the things which no one else can teach :)