General practitioners are often a patient’s first port of call when they are unwell. When it comes to time-critical conditions like sepsis, their role in recognising the symptoms early is integral in achieving optimal patient outcomes. But when the symptoms mimic that of other, less-serious illnesses like influenza or gastro, it presents a real challenge.
With more than 30 years’ experience as a general practitioner, Dr Sina Beiraghi from Logan Hyperdome Doctors has seen it all. Today he shares two stories that made him stop and think – could this be sepsis?
I recently saw a 47-year-old quadriplegic patient at their home. The patient phoned me for a telehealth consultation in the morning and was unusually difficult to understand - the patient's words sounded muffled and he may have been mumbling or slurring. It was difficult to differentiate whether the patient was unwell, or the telephone connection was poor quality. I managed to understand that he thought there was a sore on his back that needed antibiotics. I elected to convert the telehealth consult into a face-to-face consultation.
I went as soon as I could and some two hours later, I arrived at his house and the usual carer greeted me. On first examination, the patient (who weighs approximately 170 kilograms) was recumbent in bed as was normal, but his speech was unusually difficult to understand. The patient sounded dry in the mouth and the difficulties in communication caused the patient to get frustrated or to appear confused (it was difficult to differentiate). On examination the patient's mouth and tongue were dry, and his temperature was measured at 36.5 degrees Celsius.
The patient's radial pulse rate was elevated at 112 beats per minute and I did not have a blood pressure cuff large enough for the patient's arm. I asked for assistance from the carer to turn the patient over so I could inspect the back which was reported to be the site of his symptoms. Upon turning the patient, the right upper thigh area had a seven-centimetre ulcer and a strong offensive odour which I immediately recognised as the smell of necrotic tissue.
I suspected delirium with signs of dehydration. I recognised this combination of symptoms may be signs of sepsis and an urgent ambulance referral to hospital was arranged.
When he arrived at the hospital, he needed to be intubated due to imminent respiratory failure. He spent 11 days in intensive care during which he underwent surgical debridement of the thigh area which was diagnosed as necrotizing fasciitis.
This was a salient lesson for me that if a patient presents with delirium, sepsis must be on the list of the differential diagnoses. The subtle signs of dehydration on their own were not diagnostic of sepsis, however, the masquerading presentation in an obviously unwell patient was strongly suspicious of sepsis.
When examining a patient, I firstly record if the patient looks well or unwell. This simple habit immediately alerts me to look for and try to exclude sepsis.
I remember seeing a two-year-old child who was non-specifically unwell. The patient was apyrexial using a forehead pointing infrared thermometer. Peripheral pulses were, as usual, difficult to measure and notably, the child did not have tachypnoea. The parents' history suggested their child was atypically quiet and off his food and drinks, and they could not remember when he last had a wet nappy.
This was his second presentation to a doctor in a few days. His dull skin colour alerted me to the possibility of peripheral shutdown, so I used a tympanic membrane thermometer to measure his temperature which on this occasion was 40.9 degrees Celsius. Despite a normal chest examination in the surgery, the patient was sent to hospital and was diagnosed with pneumonia and sepsis.
I have referred numerous paediatric patients to hospital with potential sepsis whose eventual diagnosis was uncomplicated dehydration. Uncomplicated illnesses improve with time and patients may falsely appear to have improved or not worsened.
The biggest clue in this case was that the patient looked unwell and had not improved over a few days from what may have appeared to be an uncomplicated illness. With time, symptoms should change and sometimes no change is a warning rather than reassuring.
My mantra with every sick-looking patient is "is this sepsis?"