Part 2

Reading between the lines there was some doubt as to whether this 
patient was a bit poorly with anxiety overlay or "proper 
poorly".  From my own experience and from all I've seen of OOH this 
kind of situation is one of the most difficult, especially when every 
couple of days we get emails from our PCT and hospital pleading with 
us not to admit patients or even send them to A&E.

Though this patient did not (as far as is known to the present) have 
endocarditis, that seems to me like something worth thinking of in 
this situation (and something I wouldn't have thought of myself).

The GP opted to give the patient Clarithromycin for ??atypical chest 
infection / pneumonia, and arranged follow up on the Monday morning.
Clarithromycin 500 BD for 2 days then 250BD for further 5 days.  I 
didn't know until recently that Clarithromycin is believed to have 
some anti-inflammatory properties as well as its better known 
macrolide antibiotic effects.

Anyhow patient's account is of being marginally better but with no 
significant reduction in the tachycardia.  There was no further 
definite tachypnoea, but some SOBOE.  Physical examination Monday 
morning was once again non-contributory, but confirmed the patient 
was still alive at that time ;-)

An ECG confirmed a sinus tachycardia.
FBC showed an Hb of just over 11, and a slightly raised WBC.

ESR, CRP, Blood cultures, viral studies were not done.
CXR showed a little streakiness ? significance, normal heart size, no 
mediastinal abnormality.

Another test showed an uncommon, but apparently not "rare" diagnosis.
Any suggestions on the other test?

The GP was faced with an added problem because the patient was due to 
fly on the following day and the GP was asked to advise in general 
terms on fitness for travel.

How do people decide in this kind of situation?


Julian