Term 7 Week 3 (w/c 21/10/2013)
Welcome back to #Gasclass
This week we are starting off in the community but no dramatic accidents this time. This question is out there for all the generalists, family doctors, primary care physicians.
A 62 year old smoker comes to you with the story that she has had an increasing cough over the last two weeks and she is worried about it because she has just received her letter for an admission date to hospital. She is due to have a hysterectomy next week and she is worried that maybe she needs some antibiotics.
What information and / or diagnostic questions do you want to have answered to help you make a decision on what to do?
Her opening line is that she ‘needs antibiotics’ because she doesn’t want her operation cancelled. She has been a lifelong pack a day smoker and has had a two day hospital admission 18 months previously with chronic bronchitis exacerbation. She has a regular pair of inhalers which she uses religiously along with her cigarettes.
She is probably no different from any previous visit. She says her cough is just the same but she thinks it might be a bit more ‘yellowy’ than usual.
HR 100 BP 165/105 SatO2 93 Mild added sounds bilaterally.
Is there more information you need to help make the decision on what she will leave your consultation with?
Thanks for filling in the poll.
The results suggest a pragmatic approach to giving antibiotics is prevalent across the class.
A CXR is performed at the local drop in centre and shows no focal infections. As such she leaves primary care to head of to the preassessment clinic. A further history is taken along with some further investigations. Exercise tolerance is 100m limited by breathlessness, but she manages her shopping with some assistance. This is unchanged form the beginning of the year. FEV1 is 1.45 litres and FVC is 2.05. There is no reversibility. ECG is unremarkable.
Hb 12 WCC 11.7 Plt 234
U 8 Cr56 K 4.9
At the moment we are not discussing the relevance of the indication for hysterectomy. I would like anaesthetists to comment on this scenario. A patient has attended a GP / primary care physician a due to chest symptoms pre operatively and is taking antibiotics (by her description for a chest infection). Furthermore, she relates that her GP says she is fine for her operation.
In principle are you happy to do this case or do you want further investigations or treatment?
Lots of suggestions given to the team. It is not unusual for a preassessment team to pick up a patient who has been started on antibiotics and maybe even a short course of steroids by their family doctor to get them ready for their operation. All things being equal would you get on and give an anaesthetic for her hysterectomy assuming it is for an endometrial CA.
Would you do it on the listed date or would you wait another couple of weeks to wait for some improvement?
Thank you everyone for your contributions.
The scenario presented is common. as a practising anaesthetist in UK healthcare it is particularly usual to find patients who have commenced antibiotics within the previous week and have been told that they will be fit for their anaesthetic. Of course the evidence that the patient actually had/ has an active infection is limited at that point and there is a tendency to assume that the GP has treated something that should now lead to a cancellation even if only for a couple of weeks.
From the primary care perspective it is likely that GPs start treatment in order to prevent cancellation on the basis that leaving well alone presents more risk.
For the purposes of this case it is unlikely that a 62 year old smoker with chronic chest disease can be made better in the time frame needed for this operation. Maybe antibiotics are the completely wrong answer and perhaps a trial of steroids once a sputum culture is back could have more value and help make the patient better.
By and large most anaesthetists would choose to use some kind of regional technique to avoid respiratory complications if possible in this kind of case.
What will next week bring?
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