Examination of patients: How to carry out remotely for different symptoms - 15 April

How to remotely examine patients according to symptoms

Access the guideline here for updates

Date: 15.4.2020

Please be aware that this is a rapidly evolving situation.

Remote examination guide

Delivery of Care to Patients with Non-Covid-19 Health Needs

Principles

The principles of providing safe care during the Covid-19 pandemic described above all apply. Although we will all be experienced in providing non-Covid-19 care, we will need to rapidly adapt how we diagnose and assess these conditions in order to minimise risk to our patients.
We recommend signposting patients to patient information sites to support self-management and safety netting NHS Health A to Z or Patient – Expert Health Articles, Tips and Informatio

This is initial thinking on remote examination techniques. We are currently working with GP colleagues to develop this further and will be sharing work on safe remote examination for each system in due course.

Below are initial suggestions of what could be done but all clinicians should feel competent in the examination technique and mode of assessment. If anyone has any expertise in remote examination and would like to assist with this work, please contact Londonwide LMCs.

It should be recorded contemporaneously in the medical record that this was a video consultation/ examination, that the examination had been explained to the patient in advance and that they had verbally consented to being examined in this manner.

Some educational providers have produced webinars that are free to access, going through all of the principles of how to structure remote consultations, ensuring access to primary care for all patient groups without discrimination whilst best using the technology that is available to us, e.g:

RedWhale

NBMedical

We recommend that clinicians explore with the patient what information they are able to provide with the equipment that they have available to them (temp, pulse, O2 sats, BP, PEFR).

Most smart phones have the ability to monitor heart rate although some require the patient to download an app to enable this.
A few smart phones (e.g. Samsung) have the ability to monitor pulse oximetry so it is worthwhile checking with patients which phone they have.
Please be aware that these smart phone applications are not approved as medical appliances.

Examination by system:

ENT examination:

Inspection of the neck can be viewed by video with good light or patients can upload/send pictures to the practice if any lumps or abnormality are visible. Although tonsils can also be examined in this manner we are awaiting further guidance on the risk this poses to the person performing the examination if it is not the patient doing this directly. The feverpain score should be utilised for assessment of tonsillitis; RCPCH guidance recommends that the need for antibiotics can be based on this assessment alone without examination.

MSK examination:

This can be performed via video. It is possible to inspect and observe functionality including passive and active movements, and strength. Some specific tests can be carried out with clear patient guidance including demonstration by clinician.

Dermatological examination:

Dermatology diagnoses are best made by taking a full history and the patient electronically sending pictures of the affected area, because still pictures give better resolution than video. Patients can also measure and carry out tests during a video consult, e.g. to determine whether blanching.

Cardiovascular examination:

Most CV diagnoses are based on the history and subsequent investigations. Remote examination can include pulse both rate and rhythm, and a patient can be asked to tap out their pulse to determine the rhythm. If the patient has a monitor, blood pressure can be provided and the patient can be instructed on how to check for peripheral oedema. Auscultation can be done remotely but the equipment required is not readily available.

Respiratory examination:

Remote examination is by general observation, respiratory rate and if available pulse oximetry. This provides a very limited respiratory examination but this has to be balanced against the risk of a face-to-face examination of an acute respiratory problem, as all such patients should be assumed to have Covid-19 infection until proven otherwise and all possible precautions and safeguards are implemented.

Gastrointestinal examination:

An acute abdomen would need face to face assessment as signs of peritonitis may not be possible to observe remotely. It is possible to carry out a remote assessment of hydration status, general appearance and some obs. As a screening tool, a family member or carer can be instructed on abdominal palpation solely to elicit any signs of tenderness.

CNS examination:

A simple, basic CNS examination can be done via video, including some cerebellar signs. This could give enough information to understand whether patient can continue to be safely managed remotely, or if a more detailed assessment is required urgently in primary care (or secondary care in an emergency situation).

PNS examination:

Neuropathy/weakness can be determined based on the history. Muscle wasting and fasciculations may be identified through video consultations, and it should be possible to observe active movements and global limb strength (tip-toes, squats, raising from chair, pushing up from chair with arms etc).

Genito-urinary examination:

For acute urinary symptoms the diagnosis is normally based on the history supported by general examination observations and urinalysis. Common examples include UTI, for which NICE guidance is available. A pyelonephritis diagnosis is based on the history including renal angle tenderness, temperature, urinalysis/msu. A renal calculi diagnosis is based on the history and presence of haematuria followed by further investigations.

If a patient has a genital rash, lump or externally visible lesion it may be possible to examine this via video-link. In such a situation, you should be mindful of the following:

The limitations and sensitivity of assessment via video-link.
The possibility that a further assessment and/or investigation may be indicated (e.g. if genital herpes is identified, screening for other STIs may be indicated).
The sensitive nature of the examination and the examination setting (e.g. traditionally it is unusual for a GP to undertake an examination in this way; the patient may want to relocate to another room if there are other family members in the vicinity). It is therefore important to seek the consent of the patient, tailored to the specific circumstances of the remote examination.
With the consent of the patient, a chaperone could be present with the GP and could witness the nature and extent of the video examination that was undertaken.
The nature and extent of the examination (together with all the other aspects of the consultation) should be contemporaneously documented in the records. You should also document whether or not a chaperone was offered and either declined or present (if a chaperone was present, you should record their identity, including their designation and the extent of the assessment witnessed [e.g. “present for the complete video-linked assessment”]).

Paediatric examination:

Paediatric remote assessment guidance can be found on the Healthier Together website and has been developed in partnership between parents and healthcare professionals from across Dorset, Hampshire and the Isle of Wight.

Further resources

The following list of links is to resources produced by other organisations on the remote monitoring of patients.

RCGP resources

RCGP Covid-19 – Telephone triage podcast

RCGP – Top 10 tips for COVID-19 telephone consultations

University of Oxford – Video consultation information for GPs (RCGP endorsed)

Using Online Consultations in Primary Care – Summary Toolkit for Practices, NHS England

BMJ article – Covid-19: a remote assessment in primary care

NHS England resources

Moving to online triage and consultations with Minal Bakhai and Dr Trish Greenhalgh

Remote Total Triage Blueprint (log-in required)

GMC guidance