What could be the cause of this patient’s apparent ‘gastric flu’ symptoms?
Case of the month: In the next in our series, Dr Andy Eaton asks what else might be going on in this mid-40s male patient presenting with fever, vomiting and diarrhoea following a bout of ‘gastric flu’ in his household. Post your answers below!
Details of the case have been changed to ensure patient anonymity
The case concerns a 45-year-old male patient, a musician who is usually fit and well. His wife contacts the practice on his behalf and asks for a same-day telephone consultation, saying he is ‘really poorly with gastric flu’.
You phone and speak to the patient, as his wife has had to leave the house for an hour. He tells you that he has been unwell for 6-7 days with a bit of an upset stomach. He apologises for wasting your time because he feels his wife just got a bit panicky as his diarrhoea just seemed to be getting worse, and his temperature wouldn’t settle.
There is no recent history of any foreign travel, or any previous operations, and he is on no regular medication. He doesn’t smoke, and enjoys a few drinks after one of his gigs but never to excess.
He tells you he is managing to take some sips of water and has had half a slice of dry toast for breakfast, but he has vomited 4 times already today, and continues to have frequent, watery diarrhoea. His 8-year-old twin daughters have both had a viral sickness bug but are on the mend now, so thinks he just needs a few more days to persevere with fluids and paracetamol to get it all out of his system. He asks if an anti-emetic may help in the meantime?
However, you are worried, because the message from his wife mentions that he was unsteady on his feet and a bit muddled. The patient denies this and says that he just got up too quickly, and wobbled a bit rushing to the toilet earlier because he thought he was going to be sick. He admits he was a bit dazed when she left the house first thing today as he had just woken up, but he says he feels fine now.
You think through the various options here, which include:
- Giving him the anti-emetic with careful safety netting advice.
- Offering him a face-to-face assessment (but you really don’t want him to vomit all over your surgery).
- Sending him direct to hospital, although you can’t help thinking he sounds quite well on the phone.
What course of action should you take? Is there further information that might help you to make the most appropriate decision? Share your ideas in the comments box below. Answer to be revealed soon!
Dr Andy Eaton is a GP and GP educator in Somerset
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READERS' COMMENTS [7]
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Before weighing up the differential diagnoses – I would wish to ask 1) re urine output 2) whether the stool was particularly ‘foul’ (clue) smelling, and whether he’d eaten chicken before the illness. In the old days -Regardless, drag him into the surgery assess his hydration and do Us & Es and an FBC while your there and (sacrilage, god no) if needed VISIT HIM
Agree with Martyn. Appendicitis possible. His tummy will be tender all over from the vomiting anyway though, making it difficult. He sounds sensible. FP samples also necessary, although check where ‘bug’ came from too, Also check a BM.
I would doubt the case is an appendicitis.
Above comments suggest FBC and ESR, U+E, Campylobacter, FP test.
I would see this patient to have a full picture .
Needs a FTF assessment and possible admission for IV fluids and further investigation. Symptoms have bene ongoing for longer than a normal viral gastorenteritis and persistent pyrexia. There are reported symptoms of an altered mental state- this is a red flag, so the patients own history is unreliable, also sounds like the patient is trying to downplay things, while his wife probably has a better feel for the reality of the situation. The level of fluid loss- vomit/diarrhoea/fever described and confusion suggests an electrolyte imbalance. Avoid antiemetics, as they could mask the serious nature of this situation. Consider directing straight to A+E and not seeing in GP surgery or doing home visit.
Agree with all the comments so far. The key clinical question for me is why he is so much more unwell than his daughters from what was presumably the same bug. Points to something underlying that is making him more susceptible, such as undiagnosed hereditary haemochromatosis. His daughters may have contracted a common, self-limiting gastroenteritis, but if the bug was siderophilic (iron-loving), such as yersinia, listeria or vibrio then the high-iron environment in a patient with HH would cause a more severe infection. Ferritin result will probably be unreliable during the acute illness, but once recovered, a fasting transferrin saturation and ferritin would be a screening step for HH. If abnormal, proceed to HFE genotyping. Interesting case, thanks Andy!
agree with above comments, I would offer face to face assessment at the very least, would surely get in touch with his wife with patient’s permission for more collateral history and see if she can bring him to the practice for face to face, and then decide what to do further, depending on clinical exam findings,
agree with above comments,