What was the cause of this patient’s ‘gastric flu’ symptoms?
Case of the month – answers: In the latest in our series, Dr Andy Eaton asked 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. Answer revealed 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?
Answer: You decide to speak to his wife again. She confirms that he has not passed urine for 18 hours, has an altered mental state and is unable to stand. The Sepsis Trust are clear that 999 should be called if ANY of these red flags are present. He was assessed in A&E and found to have a fever of 38.9°C, heart rate 128 bpm and blood pressure 86/48mmHg, with a white cell count of 17.5 x 10⁹/L. Imaging confirmed a dilated colon.
The diagnosis was toxic colitis as the first presentation of ulcerative colitis.
Learning points
This case involved two potential sources of bias:
- ‘Wellness bias’ where the patient underplays their symptoms.
- Search seeking bias (‘the eureka moment’) – as both daughters are recovering from a gastric bug, we might then assume he has the same infection.
While it is good practice to speak to the patient, it is imperative to get a corroborative history if the patient’s version downplays the severity of the condition. In my experience, concerned ‘significant others’ have an annoying habit of being right! Mental state changes and inability to mobilise in someone who is usually fit and well should always be taken seriously.
Telephone triage is about ensuring patients end up in the most appropriate place. There is every chance if he comes in for an assessment, he will vomit in your surgery, but more importantly, this may delay definitive assessment, which for sepsis can be critical.
Dr Andy Eaton is a GP and GP Educator in Somerset
Sources and further reading
- UK Sepsis Trust. Sepsis screening tool telephone triage – age 16+. Available at: https://sepsistrust.org/wp-content/uploads/2024/08/Sepsis-Telephone-Triage-16-2024-V1.0.pdf
- BMJ Best Practice. Toxic colitis and toxic megacolon. 29 July 2022
- O’Sullivan E, Schofield S. Cognitive bias in clinical medicine. J R Coll Physicians Edinb 2018;48:225–32
For more diagnostic puzzles, see previous articles in our Case of the month series:
- Case of the month answers: What was causing this patient’s nausea and tingling fingers? – Pulse Today
- Case of the month answers – what was causing this patient’s panic episodes? – Pulse Today
- Case of the month – answers: Did you get the cause of the patient’s sudden memory loss? – Pulse Today
- Case of the month answers: Did you get what caused this man’s pityriasis rosea? – Pulse Today
- Case of the month answers – what was the cause of this young worker’s abdominal pain? – Pulse Today
Have you handled a case which had a slightly surprising outcome? Perhaps an elderly man with non-vertigo dizziness? Or an unexpected cause of bradycardia? Would you like to share your case studies with us to help support and inform GPs? Please get in touch if you would like to contribute! [email protected]
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