Welfare check on the ‘well’ septic patient LARU officer David Krygger reports on a code 2C case involving a welfare check on an elderly patient living in public housing who was not answering phone calls from her family. I asked Dorothy about this prescription and she was unable to remember why she needed that. This prompted me to ask about any urinary symptoms recently and whether I could conduct an abdominal examination. She answered that she had been feeling well recently, with no urinary or other symptoms. Her abdominal examination was N.A.D. When doing her vital-signs I found the following:
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LARU officer David Krygger is based at Mermaid Waters Ambulance Station on the Gold Coast.
I was met at the front door by Dorothy, an 89-year-old female who was surprised to see me.
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I explained to Dorothy that we had been called because her family had been worried about her this morning when she had not answered her phone. Dorothy seemed surprised that she had not heard the phone but stated that she had forgotten to put her hearing aids in today and was very apologetic. Dorothy presented calm and was engaging reasonably well in the conversation, she was independently mobile and even offered to make me a cup of tea, which I politely refused. She had no pain or discomfort, admitted that her sleeping hadn’t been the best recently, but that this was normal for her in recent years. On face value, her presentation seemed normal for an elderly person living at home alone– with a reasonable excuse for not hearing the phone calls from her family. I asked if I could see her medications, to which she pulled out a large plastic box filled with multiple boxes of tablets. I found anti-hypertensives, statins, a beta-blocker, aspirin, methotrexate, Panadol osteo and Ural sachets. She told me that she had high blood pressure, high cholesterol levels and rheumatoid arthritis. Many of the boxes were empty, and some had old prescription dates on them. Notably, I found a box of trimethoprim with most of the tablets still in the sleeve and a prescription date from five days ago.
• BP–110/80 • HR–70bpm–Sinus Rhythm on 4-lead ECG • RR–24 • Temp–37.1 • BSL–5.8 • SpO2–97% on room air • GCS 15–But slow in answering some more complex questions. I was now concerned about Dorothy due to her recent prescription and non-compliance of an oral antibiotic, her recent acute forgetfulness, immunocompromised status, her mild tachypnoea and likely relative hypotension. My provisional diagnosis was that she likely had an untreated and worsening Urinary Tract Infection (UTI), possibly a urosepsis. I called her General Practitioner (GP) to seek some further information, to which I found out that she had been prescribed Trimethoprim for a UTI, but had not returned to the GP as requested within two days for a follow up and that she had not been answering her phone. The GP confirmed an E.coli infection post urinalysis. Her GP and I agreed that even though she was presenting well outwardly; she was at risk of rapid deterioration. The recent history of missed phone calls could be a ‘warning shot’ symptom about her deteriorating health.
Dorothy’s outward presentation • Calm and conversing reasonably well with me • Neat, tidy home • Well dressed, but with heavy clothes on
Autumn 2021
• Not complaining of any symptoms or concerns.
Dorothy’s clinical status • Likely relative hypotension (110mmHg) in a normally hypertensive elderly patient • Tachypnoea at 24bpm in the setting of a known infection–Is she currently acidotic? • GCS 15, but with some key memory loss.
Dorothy has a high-risk acute medical profile • Advancing age • Lives alone • Meets SIRS moderate risk clinical features • Q-SOFA score = 1 • Evidence of poor medication compliance • Immunocompromised due to RA treatment • Confirmation from GP of recently diagnosed and unmanaged UTI • Recent abnormal behavioural changes– forgetfulness.
RESULT: Ultimately, I determined that Dorothy required a hospital admission because she was at high-risk of deterioration. I didn’t feel that referring her back to her GP would eliminate or significantly minimise her risk of deterioration. Dorothy was transported to the Emergency Department via a stretcher ambulance with O2 and IV fluids running where she was admitted as an in-patient for seven days with urosepsis.
FINDINGS: ‘Low acuity’ patients represent our most complex and certainly highest risk patient category. The risk for both the patient and the paramedic can be reduced significantly by taking a thorough history, a detailed assessment and testing a variety of differential diagnoses. Be aware of the patient who appears well; but isn’t.
