Hi guys,
This is to remind you that all of us these days are doing video consultation in telemedicine. You need to remember few red flags..
Remember the fresh allowance for telemedicine seems to be temporary, for this epidemic. So, do not be in a hurry to think everything of this is permanent. You will have to remember that the patient has to “ask for” your consultation through whatever form in the WhatsApp or SMS.
Video calls on WhatsApp et-all can be an excellent tool for us to be able to segregate off the red flags and to be able to diagnose emergencies and tell them to rush to the nearest hospital.
So utilizing this particular technology by ourselves is important and we should remember how to use them. These are the few tips that I am telling you what I have used. This could be an excellent and nice armamentarium for you to use it in your patient and help them relieve their anxiety.
Tell the patient’s relative to hold the phone away from the patient where they have switched from the selfie mode to the main camera mode so that you can see the patient fully.
You tell the patient’s relative that he is going to be keeping his camera steady and to move in towards the patient or away from the patient and to go to the side of the patient of front of the patient or back of the patient as you tell him to do so.
Utilize this part of the technology well so that you can gain enough amount of information to pick up red flags. And to know that the patient is in trouble and needs urgent hospitalization. For you to get to a specific area of diagnosis and where you know what to look for in the patient.
From the history you would have known whether the pain is from the back, from the hip, thigh or from the knee. Because I am talking of orthopaedics, you can use this for any of your systems depending on the patient symptoms.
Scenario 1: Now imagine the patient is a 80 year old where they have said that this lady had a fall in the bathroom and is now not able to move and has pain in her thigh. So what you do is make the relative go a little distance so you can see the entire length of the patient who has been to lie down on their bed. Then tell them to take you towards the lower limb and see the lie of the limb. If the right lower limb is the painful one, and you see that the right lower limb is externally rotated and slightly shorter than the opposite side. Ask them to tell the patient to point out the area of pain. Suppose the patient is pointing towards the groin and the upper thigh, then you know that you are looking at a possible injury in the upper end femur. Now ask the patient if she can hear you or tell the relative to tell the patient to attempt to lift the lower limb on her own (that is active SLR).
If the patient is unable to do an active SLR, then you know you are looking at a possibility of a fracture neck femur.
This scenario is a red flag. And this is a possibility of a upper end of femur/neck femur fracture, which will require the patient to be hospitalized. So ask the relative to arrange for an ambulance and take the patient to the hospital get x-rays done and then accordingly treat.
Scenario 2: The patient is saying that I have severe pain, following a possible injury yesterday. And today morning it is excruciating pain in my arm. I am just not able to lift it. “I think I have a dislocation of the shoulder”. So the first thing is thinking of a dislocation, but hold on; get back to the history.
Ask him that do you definitely remember of a fall/injury and if he is not very sure of the event and if he does not remember the exact time that so called injury took place, and the pain did not start immediately on that second, then it is unlikely that it was a post traumatic problem.
If they are not sure then now go to video call mode and tell the relative to hold the phone in the non selfie mode and be away from the patient so that you can see the range of motion or if there is any deformity or swelling of the shoulder area. If the patient is able to be topless then you will be able to see if there is any deformity of the shoulder area if there is any echymosis, if it is not possible to see any bruising or the patient is clothed it’s alright. No problem, go ahead and examine further.
Ask the patient to actively abduct or actively flex the shoulder without using the other upper limb help. If the patient has pain, but is able to raise that arm, and there is no deformity or echymosis, it is highly unlikely that it is a dislocation. Then look for tenderness, ask the patient or the relative to press that area and point to the area on pressure if there is any pain.
So if you have a situation where there was no specific trauma only acute onset pain with active abduction are active flexion difficult but possible and severely painful it is more likely to be calcific rotator cuff tendinitis or crystal induced rotator cuff tendinitis.
However you have to be very sure that there is no swelling or no deformity of that shoulder when you were examining remotely because if you are sure then you can tell the patient to relax and no urgency to rush to the hospital.
You can manage him by giving him a sling, applying local ice, and no massage. Give anti-inflammatories and colchicine. Ask the patient to call back in 24hrs.
PS: For the above scenarios, I want to tell everyone to be very confident about your clinical examination skills. Otherwise, instead of helping your patients in this lockdown scenario, you may cause harm.
-Dr. P. S. Mamtora
MS Orth, D. Orth.