Case 25 Cough and fever in a 42-year-old accountant

David was a 42-year-old accountant who kept very fit. His past medical history was unremarkable. He developed an irritating cough and went to see his GP because he was due to go away on holiday. Dr Hope diagnosed an upper respiratory tract infection.

Two days later David contacted the Out of Hours service. He felt feverish, had a headache and was vomiting. He was visited by Dr Jumali who noted that David had felt unwell for a few days, was now generally achy, had vomited and had a headache. He recorded a temperature of 37.1 °C, a pulse of 80, a blood pressure of 140/70, no neck stiffness, and that ENT and respiratory system examinations were normal. Dr Jumali diagnosed a viral illness and advised David to keep his fluid intake up and take regular paracetamol.

Would you have done anything else?

The following afternoon David’s wife telephoned the Out of Hours service again. She was concerned that David had been unable to get out of bed in the morning and was slightly breathless. Dr Obi visited in the early evening. She noted that David had been diagnosed with a viral illness and that although his vomiting had settled he still had a headache, his whole body ached, his cough was slightly worse and he felt breathless. Dr Obi measured his pulse, blood pressure and oxygen saturation. These were 70/min, 130/70 mmHg and 92% respectively. Dr Obi listened to his chest, which was normal. She explained that it was common to feel so achy with ’flu and that there was no evidence that he had a chest infection. Dr Obi explained that he would fight the infection himself and antibiotics would not be helpful.

David’s condition deteriorated during the evening and his wife dialled 999 when he collapsed trying to get to the toilet. The ambulance arrived 10 minutes later but resuscitation was unsuccessful.

The cause of death at postmortem was bronchopneumonia.

It was alleged that Dr Jumali and Dr Obi failed to appreciate how unwell David was and that they failed to make an adequate assessment.

Do you think his claim will succeed?

Expert comment

Death due to pneumonia in a patient aged 42 without pre-existing risk factors that compromise his/her immunity (such as HIV infection or cystic fibrosis) is very rare indeed.

A national confidential enquiry into community acquired pneumonia deaths in young adults in England and Wales found 27 deaths from community acquired pneumonia (CAP) in previously fit adults aged 15–44 in England and Wales in a one year period from September 1995. This is an incidence of 1.2 per million per year in this age group (Simpson et al., 2000).

Two key questions in this case are whether it was possible to diagnose David’s pneumonia and if the doctors who saw him recorded sufficient detail to demonstrate that they performed an adequate assessment.

It is well recognized that there are no symptoms or signs that ‘rule in’ the diagnosis of pneumonia (Metlay et al., 1997). The diagnosis is often made on clinical grounds. However there is poor internal consistency between the auscultatory findings of different physicians and poor correlation between those findings and X-ray evidence of pneumonia (Wipf et al., 1999).

The cardinal signs of pneumonia are (Metlay et al., 1997; Hooker et al., 1989):

• A temperature of over 37.8 °C
  
• A heart rate over 100 bpm
  
• A raised respiratory rate (tachypnoea)– normal rate at rest 16 to 25 breaths/minute.
  
• Crackles in the chest on auscultation.

Fever, raised respiratory rate and tachycardia are commonly present in acute bronchitis. Most studies indicate that if the clinician makes a clinical diagnosis of pneumonia it is only confirmed on chest X-ray in 13% to 39% of cases (Metlay et al., 1997).

Although it is well recognized that these clinical features may be absent in the elderly who have pneumonia (McFadden et al., 1982), most practising clinicians would expect them to be present in a younger person with pneumonia. The updated British Thoracic Society guidelines in 2009 on Community Acquired Pneumonia (BTS, 2009) cites studies which suggest that the absence of abnormal vital signs and a clear chest on auscultation excludes the possibility of pneumonia to a high level of probability. This is an example of a ‘SNOUT’ (if a high Sensitivity clinical feature (the presence of abnormal vital signs or chest signs) is Negative it rules the diagnosis OUT). Therefore the common belief would be that, in the absence of fever, tachycardia and a raised respiratory rate, pneumonia can be effectively excluded as a possibility.

Pulse oximetry is being used more frequently in primary care. One study of 664 healthy volunteers and patients of mean age 50.6 years who had pulse oximetry and arterial blood gases measured for the purposes of the study found that the mean pulse oximetry measurement was 92.2% and the standard deviation was 6.4%. 29% of the study population had a pulse oximetry level below 90% (Lee et al., 2000). The place of pulse oximetry in the assessment of CAP in primary care is not yet clear. The Primary Care Respiratory Society guidelines on the management of CAP in the community state that ‘A low oxygen saturation of < 90%, especially in young patients without chronic lung disease, supports a decision to refer to hospital’ (PCRS, 2010).

There is considerable pressure on general practitioners to avoid prescribing antibiotics in uncomplicated respiratory tract infections (Macfarlane et al., 2001) (this is referred to as ‘antibiotic stewardship’ (Hooker, 1989)) but antibiotics are required treatment for CAP (BTS, 2001, 2009). However while other infections presenting as acute cough, such as acute bronchitis or rhinosinusitis, may respond to antibiotics, the only acute respiratory infection in which delayed treatment with antibiotics has been shown to increase the risk of death is pneumonia (Metlay & Fine, 2003).

Once the diagnosis of (probable) pneumonia is made in the community the general practitioner has to decide whether or not the patient requires admission to hospital. Most CAP is managed in the community and the condition does not usually require confirmation of the diagnosis with a chest X-ray (BTS, 2001, 2009). Most patients with pneumonia who are at low risk can be treated with a broad spectrum antibiotic such as amoxicillin (BTS, 2001, 2009). Only patients who are at increased risk of death or serious complications require admission to hospital (BTS, 2001, 2009). CRB-65 ‘rule’ (BTS, 2001, 2009) defines those at high risk:

• confusion
  
• raised respiratory rate (≥ 30/min)
  
• low blood pressure (< 90/ ≤ 60)
  
• aged ≥ 65 years.

Neither Dr Jumali nor Dr Obi recorded a complete assessment of David. Even if Dr Jumali did ask about respiratory symptoms he has not documented the fact. Dr Obi recorded the fact that David’s cough had worsened and that he was breathless. However she did not clarify the features of David’s breathlessness nor record other symptoms such as chest pain, sputum or haemoptysis. The presence or absence of confusion is not recorded but it is likely that had this been present the doctors would have noted it. Nether general practitioner recorded David’s respiratory rate. The oxygen saturation measured by Dr Obi was not low enough to alert her to the need to consider admitting David to hospital.

In her witness statement David’s wife said that he was extremely unwell and very breathless.

If an adequate history and examination had been recorded and there were no fever, tachycardia, tachypnoea or chest signs then it would be possible to defend Dr Jumali and Dr Obi’s actions. The outcome of cases often ends up being determined by whether the Court prefers the account of Claimant or the Defendant as to what features were present at what time. That is one reason why good quality notes are usually helpful to the general practitioner.

Legal comment

Dr Jumali found none of the four cardinal signs of pneumonia. The potential weakness for his defence is that although he did examine the respiratory system, his notes do not mention the respiration rate. He will probably say that if the respiration rate had been high, he would have noticed and recorded it.

Dr Obi noted that David felt breathless, but again did not record the respiration rate. Nor does she record any temperature. She is likely to say the same. Both doctors are likely to say they found nothing to indicate catastrophic illness.

David’s wife, on the other hand, says he was extremely unwell and very breathless. However, it is interesting to note that the Out of Hours service records her as saying at the time that he was ‘slightly breathless’.

This is a case which the lawyers may well wish to defend at least at first. After all, the two doctors present similar accounts and the illness is extremely rare. A final decision on whether to defend or settle the case will probably be made after expert reports have been exchanged and after the experts have met to discuss the case.

As an accountant, David may well have been a high earner. The claim will be expensive, if it needs to be settled.

Stay updated, free articles. Join our Telegram channel

Join