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Dear Readers! I started this blog when my daughter was in the NICU. She had ventriculitis. Her CSF report grew E.coli. But, she was injected Teicoplanin directly into her brain. The doctors made two errors here:

Teicoplanin is for gram-positive bacteria only. It does not treat E.coli.
Teicoplanin is not for intraventricular use. The manufacturer strongly discourage injecting Teicoplanin into the brain.

My daughter bled into the brain. She lived for another two years and ultimately died.

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Why Online Medical Consultation Can Be Tragic?

Online Medical Consultation is in vogue - Thanks to the COVID-19 pandemic. It has got its own advantages, however, the exclusion of medical examination by a doctor can not be replaced by laboratory investigations.

Online medical consultations may have made our lives easier by connecting us to any doctor from anywhere in the world 24/7 with the ease of staying at home, but the risks of missing a serious diagnosis are always there.

A huge list of facilities, blogs, and hospitals that provide online medical consults is available when you search for it on google. Even the private sector hospitals are advertising their online clinics nowadays.

Here, I am narrating a story of one of our patients who came to our clinic after he had two online medical consultations for his problem but his condition did not improve.

Online medical consultation for Vertigo:

A young boy, 22 years of age, developed vertigo associated with vomiting and headache. He denied fever, fits, or focal weakness in the limbs. He did not complain of other symptoms pertaining to any other system.

The first prescription via Online Medical Consultation ...

An online consultation was sought with a senior physician. Some laboratory workup was advised and he was prescribed medicines for vertigo and vomiting along with multivitamins. Some of his medications are listed here:

Domperidone thrice daily before meals
Omeprazole 20 mg once before meals
Betahistine (Serc) 16 mg twice daily after meals
Levofloxacin 500 mg once daily
Paracetamol and Orphanedrine thrice daily after meals.

The patient noted a slight improvement in his condition but did not completely recover. He continued to have vertigo and anorexia with occasional vomiting.

The second prescription via Online Medical Consultation ...

Another online consultation was done with a very senior professor of medicine. He advised injectable medications and intravenous hydration as listed here:

Injection Omeprazole 40 mg once daily
Injection of ondansetron 16 mg thrice daily
Injection of ceftriaxone 2.0 gms twice daily
Tab. Naproxen 550 mg thrice daily
Intravenous Ringer lactate 1000 ml twice daily
Tab. Stemetil (prochlorperazine) thrice daily
Tab. Serc (Betahistine) 16 mg thrice daily

However, after a week of the injectable medications, he continued to have the same problems i.e. vertigo, nausea, vomiting, and the occasional headache. His Blood CBC, renal functions, liver functions, and Typhi dot tests were all normal.

When No Improvement Was Noted With Medications That Were Prescribed Online ...

He was brought to our clinic after about two weeks of treatment. On examination, he was afebrile, vital signs were all normal. He was conscious and oriented in time, space, and person. Power and sensory examination were normal in both the upper and the lower limbs.

He had a left lateral rectus palsy. His left eye deviated to the right but the relatives and the patient were unaware of it. A fundus examination was performed. He was found to have grade IV papilledema that was suggestive of a raised intracranial pressure.

An urgent CT scan of the brain was advised. A large hypodense lesion with surrounding edema suggestive of a brain tumor was suspected.

MR of the brain and urgent neurosurgical consultation was advised. He was put on high-dose dexamethasone and valproic acid along with other supportive treatments.

What are the PROS and CONS of Online Medical Consultation?

Pros of Online medical consultations?

The patient does not have to wait for his turn or wait in a queue.
The patient does not need to go out of home or travel to a hospital.

Thus, it saves time and energy

Online consultation can be done at any time of the day, especially, when one can not travel at odd times.
Some patients may feel embarrassed when describing certain symptoms. Most of these symptoms are related to sexual health and genitourinary problems. Patients can describe their symptoms without getting embarrassed by an online doctor.

You don't feel embarrassed

Patients have the option of choosing a variety of doctors and taking expert consultations instantly.
Online consultations may be best for certain specialties such as a psychiatrist who rarely perform a physical examination.
It is best in conditions where the patient needs counseling or an explanation of an already diagnosed condition.

Online medical consultation is best for an already diagnosed disease

Online consultations may also benefit patients, especially diabetics and those with other chronic conditions who have once been seen physically by the doctor and need just dose adjustments.
People residing in areas where medical facilities and doctors are not available may take benefit from online consultations.

CONS of Online Medical Consultations?

The most important disadvantage of Online Medical Consultation is the lack of physical examination. A lack of physical examination may result in diagnostic errors.
- People think that laboratory investigations are enough for diagnosis. But between 80 and 100 percent of the time, a complete medical history and physical examination are used to make the diagnosis.
- Only to confirm the diagnosis or determine the severity of the ailment are laboratory studies performed.

Laboratory investigations can not replace the clinical examination

Patients may have problems in describing their issues. Miscommunication may lead to misdiagnosis too.
Patients can not judge the doctor. An overtalkative but less skilled person may seem more skilled and expert in online communication than an experienced physician.

From a doctor's Point of view, you need to be more expressive than skilled to have more online patients

What did we learn from this case?

This case highlights a few very important points in the context of online consultations:

However senior the physician is, he/ she can not diagnose you (in certain cases) if you have not been examined.
Common symptoms may be caused by uncommon diseases sometimes. One can only diagnose these cases if one thinks sensibly and out of the box.
Online consultation may make life easier for some patients, however, it may lead to serious misdiagnosis and complications in others.

Recommendations:

It is therefore recommended to take online consultations for minor queries such as:

What to eat if you have got liver, kidney, heart disease, or diabetes and hypertension?
How to adjust diabetes and hypertension medications?
How to cope with daily stress or depression?
To know the effects and side effects of certain medications
To ask about the interpretation of certain medical tests and laboratory investigations.
For a second opinion from a second doctor.
To discuss the prognosis of a serious disease (especially of a relative).