Step-by-step cases

Crushing chest pain at 06:40

A 58-year-old man with hypertension and a 30-pack-year smoking history arrives 90 minutes after sudden crushing central chest pain radiating to the jaw. He is sweaty, blood pressure 138/84 mmHg, pulse 92/min, SpO2 97% on air.

Cardiologymoderate4 decisions

Day 4 fever that just broke

A 24-year-old woman living in an endemic city has had 4 days of high fever, severe myalgia and retro-orbital pain. Today she is afebrile but has severe abdominal pain and repeated vomiting. Blood pressure 110/95 mmHg, pulse 108/min, platelets 55 × 10⁹/L, haematocrit risen from 38% to 47%.

Infectious diseasemoderate5 decisions

Ketones 5.8, potassium 3.1

A 19-year-old with type 1 diabetes has vomited all day after running out of insulin. Glucose 32 mmol/L, capillary ketones 5.8 mmol/L, venous pH 7.05, bicarbonate 6 mmol/L, potassium 3.1 mmol/L, pulse 122/min, blood pressure 96/58 mmHg. He weighs 60 kg and has had 1 L of 0.9% sodium chloride.

Endocrinologyhard4 decisions

SpO2 99% and getting drowsy

A 70-year-old with severe COPD arrives by ambulance on 15 L/min oxygen via a reservoir mask. He is drowsy with a flapping tremor. SpO2 99%, respiratory rate 12/min, pH 7.21, PaCO2 9.4 kPa, PaO2 24 kPa, bicarbonate 32 mmol/L.

Respiratorymoderate4 decisions