Approach to a presentation

Acute chest pain

Undifferentiated chest pain in an adult presenting to acute care

Cardiology7 stepsEmergency

Acute breathlessness

Adult with acute or acutely worsened dyspnoea

Respiratory6 stepsEmergency

Fever in an adult

Acute febrile illness with or without an obvious source

Infectious disease6 stepsEmergency

Hyperglycaemia in an unwell adult

High capillary glucose in an acutely unwell patient with or without known diabetes

Endocrinology6 stepsEmergency

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