Consultant Emergency Medicine oral assessment prep

Knowledge: A fever of 38 degrees or more in an infant under 28 days is an emergency until proven otherwise, because neonates have immature immunity, an unreliable clinical examination and a high rate of invasive bacterial infection, and this baby additionally has signs of poor perfusion and respiratory distress which mean he is not simply febrile, he is potentially septic.

Management: This is a resuscitation-room case. I would attach monitoring, check a capillary glucose immediately and correct hypoglycaemia with 2 mL/kg of 10 percent dextrose, give oxygen as required, and obtain intravenous access, moving to intraosseous access without prolonged delay if two attempts fail. The full septic screen means blood culture, full blood count, C-reactive protein and procalcitonin where available, blood gas with lactate, urine by catheter or suprapubic aspirate rather than a bag specimen, and a lumbar puncture.

Ethics and communication: The parents' request to go home is fear, not neglect, and the way I respond determines whether they cooperate for the next twelve hours. I would sit down, use their language or an interpreter, explain in concrete terms that at three weeks of age a fever with these signs carries a real risk of a blood or brain infection that we cannot exclude by examination, and that the tests and antibiotics are urgent rather than precautionary.

Reference: American Academy of Pediatrics Clinical Practice Guideline: Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old (Pediatrics, 2021); NICE NG143 Fever in Under 5s (updated 2021)

Knowledge: This is a declared cannot intubate, cannot oxygenate situation and the single greatest danger is task fixation on repeated laryngoscopy while the patient becomes hypoxic and bradycardic from hypoxaemia.

Management: I would say out loud that this is a CICO situation and that we are proceeding to a surgical airway, which both commits the team and stops further futile attempts. While I position, someone continues attempted oxygenation with two-person mask technique, jaw thrust and adjuncts, and nasal apnoeic oxygen stays on.

Ethics and communication: Consent is implied by necessity here, but I still owe the patient and his family a full explanation afterwards of why a surgical airway was performed and what it means, delivered honestly and without defensiveness, because a neck incision is a visible intervention that families question.

Reference: Difficult Airway Society Guidelines for Management of Unanticipated Difficult Intubation in Adults (Br J Anaesth, 2015); NAP4 Royal College of Anaesthetists Fourth National Audit Project (2011)

Knowledge: She has severe diabetic ketoacidosis with an immediately life-threatening hyperkalaemia, and the two problems must be managed together rather than sequentially. The important physiological insight is the potassium paradox: her serum potassium is high because insulin deficiency and acidosis have driven potassium out of cells, but her total body potassium is profoundly depleted, so once insulin and fluids start, the level will fall rapidly and she can become dangerously hypokalaemic within hours.

Management: First, membrane stabilisation with intravenous calcium gluconate or chloride, repeated as needed while the ECG remains abnormal. Then intracellular shift and definitive treatment run together: isotonic crystalloid resuscitation starting with about a litre in the first hour and continuing per protocol, and a fixed-rate intravenous insulin infusion at roughly 0.1 units per kilogram per hour, which is itself the best treatment for both her ketoacidosis and her hyperkalaemia.

Ethics and communication: Recurrent DKA in a young adult is frequently a social and psychological problem rather than a purely metabolic one, and the ethical failure is to fix the numbers, discharge her and never ask why she stopped her insulin.

Reference: ADA/EASD Consensus Report: Hyperglycemic Crises in Adults with Diabetes (Diabetes Care, 2024); Joint British Diabetes Societies Guideline for the Management of DKA in Adults (2023)

Knowledge: This patient is dying from progressive metastatic disease and the clinical picture of unresponsiveness, hypoventilation, mottling and terminal secretions is consistent with the final hours to days. My clinical duty first is to confirm that there is no rapidly reversible contributory factor that would be reasonable to treat within his overall goals of care: hypoglycaemia, opioid toxicity which is reversible and worth considering, hypercalcaemia of malignancy, sepsis, urinary retention, or an obstructing lesion.

Management: I would begin by treating the patient in front of me: reposition him, stop anything that is causing distress, and provide symptom control with a titrated opioid for dyspnoea and pain, an antimuscarinic such as hyoscine butylbromide or glycopyrronium for secretions, a benzodiazepine such as midazolam for terminal agitation, and mouth care, with the subcutaneous route preferred if intravenous access is not already in place.

Ethics and communication: The son's demand is almost always an expression of love, guilt and fear of being seen as the one who let his father go, so I would name that explicitly and remove the burden of decision from him by saying that this is our medical judgement and not a choice we are asking the family to make.

Reference: American College of Emergency Physicians, Code of Ethics for Emergency Physicians (2017); Quill TE, Arnold R, Back AL. Discussing Treatment Preferences with Patients Who Want Everything (Ann Intern Med, 2009)