Consultant Internal Medicine oral assessment prep

Knowledge: This is severe diabetic ketoacidosis in its euglycaemic form, precipitated by an SGLT2 inhibitor, prolonged fasting and dehydration. Severity is judged by acidosis, ketones and physiology, not glucose, and ketones above 6 mmol/L with a pulse above 100 are markers that call for consultant review and high-dependency care. Glycosuria keeps glucose low while relative insulin deficiency drives ketogenesis. I would still check lactate and exclude metformin-associated lactic acidosis, sepsis, pancreatitis and myocardial ischaemia as precipitants or co-existing causes. A normal potassium hides a total-body deficit that will fall quickly once insulin starts.

Management: I would admit him to a high-dependency bed, give 0.9% saline 1 L over the first hour and titrate further fluid to response. I would start fixed-rate insulin at 0.1 units/kg/hour with 10% glucose alongside from the start, because glucose is already below 14 mmol/L. I would add potassium chloride 40 mmol/L to fluids while potassium is 3.5 to 5.5 and check potassium, ketones and venous gas every 1 to 2 hours. I would stop all three oral agents and look for a precipitant with ECG, troponin, lactate and cultures. I would not stop insulin because glucose is normal, nor give bicarbonate. Resolution means ketones below 0.6 mmol/L and pH above 7.3, then subcutaneous insulin overlapping the infusion, and a review of whether the SGLT2 inhibitor should ever be restarted.

Ethics and communication: I would explain openly that a prescribed medicine contributed, without blaming the prescriber. If he wishes to keep fasting I would respect his choice while giving a clear, documented risk assessment, involving his family or an imam if he wishes. I would record the adverse drug reaction in his allergy and alert record and report it through the facility pharmacovigilance route.

Reference: Joint British Diabetes Societies for Inpatient Care, The Management of Diabetic Ketoacidosis in Adults; Umpierrez GE et al, Hyperglycemic Crises in Adults With Diabetes: A Consensus Report (Diabetes Care, 2024); IDF-DAR Diabetes and Ramadan: Practical Guidelines (2021)

Knowledge: This is severe acute salicylate poisoning, with an ingestion of about 250 mg/kg, a mixed respiratory alkalosis and high anion gap metabolic acidosis, and neurological features. Salicylate uncouples oxidative phosphorylation, causing fever, acidosis and fluid loss, and acidaemia drives more salicylate into the brain. Altered mental status is an indication for extracorporeal removal under the EXTRIP recommendations, whatever the concentration, and haemodialysis is the preferred method. Levels can keep rising for many hours after large or enteric-coated ingestions. Brain glucose can be low even when blood glucose is normal.

Management: I would give intravenous fluids, glucose to keep blood glucose high-normal, and potassium. I would start urinary alkalinisation with intravenous sodium bicarbonate, aiming for a urine pH of 7.5 to 8.5 while keeping arterial pH below about 7.55, knowing that alkalinisation fails if hypokalaemia is not corrected. I would contact nephrology and intensive care now for urgent haemodialysis because of his altered mental status. I would repeat salicylate levels, gases and potassium every 2 hours until levels are clearly falling. I would avoid intubation if possible, because losing his compensatory hyperventilation can cause sudden acidaemia and cardiac arrest. If intubation became necessary, I would give bicarbonate first and set a high minute ventilation. I would arrange psychiatric assessment once he is medically fit.

Ethics and communication: If he refuses treatment, I would assess his capacity carefully, as poisoning and distress can impair it, and treat as an emergency if he lacks it. If he has a mental disorder and poses a serious risk, involuntary assessment may be possible under Federal Law No. 10 of 2019 on Mental Health. I would keep the details confidential from his employer and involve family only with his consent or for his safety. I would document my capacity and risk assessments.

Reference: Juurlink DN et al, Extracorporeal Treatment for Salicylate Poisoning: Systematic Review and Recommendations From the EXTRIP Workgroup (Annals of Emergency Medicine, 2015); Nelson LS et al, Goldfrank's Toxicologic Emergencies (11th ed, 2019)

Knowledge: This is severe falciparum malaria by several WHO criteria: impaired consciousness, creatinine above 265 micromol/L, jaundice with a parasite count above 100,000 per microlitre, glucose below 2.2 mmol/L and raised lactate. Any one criterion mandates parenteral treatment, and in a non-immune traveller even parasitaemia below the WHO 10% threshold is high risk. Intravenous artesunate is first line because it reduced mortality compared with quinine in large trials. Co-existing bacterial sepsis is common in severe malaria, and hypoglycaemia may recur, especially if quinine has to be used. Delayed haemolysis after artesunate can occur one to several weeks later and needs planned follow-up.

Management: I would correct hypoglycaemia at once with intravenous glucose and give artesunate 2.4 mg/kg intravenously at 0, 12 and 24 hours and then daily, without waiting for transfer. I would involve intensive care immediately for monitoring and likely renal replacement therapy, and give fluids cautiously because severe malaria is prone to pulmonary oedema. I would take blood cultures and give broad-spectrum antibiotics given shock and possible bacteraemia. Parasitaemia and glucose would be repeated at least every 12 hours. Once he can swallow and has had at least 24 hours of artesunate, I would complete a full course of an artemisinin combination such as artemether-lumefantrine. I would not use steroids or give oral treatment alone. I would arrange haemoglobin checks at days 7, 14, 21 and 28 for delayed haemolysis.

Ethics and communication: Malaria is notifiable, so I would report it to the public health authority in line with Federal Law No. 14 of 2014. His employer may ask for information, but I would share nothing without his consent beyond what the law requires. When he recovers I would advise on prophylaxis for future travel and document the discussion.

Reference: WHO Guidelines for Malaria; Dondorp A et al, Artesunate versus quinine for treatment of severe falciparum malaria: a randomised trial (SEAQUAMAT, Lancet, 2005); Harrison's Principles of Internal Medicine (21st ed, 2022)

Knowledge: This is a thrombotic microangiopathy with a high clinical probability of immune thrombotic thrombocytopenic purpura: severe thrombocytopenia, microangiopathic haemolysis, neurological symptoms and only mild renal impairment with a normal coagulation screen. Her PLASMIC score is high. That supports treatment before the ADAMTS13 result. Differentials include atypical or Shiga toxin haemolytic uraemic syndrome, disseminated intravascular coagulation, malignant hypertension, drug-induced microangiopathy, systemic lupus and, in pregnancy, HELLP syndrome, so a pregnancy test is required. Untreated, mortality is very high, mostly from cardiac and cerebral microthrombi.

Management: I would cancel the platelet transfusion unless she develops life-threatening bleeding, because it may worsen thrombosis. I would send ADAMTS13 activity and inhibitor before any plasma, plus troponin, ECG, pregnancy test, HIV and hepatitis serology, and direct antiglobulin test. I would contact the on-call haematologist immediately and arrange plasma exchange the same day, transferring to a unit that can deliver it if needed, with plasma infusion as a bridge. I would start methylprednisolone and discuss caplacizumab and rituximab with haematology. She should be in a monitored bed, not a general ward. I would give folic acid and start thromboprophylaxis once platelets exceed 50 x 10^9/L. Daily platelets and lactate dehydrogenase guide response, and long-term ADAMTS13 monitoring is needed because relapse occurs.

Ethics and communication: I would explain the seriousness honestly and obtain consent for central venous access and plasma exchange, explaining the risks of blood products. If she declines blood products for personal reasons, I would explore this respectfully, document her informed decision and seek alternatives with haematology. I would discuss the emergency physician's order directly and collegially rather than through the notes.

Reference: Zheng XL et al, ISTH Guidelines for Treatment of Thrombotic Thrombocytopenic Purpura (Journal of Thrombosis and Haemostasis, 2020); Bendapudi PK et al, Derivation and external validation of the PLASMIC score (Lancet Haematology, 2017)

Knowledge: Clinically this is stage IV pancreatic adenocarcinoma with poor performance status, where survival is usually short and chemotherapy is unlikely to help unless function improves. The priorities are biliary drainage for symptoms and itch, pain control, nutrition, and early specialist palliative care. Ethically, he appears to have capacity and has asked directly. He is therefore entitled to an honest answer at the depth he wants. Family requests to withhold information are common in GCC practice and come from love, but they do not override a capacitous adult's wishes.

Management: I would not answer in front of others without his agreement. I would first meet the sons privately, acknowledge their concern, explain that I cannot deceive their father, and offer to let them be present. I would then see him in a quiet room, ask what he already understands and how much he wants to know, and follow his lead using a structured approach such as SPIKES. If he prefers that his sons receive the details, I would document this as his decision. I would refer for biliary stenting, start regular analgesia and involve palliative care within days. I would discuss goals of care and resuscitation status, recording any do-not-resuscitate decision in line with UAE law and facility policy.

Ethics and communication: Under Federal Decree-Law No. 4 of 2016 and its executive regulation, consent for treatment is given by the patient and requires adequate information, so withholding the diagnosis from a capacitous man would undermine valid consent. Respecting a patient's choice to delegate information to family is acceptable when it is truly his choice. I would document each conversation, who was present and what he asked to know.

Reference: Federal Decree-Law No. 4 of 2016 on Medical Liability (UAE); Baile WF et al, SPIKES: A Six-Step Protocol for Delivering Bad News (The Oncologist, 2000); WMA Declaration of Lisbon on the Rights of the Patient

Knowledge: Initially she was intermediate-high risk: normotensive with both right ventricular dysfunction on imaging and a raised troponin. A systolic pressure below 90 mmHg for more than 15 minutes, despite adequate filling, now defines high-risk pulmonary embolism with obstructive shock, which carries a high early mortality. In high-risk embolism, reperfusion is indicated. The ESC lists major surgery within the previous three weeks as an absolute contraindication to systemic thrombolysis. Surgical embolectomy or catheter-directed treatment is therefore preferred, although absolute contraindications may become relative if death is imminent.

Management: I would call intensive care and the pulmonary embolism response team or cardiology immediately, and avoid further large fluid boluses that can worsen right ventricular failure. I would start noradrenaline to support pressure and give oxygen, avoiding intubation if possible because induction can cause collapse. I would arrange surgical embolectomy or catheter-directed treatment within the hour, transferring if needed, and keep unfractionated heparin running because it can be stopped quickly. If she arrests or is peri-arrest before that is possible, I would give systemic alteplase, accepting the bleeding risk, with blood products ready. I would monitor the knee and haemoglobin closely. After stabilisation, she transitions to oral anticoagulation for at least three months, with review for provoked embolism.

Ethics and communication: Consent should be brief but genuine, explaining the risk of death without treatment and the risk of bleeding, including into the knee or brain, and I would document the discussion and the multidisciplinary decision. If she cannot participate, I would act in her best interests as an emergency and update her family afterwards. I would keep the orthopaedic team involved in the decision.

Reference: Konstantinides SV et al, 2019 ESC Guidelines for the Diagnosis and Management of Acute Pulmonary Embolism (European Heart Journal, 2020); Stevens SM et al, Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report (Chest, 2021)