A Internal Medicine Training (CT1) station on MedMock, start to finish

Welcome to the clinical station. I'll read you a short scenario, and you're welcome to make notes. You're the junior doctor on the medical take. A 74-year-old man has just arrived on the acute medical unit, sent in by his GP with two days of fever and a cough productive of green sputum. His wife, who has come in with him, says he has become increasingly confused since this morning. His observations are: respiratory rate 24, oxygen saturations 93% on room air, blood pressure 102 over 58, heart rate 108, and temperature 38.4 degrees. Talk me through your initial assessment and management.

He's acutely unwell, and I'd treat this as suspected sepsis, most likely from a chest source. His NEWS2 is 10: a respiratory rate of 24 scores 2, saturations of 93% on air score 2, a systolic of 102 scores 1, a heart rate of 108 scores 1, a temperature of 38.4 scores 1, and the new confusion alone scores 3. Seven or more is the NEWS2 emergency-response threshold, and with a suspected infection NICE classes him as high risk of severe illness or death from sepsis. So I'd see him immediately, ask the nurse in charge for help, put him on continuous monitoring, and let the medical registrar know now rather than when I've finished. Then A to E. Airway: is he talking and protecting it? Breathing: I'd examine his chest and give oxygen to a target of 94 to 98%, unless he's at risk of hypercapnic respiratory failure, when it would be 88 to 92%, so I'd want to know whether he has COPD. Circulation: a large-bore cannula, blood cultures before antibiotics, a full set of bloods, and a venous gas for lactate and glucose. Because he's high risk, I'd give a fluid bolus within the hour: 250 mL of a balanced crystalloid over 10 to 15 minutes, reassessing after each bolus, and I'd start a fluid balance chart. Disability: his glucose, and a check for neck stiffness or a rash so I don't miss meningitis as the cause of his confusion. Exposure: I'd look for another source, such as his urine, skin or abdomen. And IV antibiotics within an hour of that NEWS2, following our local guideline for a chest source. I wouldn't wait for the chest X-ray to give them.

He has hypertension and type 2 diabetes, for which he takes metformin. He has never smoked, has no lung disease, and has no known drug allergies. He's normally independent and lives with his wife. On examination there's bronchial breathing and coarse crackles at the right base, and no neck stiffness or rash. What is your differential, and what investigations would you like?

With focal signs at the right base, the leading diagnosis is community-acquired pneumonia with sepsis, and his confusion is most likely delirium from the sepsis. I'd keep a few alternatives in mind. Aspiration, given he's confused, so he'd need a swallow screen before he eats or drinks. Influenza or COVID-19, so a viral swab, and isolation until the result is back. A pulmonary embolism can cause fever, tachycardia and hypoxia, although the sputum and focal chest signs make pneumonia much more likely. And in a man with diabetes I wouldn't want to miss an acute coronary syndrome, so an early ECG. On severity, his CRB-65 is already 3: confusion, a diastolic of 58, and age over 65. So this is a high-severity pneumonia even before I have his urea. For investigations: full blood count, U&Es, liver function, CRP, clotting and blood cultures; the venous gas; a chest X-ray, portable if he isn't safe to move; the ECG; a urine sample for culture; a sputum sample; and a pneumococcal urinary antigen, which helps us narrow the antibiotics later. I'd add a legionella antigen if he had risk factors such as recent travel. And I'd check whether his GP has already started antibiotics.

Here are his results. The venous gas shows a lactate of 3.1 millimoles per litre and a glucose of 12.6. His white cell count is 18.4, CRP 236, sodium 134, urea 9.8 and creatinine 148; three months ago his creatinine was 90. The chest X-ray shows right lower zone consolidation, and the ECG shows sinus tachycardia. How do you interpret these, and what do they change?

They confirm a right lower zone pneumonia with sepsis. A urea of 9.8 takes his CURB-65 to 4, so it's high severity. The lactate of 3.1 suggests hypoperfusion, and he has an acute kidney injury: a creatinine of 148 against a baseline of 90 is about 1.6 times, so stage 1, most likely from the sepsis and poor intake. So, antibiotics should already be in. For high-severity pneumonia our guideline, like NICE's, is IV co-amoxiclav with clarithromycin, and he has no allergies. I'd review the choice once the cultures and antigen result are back. Fluids: I'd reassess after each 250 mL bolus and repeat it if he's still tachycardic or his pressure is soft, up to a litre, listening to his chest each time. I'd repeat the gas after the fluids to see whether the lactate is clearing, and catheterise him to measure his urine output hourly. For his kidneys, I'd hold the metformin and anything nephrotoxic, including an ACE inhibitor if he's on one for his blood pressure, and check his drug doses against his renal function. The glucose of 12.6 is likely a stress response, so I'd check ketones and keep monitoring it. He'll also need a VTE assessment. Then I'd update the registrar with the results and ask whether critical care outreach should see him now.

An hour later the nurse calls you back. He has now had a litre of fluid in boluses. His blood pressure is 86 over 50, his heart rate 118, and his saturations are 91% on 15 litres through a non-rebreather mask. A repeat lactate is 4.4. What do you do?

He's getting worse despite the right initial treatment. His blood pressure hasn't responded to a litre of fluid and his lactate is rising, so this looks like evolving septic shock, and his oxygenation is worsening on 15 litres. He needs critical care input now. I'd go straight back and reassess him from A to E, and at the same time ask the medical registrar to come to the bedside and refer him to the critical care team or outreach. If the registrar couldn't come immediately, I'd put out a medical emergency call rather than wait. And I'd make sure the consultant is told. I'd take an arterial gas to look at his oxygenation, carbon dioxide and acid-base status. He's had the full litre, so rather than giving more fluid reflexively I'd listen to his chest and assess his fluid status first. He may need vasopressors and more respiratory support, and those are decisions for the critical care team. While they're coming, I'd check the antibiotics actually went in, repeat his ECG, and consider a repeat chest X-ray or a lung ultrasound to look for an effusion. We also urgently need a treatment escalation plan. I'd assess whether he has capacity for that decision, although with this degree of confusion he may well not at the moment. I'd ask his wife what he would want and whether he has an advance decision or a lasting power of attorney. If not, the senior team would decide in his best interests, taking his wishes into account.

The ICU registrar is on the way. His wife asks to speak to you. She is very anxious, and she asks you directly: 'Is he going to die?' How would you handle that?

I'd make sure a nurse is with him, then take her somewhere private, sit down and introduce myself. I'd ask briefly what she's understood so far, so that I start from where she is. But she's asked a direct question, so I wouldn't make her wait long for an honest answer. I'd say something like: 'He is very seriously ill. He has a severe pneumonia, and the infection is affecting his blood pressure, his kidneys and his breathing. I can't promise you he'll get through this. There is a real chance he could die. But he's getting the right treatment, and the intensive care team are on their way to see him.' Then I'd stop and give her time, because that's a lot to take in. When she's ready, I'd explain that he may need to move to intensive care, and ask her about him: what he's normally like, whether he's ever said what he'd want if he became this unwell, and whether he has an advance decision or a lasting power of attorney. I'd check whether she has someone with her or someone we can call for her, tell her the registrar or the intensive care team will speak to her after they've seen him, and make sure we have her phone number. Then I'd document the conversation.

Thank you. She tells you he has no advance decision or lasting power of attorney, and that he has always said he would want to be treated. The ICU registrar is now assessing him. We have about a minute left. The night medical registrar has just arrived: please hand this patient over to them, speaking as if directly to them.

Hi, I'll start with the sickest patient on the unit. Situation: bed 6, a 74-year-old man with a high-severity right lower zone pneumonia and evolving septic shock. ICU are assessing him now. Background: independent at baseline, with hypertension and type 2 diabetes. Two days of productive cough and fever, and new confusion today. Assessment: NEWS2 of 10 on arrival, CURB-65 of 4. IV co-amoxiclav and clarithromycin went in within the hour, and he's had a litre of fluid, but his pressure is 86 over 50, his lactate is up from 3.1 to 4.4, and he's 91% on 15 litres. Arterial gas pending. Stage 1 AKI, creatinine 148 from 90; catheterised, metformin held. Cultures and a viral swab are sent. When I assessed him he lacked capacity for escalation decisions; his wife knows he could die and says he'd want to be treated. No escalation plan is documented yet. Recommendation: please see him with ICU now, agree an escalation plan with the consultant, and chase the gas. Any questions?

Thank you. That's the end of the station.