Acute medicine and infectious diseases · FICTIONAL CASE

The ward patient who is deteriorating—and may have sepsis

Recognise evolving organ dysfunction, use structured risk assessment and coordinate treatment, monitoring and source control without anchoring on one score.

Escalation, source control and parallel working≈ 16 minutes0/3 decisions explored
PAUSE BEFORE USING

This is educational content, not a clinical protocol. Verify current guidance, use local pathways and seek appropriate senior or specialist help.

THE CASE

A fictional 74-year-old admitted with probable urinary infection becomes newly confused, tachypnoeic and hypotensive. Their temperature is 37.4°C and urine output has fallen.

01 · INITIAL PRESENTATION

Listen for the assumption.

SHO

The temperature is not high, but the physiology and change from baseline concern me. I have repeated observations and started a structured sepsis assessment.

Registrar

Good. What must happen in parallel rather than sequentially?

SHO

Resuscitation, time-critical treatment, cultures where they do not delay care, source identification, monitoring and senior escalation.

WHERE IS THE CONSULTANT?

Choose an answer below and reveal the reasoning to see consultant feedback at every checkpoint. The full consultant-led synthesis follows after all three decisions.

Go to the first decision ↓
EVOLVING INFORMATION

The picture develops.

  1. NEWS2 rises because of respiratory rate, blood pressure and confusion
  2. Lactate is elevated and renal function has worsened
  3. The urinary catheter has produced little urine and may be a source or obstruction clue
02 · DECISION CHECKPOINTS

Commit before you reveal.

After you select an option, reveal the model reasoning and the consultant’s feedback.

DECISION 1What is the safest interpretation of the normal-range temperature?
DECISION 2Which plan best avoids delay?
DECISION 3Blood pressure transiently improves. What remains essential?
03 · CONSULTANT-LED SYNTHESIS

Hear the senior team refine the plan.

The registrar tests the plan, the consultant synthesises the key principle, and the SHO confirms the safer next steps.

Registrar

I want the risk category, time of recognition, treatment times, response and suspected source stated explicitly.

Consultant

And keep alternatives open. Haemorrhage, pulmonary embolism, cardiogenic shock and medication effects can coexist with or mimic infection.

SHO

I will hand over the physiological trend, actions and response, outstanding source-control decision and clear escalation triggers.

CLINORA DECISION TRACE
01 · CUENew confusion, tachypnoea, hypotension and oliguria with suspected infection
02 · INTERPRETPossible sepsis with evolving organ dysfunction
03 · ACTStructured risk assessment, parallel emergency care, repeated review and source-control escalation
SAFETY CHECK

What must remain explicit.

  • Use the current NICE sepsis pathway and local antimicrobial guidance.
  • Record recognition, treatment and reassessment times.
  • Escalate persistent hypotension, rising lactate, hypoxia or altered consciousness immediately.
COMMON ERRORS

Where reasoning fails.

  • Requiring fever before considering sepsis
  • Using NEWS2 as a substitute for clinical judgement
  • Delaying source control while physiology worsens
STRUCTURED HANDOVER
Possible sepsis from [source] recognised at [time], with NEWS2/physiology [trend]. Actions and response are [details]; cultures and source control are [status]. I need senior and critical-care review for [specific concern].
REFLECTIVE PAUSE

How would you divide the first ten minutes of work across your team while keeping one person responsible for reassessment?

CONTINUE INTO EXAM PRACTICE

Test the related knowledge.

Move from discussion to MRCP Part 1 questions mapped to the same clinical domains.

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