The deteriorating ward patient — sepsis and NEWS2 escalation
PLAB 2 & PRES 3 · acute medicine / emergency medicine · hard · 10 minutes
Candidate brief
You are an FY2 doctor on an acute medical ward. Mrs Edith Lawson, 79, was admitted yesterday with a urinary tract infection and started on oral antibiotics. The nurse has just asked you to review her urgently: over the last two hours she has become drowsy and newly confused, and her observations have changed. Observations now (NEWS2 total 11): respiratory rate 24/min, SpO2 94% on air, BP 98/58 mmHg, pulse 115/min, temperature 38.6 °C, new confusion (alert to voice). She has a urinary catheter in place; the bag has produced about 15 ml of urine in the last hour. Yesterday evening her NEWS2 was 2. Please assess and manage this patient, and escalate appropriately.
What examiners look for
NEWS2 is a trigger, not a diagnosis — but a jump from 2 to 11 with new confusion is the ward shouting. The candidate who recalculates the score, states the number, and lets it change their tempo has understood the chart's entire purpose. Confusion in an elderly patient with an infection is organ dysfunction until proven otherwise, never "just her age". Septic encephalopathy plus a rising creatinine plus a falling urine output is three organs declaring themselves; counting them out loud is how the severity becomes undeniable. The Sepsis Six is a bundle against the clock, and the clock starts at recognition, not at the end of the clerking. Cultures before antibiotics, antibiotics within the hour, lactate measured, fluids with reassessment, urine output charted, oxygen to a target — examiners score the elements AND the sequence under time pressure. The allergy label is the station's tripwire, set deliberately. Ignoring a penicillin label fails; so does paralysing the treatment because of a vague decades-old rash while a woman is septic. The professional move is the middle path: clarify the reaction, note she is tolerating the drug, and put the decision to the registrar/microbiology — in minutes, not as an excuse for delay. Lactate converts suspicion into evidence. 3.4 mmol/L in a hypotensive, confused patient means tissues are underperfused even before the blood pressure collapses completely — and it changes who needs to be in the room (critical care) and how fast. Escalation is a skill with a format. SBAR with the NEWS2, the lactate, what has been given and what happened next will get a registrar moving at 2 a.m.; "she's just not herself and looks a bit worse" will not, however true it feels. Fluids in a 79-year-old are a drug with a ceiling: bolus, reassess, listen to the chest, look at the numbers, then decide again. Sepsis kills with too little resuscitation and, in the elderly heart, finishes the job with too much.
Guideline references
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