Urgent & Unscheduled Care for GPs

Urgent & Unscheduled Care for GPs: Your Essential Guide

From “Is this serious?” to “I’ve got this” — mastering acute presentations without the panic

🥇 Tea-Friendly Learning 🥈 For GP Trainees Short on Time 🥉 Red Flag Focused

Last Updated: March 2026

Executive Summary — What You Will Learn

Because you have 47 other things to do before lunch, and that’s just the morning list

📋 What This Page Covers:

ABCDE assessment for acutely unwell patients
Risk stratification tools — NEWS2, qSOFA, Wells score
Dangerous diagnoses not to miss (8 red flag conditions)
Common urgent conditions & NICE-verified management
Investigations, referral decisions & SBAR handover
Safety-netting, ethics & medico-legal documentation
Multi-professional working & service organisation
MRCGP links — AKT, RCA, CBD & WPBA

📊 Quick Facts at a Glance:

30%

Sepsis mortality if antibiotics delayed

NICE NG253 2025

4.5hrs

Stroke thrombolysis window

NICE NG128 2025

15%

GP consultations urgent/same-day

NHS England 2025

NEWS2 score = emergency response

RCP NEWS2 2025

Key Learning Objectives

Master systematic ABCDE assessment for acutely unwell patients
Recognize red flag symptoms requiring immediate action
Apply NEWS2 scoring and risk stratification tools

Navigate appropriate service pathways and referral criteria
Deliver effective safety-netting and communication in crisis
Understand ethical and governance frameworks for urgent care

📥 Downloads & Resources

Handouts, reference tools and trusted UK online resources for urgent care

📥 Downloads

path: URGENT UNSCHEDULED ACUTE MEDICAL CARE

🌐 Web Resources

LITFL — Life in the Fast Lane Free gold-standard acute medicine resource with ECG library, critical care compendium and 250+ clinical cases.
Resuscitation Council UK — Guidelines 2021 Official ABCDE, ALS and anaphylaxis algorithms with free downloadable reference cards.
UK Sepsis Trust — Clinical Resources Sepsis Six poster and GP-specific sepsis screening tools directly applicable to same-day consultations.
MDCalc — Clinical Calculators Free point-of-care calculators for NEWS2, Wells score, CRB-65 and ABCD² risk stratification.
St Emlyn’s — Evidence-Based Emergency Medicine UK emergency medicine blog with practical summaries and podcasts, highly rated by trainees.
e-Learning for Healthcare — Acute Care Free NHS eLearning on acute presentations, ABCDE and deteriorating patient recognition. Counts as CPD.
Spotting the Sick Child Free NHS e-learning covering PEWS, paediatric red flags and safety-netting. Highly rated by GP trainees.
Don’t Forget the Bubbles — Non-blanching Rashes Module Interactive case-based module on petechiae and meningococcal fear; strong safety-netting focus, great teaching resource.
Geeky Medics — ABCDE Assessment Clear checklist-style A-E guide; excellent mental model for any suddenly unwell patient before escalation.
Geeky Medics — Recognition and Management of the Sick Child Structured developmentally adapted A-E approach to the acutely unwell child; strong teaching value.
GPnotebook — Assessment of Head Injury Quick-reference head injury assessment prompts focused on urgent decision-making in minor injury settings.
Healthier Together — Fever / High Temperature Paediatric red/amber/green fever guide; excellent for safety-netting and sharing with families in same-day triage.
Healthier Together — Difficulty Breathing Traffic-light paediatric breathing guide; helpful for wheeze and disposition decisions in OOH and same-day clinics.
GPnotebook — Doctor’s Emergency Bag Practical emergency bag checklist with drug suggestions; useful for practice review and trainee teaching.
GPnotebook — Initial Assessment of Acute Chest Pain Focused ACS recognition guide with referral thresholds; useful quick check during urgent consultations.

🧠 Brainy Bites

Essential mnemonics and memory aids for urgent care

SEPSIS SIX

Give 3, Take 3

Give: O₂, Antibiotics, Fluids | Take: Cultures, Lactate, Urine output

FAST Stroke

Face-Arms-Speech-Time

Facial droop, Arm weakness, Speech difficulty, Time to call 999

NEWS2 Triggers

3-5-7 Rule

Score 3: Increase monitoring | 5: Urgent review | 7: Emergency response

Chest Pain RED FLAGS

CARDIAC

Crushing pain, Arm/jaw radiation, Radiation to back, Diaphoresis, Ischaemic history, Acute breathlessness, Collapse

🚨 Red Flag Patterns

5 Combos Not to Miss

• Chest pain + sweating + nausea → ACS

• Sudden severe headache → SAH

• Fever + rash + neck stiffness → Meningitis

• Abdominal pain + hypotension → Bleeding (AAA/ectopic/GI)

• Breathlessness + chest pain + tachycardia → PE

💪 CASH-A

Surgery Emergencies

• Cardiac arrest — CPR immediately; AED in every GP surgery — know how to use it before you need it

• Anaphylaxis — adrenaline 500mcg IM; inject the right way round (auto-injector: protected end is NOT the button)

• Seizures — most self-resolve; status epilepticus needs benzodiazepine; O₂ after tonic-clonic phase

• Hypoglycaemia — fast-acting glucose in every surgery

• Asthma attack

💊 SADMAN

Stop on Sick Days

• SGLT-2 inhibitors (“flozins”)

• ACE inhibitors (“prils”)

• Diuretics (“ides”)

• Metformin

• ARBs (“sartans”)

• NSAIDs (ibuprofen, naproxen)

📋 Data Gathering Pearls

Before You Decide Anything

• Always assess severity first

• Pain + systemic upset = urgent

• Trust your gut feeling

• Document everything

• Safety-net every acute case

1️⃣ ABCDE Assessment Framework

Systematic approach to assessing acutely ill patients

The ABCDE approach provides a systematic method for assessing and treating acutely unwell patients. This structured framework ensures critical issues are identified and managed in order of priority.

Critical Principle

Complete each step before moving to the next. Treat life-threatening problems as you find them. Call for help early if patient is critically unwell.

Look For

• Can the patient speak in full sentences?
• Signs of airway obstruction (stridor, gurgling, snoring)
• Visible foreign body or secretions
• Is the patient maintaining their own airway?

Red Flags

• Complete airway obstruction (silent chest, unable to speak)
• Stridor (inspiratory noise — upper airway obstruction)
• Reduced consciousness (GCS ≤8 cannot protect airway)
• Facial burns or inhalation injury

Immediate Actions

Open airway: head tilt-chin lift (jaw thrust if C-spine injury suspected)
Remove visible obstruction (suction if available)
Insert airway adjunct if needed (oropharyngeal or nasopharyngeal)
Give high-flow oxygen (15L/min via non-rebreathe mask)
Call for senior help/999 if airway compromised

Inspection

• Respiratory rate (normal 12-20/min)
• Work of breathing (accessory muscles, intercostal recession)
• Chest expansion (symmetrical?)
• Cyanosis (central vs peripheral)
• Tracheal position

Palpation & Percussion

• Chest expansion equal bilaterally
• Percussion note (resonant, dull, hyper-resonant)
• Tactile vocal fremitus

Auscultation

• Air entry (equal bilaterally?)
• Breath sounds (vesicular, bronchial, absent)
• Added sounds (wheeze, crackles, pleural rub)

Life-Threatening Breathing Problems

Tension Pneumothorax:

Absent breath sounds, hyper-resonance, tracheal deviation, hypotension, distended neck veins

Massive Haemothorax:

Absent breath sounds, dullness to percussion, shock

Acute Severe Asthma:

SpO₂ <92%, silent chest, exhaustion, altered consciousness

Pulmonary Oedema:

Severe breathlessness, pink frothy sputum, widespread crackles

Immediate Management

• Give high-flow oxygen (target SpO₂ 94-98%, or 88-92% in COPD)
• Sit patient upright if not contraindicated
• Acute asthma/COPD bronchospasm: salbutamol 5mg nebulised (short-acting beta-2 agonist, first-line; repeat every 15-30 min as needed) — NICE CKS
• Acute pulmonary oedema: furosemide 40-80mg IV (loop diuretic, first-line) + GTN 400mcg sublingual if BP >100mmHg — NICE CKS

Cardiovascular Examination

• Heart rate and rhythm (normal 60-100 bpm)
• Blood pressure (normal systolic >100 mmHg)
• Capillary refill time (normal <2 seconds)
• Peripheral pulses (present, volume, character)
• Skin colour and temperature (warm/cold, mottled?)
• JVP (elevated in fluid overload/right heart failure)

Shock Recognition

Shock = inadequate tissue perfusion. Types:

• Hypovolaemic: Low BP, tachycardia, cold peripheries
• Cardiogenic: Low BP, tachycardia, pulmonary oedema
• Distributive: Low BP, warm peripheries (sepsis, anaphylaxis)
• Obstructive: Low BP, raised JVP (PE, tamponade)

Immediate Management of Shock

Secure IV access (two large-bore cannulae if shocked)
Take bloods: FBC, U&E, glucose, lactate, blood cultures if sepsis suspected
IV fluid bolus: sodium chloride 0.9% or Hartmann’s 500ml over 15 minutes (reassess after each bolus; repeat up to 30ml/kg in sepsis) — NICE NG51
ECG (12-lead) to identify arrhythmia or ischaemia
Analgesia for ACS pain: morphine 2–5mg IV titrated + metoclopramide 10mg IV (antiemetic)
Call 999 if systolic BP <90 mmHg despite fluids

AVPU Scale

• A - Alert (fully conscious, orientated)
• V - Responds to Voice
• P - Responds to Pain only
• U - Unresponsive

If V, P, or U → perform full GCS assessment

Glasgow Coma Scale (GCS)

Eye Opening (E): 4=spontaneous, 3=to voice, 2=to pain, 1=none

Verbal Response (V): 5=orientated, 4=confused, 3=words, 2=sounds, 1=none

Motor Response (M): 6=obeys, 5=localises, 4=withdraws, 3=flexion, 2=extension, 1=none

GCS ≤8 = severe brain injury; cannot protect airway

Causes of Reduced Consciousness

Reversible (Don’t Ever Forget Glucose):

• Hypoglycaemia (check BM immediately; treat if <4 mmol/L)
• Hypoxia (check SpO₂, give oxygen)
• Hypotension (treat shock)
• Opioid overdose: naloxone 400mcg IM/IV (first-line antidote; repeat every 2-3 min up to 10mg) — BNF

Structural/Serious:

• Stroke (FAST assessment)
• Head injury (raised ICP)
• Seizure (post-ictal state)
• Meningitis/encephalitis
• Metabolic (hyponatraemia, uraemia, liver failure)

Immediate Actions

Check blood glucose immediately; treat hypoglycaemia: Lucozade 150-200ml orally if conscious, or glucagon 1mg IM if unconscious — NICE CKS
Ensure adequate oxygenation (SpO₂ >94%)
Protect airway if GCS ≤8 (recovery position)
Consider Wernicke’s encephalopathy (alcohol): thiamine (Pabrinex) IV if indicated
Urgent CT head if trauma, focal neurology, or unexplained reduced GCS
Call 999 if GCS <13 or deteriorating

Full Examination

• Expose patient fully (maintain dignity with blankets)
• Look for rashes (meningococcal sepsis, anaphylaxis)
• Check for injuries (trauma, self-harm)
• Examine abdomen (peritonism, masses)
• Check calves for DVT signs
• Look for signs of chronic disease

Temperature Control

• Measure core temperature
• Hypothermia (<35°C): warm gradually, monitor for arrhythmias
• Hyperthermia (>38.5°C): consider sepsis, heat stroke
• Prevent heat loss (warm blankets, warm IV fluids)

Key Findings Not to Miss

• Non-blanching purpuric rash (meningococcal sepsis — give ceftriaxone 2g IV/IM immediately)
• Surgical scars (previous operations)
• Track marks (IV drug use)

• Peripheral oedema (heart failure, liver disease)
• Jaundice (liver disease, haemolysis)
• Medical alert bracelets (diabetes, epilepsy, allergies)

2️⃣ Risk Stratification & Scoring Systems

NEWS2, qSOFA, Wells, and other clinical prediction tools

National Early Warning Score 2 (NEWS2)

Standardised tool for detecting clinical deterioration — RCP 2025

NEWS2 Parameters

Parameter	Score 3	Score 2	Score 1	Score 0	Score 1	Score 2	Score 3
Resp Rate	≤8		9-11	12-20		21-24	≥25
SpO₂ Scale 1	≤91	92-93	94-95	≥96
SpO₂ Scale 2*	≤83	84-85	86-87	88-92 / ≥93 on O₂		93-94 on air	≥95 on air
Supplemental O₂		No			Yes (score 2)
Systolic BP	≤90	91-100	101-110	111-219			≥220
Heart Rate	≤40		41-50	51-90	91-110	111-130	≥131
Consciousness				Alert	CVPU (score 3)
Temperature	≤35.0		35.1-36.0	36.1-38.0	38.1-39.0	≥39.1

*Scale 2 for patients with hypercapnic respiratory failure (COPD with CO₂ retention)

Score 0-4 (Low Risk)

• Minimum 12-hourly observations
• Managed by registered nurse

Score 5-6 (Medium Risk)

• Increase observations to hourly
• Urgent review by clinician
• Consider escalation to critical care

Score ≥7 (High Risk)

• Continuous monitoring
• Immediate critical care assessment
• Call 999 if in community

Clinical Judgement

NEWS2 is a guide, not a substitute for clinical assessment. A score of 3 in any single parameter warrants urgent review.

Sepsis Recognition & Management

NICE NG253 (Updated December 2025)

Critical Time Window

Sepsis mortality increases by 7.6% for every hour delay in antibiotic administration. Antibiotics must be given within 1 hour of recognition.

Sepsis Recognition: Think SEPSIS

Suspect sepsis if infection + ANY of:

• NEWS2 score ≥5
• Lactate ≥2 mmol/L
• Systolic BP <90 mmHg (or drop >40 from baseline)
• Heart rate >130 bpm
• Respiratory rate ≥25/min
• New confusion or agitation

High-Risk Groups:

• Age >75 years
• Immunosuppressed
• Recent surgery/trauma
• Indwelling lines/catheters
• Pregnant/postpartum
• Chronic disease (diabetes, COPD, CKD)

Sepsis Six Bundle (Complete within 1 hour) — NICE NG253

GIVE 3:

Oxygen: 15L/min non-rebreathe mask (target SpO₂ 94-98%)
IV Antibiotics within 1 hour (see table below)
IV Fluids: sodium chloride 0.9% or Hartmann’s 500ml over 15 min (reassess; repeat up to 30ml/kg)

TAKE 3:

Blood Cultures: Before antibiotics if possible
Lactate: Venous/arterial (>2 mmol/L = hypoperfusion; >4 = severe sepsis)
Urine Output: Catheterise and monitor hourly (target >0.5ml/kg/hr)

Antibiotic Choices — NICE CKS / Local guidelines (confirm locally)

Source	First-Line IV	Penicillin Allergy
Unknown/Community	Co-amoxiclav 1.2g IV TDS + gentamicin 5-7mg/kg IV OD	Ciprofloxacin 400mg IV BD + gentamicin
Respiratory	Co-amoxiclav 1.2g IV TDS + clarithromycin 500mg IV BD	Levofloxacin 500mg IV OD
Urinary	Co-amoxiclav 1.2g IV TDS + gentamicin 5-7mg/kg IV OD	Ciprofloxacin 400mg IV BD
Abdominal	Piperacillin-tazobactam 4.5g IV TDS + metronidazole 500mg IV TDS	Ciprofloxacin 400mg IV BD + metronidazole
Meningococcal	Ceftriaxone 2g IV/IM STAT	Chloramphenicol 25mg/kg IV STAT

Adjust for renal impairment. Review at 48-72h based on cultures. Always follow local antibiotic guidelines.

Wells Score for Pulmonary Embolism

Clinical probability assessment for suspected PE — NICE NG158

Wells Score Criteria

Clinical Feature	Points
Clinical signs of DVT (leg swelling, palpable cord)	3.0
PE is most likely diagnosis (no alternative explanation)	3.0
Heart rate >100 bpm	1.5
Immobilisation ≥3 days or surgery in previous 4 weeks	1.5
Previous DVT or PE	1.5
Haemoptysis	1.0
Malignancy (active treatment or palliative)	1.0

Score ≤4 (PE Unlikely)

~4% probability of PE

Perform D-dimer
Negative D-dimer: PE excluded
Positive D-dimer: arrange CTPA

Score >4 (PE Likely)

20-40% probability

Arrange immediate CTPA
Start LMWH while awaiting scan
Do not wait for D-dimer

Massive PE (Emergency)

• Systolic BP <90 mmHg
• Cardiac arrest
• Call 999 immediately
• Thrombolysis decision by specialist

Anticoagulation for Confirmed PE — NICE NG158

First-Line: DOACs (preferred unless contraindicated)

• Apixaban (first-line): 10mg twice daily for 7 days, then 5mg twice daily for at least 3 months
• Rivaroxaban (alternative): 15mg twice daily with food for 21 days, then 20mg once daily with food for at least 3 months

Second-Line: LMWH + Warfarin (if DOACs unsuitable, e.g. severe renal impairment, antiphospholipid syndrome, pregnancy)

• Enoxaparin 1.5mg/kg SC once daily (or 1mg/kg twice daily) for minimum 5 days; stop when INR ≥2 for 2 consecutive days
• Warfarin: start simultaneously; target INR 2-3; continue for at least 3 months

Stroke & TIA Assessment

NICE NG128 (Updated March 2025) — Time is Brain

Critical Time Windows

• Thrombolysis: Within 4.5 hours of symptom onset
• Thrombectomy: Within 6 hours (up to 24h in selected cases)
• Every 15-minute delay reduces good outcome by 4%

FAST Assessment

F - Face

Can the person smile? Has their face fallen on one side?

A - Arms

Can they raise both arms and keep them there?

S - Speech

Is their speech slurred?

T - Time: If ANY sign present, call 999 IMMEDIATELY. Note onset time.

TIA Management — NICE NG128

High-Risk TIA (ABCD² ≥4 or crescendo TIAs): specialist assessment within 24 hours

• Aspirin 300mg orally immediately (antiplatelet loading dose)
• Urgent carotid imaging and brain imaging

Secondary Prevention (after imaging) — NICE NG128:

• Antiplatelet (first-line): clopidogrel 75mg once daily (long-term)
• Antiplatelet (if clopidogrel unsuitable): aspirin 75mg once daily + dipyridamole MR 200mg twice daily
• Statin (first-line): atorvastatin 20-80mg at night (start after 48 hours)
• Antihypertensive: target BP <130/80 mmHg (start after 2 weeks)

3️⃣ Focused History for Acute Presentations

Efficient history-taking in time-critical situations

SOCRATES for Pain Assessment

S - Site

Where is the pain? Can you point to it?

O - Onset

When did it start? Sudden or gradual? What were you doing?

C - Character

Sharp, dull, crushing, burning, stabbing?

R - Radiation

Does it spread anywhere?

A - Associated symptoms

Nausea, sweating, breathlessness?

T - Timing

Constant or intermittent? Duration?

E - Exacerbating/Relieving factors

What makes it better or worse?

S - Severity

0-10 scale. Worst pain ever?

AMPLE for Background History

A - Allergies

Any drug allergies? What reaction?

M - Medications

Current medications (including OTC, herbal)? Recent changes?

P - Past medical history

Relevant conditions? Previous similar episodes? Recent surgery?

L - Last meal

When did you last eat or drink? (Important for anaesthesia risk)

E - Events leading up

What happened before symptoms started?

Red Flag Questions (Don’t Forget to Ask)

Chest Pain:

• “Is this the worst pain you’ve ever had?”
• “Does it go to your arm or jaw?”
• “Are you sweating or feeling sick?”

Headache:

• “Is this the worst headache of your life?”
• “Did it come on like a thunderclap?”
• “Any neck stiffness or rash?”

Abdominal Pain:

• “Could you be pregnant?”
• “Have you vomited blood or passed black stools?”
• “Is the pain constant or colicky?”

ICE Framework

Ideas

“What do you think might be causing this?”

Concerns

“Is there anything you’re particularly worried about?”

Expectations

“What were you hoping we could do today?”

Remote Assessment — Telephone Triage

Telephone Triage Essentials:

• Identify yourself and confirm patient identity
• Presenting complaint: “What’s the main problem today?”
• Red flags first: chest pain, breathlessness, reduced consciousness
• Severity markers: Can they speak in sentences? Walking around?
• Time course: Sudden vs gradual onset

When Face-to-Face Is Required:

• Any red flag symptoms
• Diagnostic uncertainty
• High-risk patient groups
• Examination needed for diagnosis
• Patient or clinician concern

High-Risk Groups — Lower Threshold for Review:

Children:

Lower threshold. Assess hydration, activity level, parental concern. Use NICE traffic light system.

Older Adults & Frailty:

Atypical presentations common. Confusion may be the only sign of sepsis. Check baseline function.

Pregnancy:

Consider ectopic if abdominal pain + positive test. Increased PE risk. Physiological changes affect vital signs.

Immunocompromised:

Chemotherapy, steroids, HIV, diabetes. Lower threshold for antibiotics and admission.

4️⃣ Acute Examination Skills for GPs

Focused examination techniques for urgent presentations

Vital Signs — The Foundation of Urgent Assessment

The vital signs will always come to your rescue, especially when you’re baffled as to what is going on. If they go off, something is seriously wrong. Use NEWS-2 to score them.

📌 Clinical Pearl — History saves lives

A patient arrived “just to get niggles checked before flying to Pakistan.” He kept brushing it off. Slowing down and taking a careful history revealed crushing exertional chest pain 5–6 times a day for 5 days. Sent to A&E for unstable angina — turned out to be MI. A focused history is your most powerful tool.

📌 Clinical Pearl — Vitals expose the hidden

Called to a nursing home for a patient who “wasn’t himself.” No clear history. Nursing staff said “he doesn’t speak much anyway.” But his BP was very low and HR high — pale and clammy. No pain reported. Admitted on the basis of vitals alone. Turned out to be a leaking AAA. When the story is unclear, let the vitals guide you.

1. Respiratory Rate

Normal: 12-20/min. Most neglected but highly predictive vital sign.

2. Oxygen Saturation

Normal: 94-98% (88-92% in COPD). Measure on air if possible.

3. Heart Rate

Normal: 60-100 bpm. Check rhythm (regular/irregular) and volume.

4. Blood Pressure

Normal systolic >100 mmHg. Postural drop >20mmHg suggests hypovolaemia.

5. Temperature

Normal: 36.5-37.5°C. <36°C or >38°C warrants investigation.

6. Consciousness (AVPU)

Alert / Voice / Pain / Unresponsive. Any reduction from Alert needs urgent assessment.

7. Capillary Refill

Normal: <2 seconds. >2 seconds suggests poor perfusion / shock. Check centrally (sternum) and peripherally.

Acute Respiratory Examination

Inspection:

• Respiratory rate and pattern
• Use of accessory muscles
• Intercostal recession
• Cyanosis
• Chest expansion symmetry

Auscultation:

• Air entry (reduced/absent on affected side)
• Wheeze (asthma, COPD, anaphylaxis)
• Crackles (pulmonary oedema, pneumonia)
• Pleural rub (pleurisy, PE)

Measurement:

• Respiratory rate, SpO₂, work of breathing
• Chest expansion symmetry
• Peak flow if asthma or COPD suspected (compare to best/predicted)

Percussion:

• Hyper-resonant (pneumothorax)
• Dull (consolidation, effusion)

Targeted System Examination

Rapid, focused examination based on the presenting symptom — not a full clerking. Examine what the history points to, but always measure and record vital signs first.

Abdominal (Abdominal Pain):

• Inspection: distension, scars, hernias, visible peristalsis
• Palpation: tenderness, guarding, rebound tenderness, masses
• Percussion: tympanic (gas) vs dull (fluid/mass); bowel sounds
• PR exam if indicated: GI bleed, obstruction, prostate symptoms

Respiratory (Breathlessness):

• Respiratory rate, SpO₂, work of breathing
• Chest expansion (symmetrical?)
• Percussion note: resonant / dull / hyper-resonant
• Auscultation: air entry, wheeze, crackles, pleural rub
• Peak flow if asthma or COPD suspected

Acute Cardiovascular Examination

Pulse:

• Rate, rhythm, volume, character
• Radio-radial delay (aortic dissection)

Blood Pressure:

• Both arms (difference >20mmHg suggests dissection)
• Lying and standing (postural drop)

Auscultation:

• S3 gallop (heart failure)
• Murmurs (aortic stenosis, mitral regurgitation)

Perfusion:

• Capillary refill time (<2 sec = normal)
• Mottling (shock)

Mental State Examination in Crisis

Suicide Risk Assessment — ask directly (it does NOT increase risk):

• “Have you had thoughts of harming yourself?”
• “Have you made any plans?”
• “Do you have access to means?” (tablets, weapons)
• “What has stopped you so far?”
• Previous attempts, family history of suicide

Risk to Others:

• Thoughts of harming specific people
• Command hallucinations
• Paranoid delusions about specific individuals
• History of violence
• Safeguarding concerns (children, vulnerable adults)

When to Involve Crisis Team / Admit:

• Active suicidal ideation with a specific plan
• Acute psychosis
• Severe depression with psychotic features
• Mania with risk-taking behaviour
• Unable to keep themselves safe

Safety First

If in doubt, call the crisis team or arrange emergency psychiatric review. Duty of care applies. Document your risk assessment fully.

4b️⃣ Basic Life Support & Resuscitation Skills

Core resuscitation competencies expected of all GPs

Adult CPR — Resus Council UK 2021

Check scene safety; check responsiveness
Call for help / shout for someone to call 999
Open airway: head tilt-chin lift (jaw thrust if C-spine injury suspected)
Check breathing for maximum 10 seconds
Start chest compressions: 30 compressions (5–6cm depth, 100–120/min)
Give 2 rescue breaths
Continue 30:2 until AED arrives, help arrives, or patient shows signs of life

AED Use

Switch on AED, follow voice prompts
Attach pads to bare, dry chest
Ensure nobody touching patient during rhythm analysis
Deliver shock if advised (stand clear)
Resume CPR immediately after shock
Continue until patient shows signs of life

Reversible Causes — 4 H’s & 4 T’s

4 H’s:

• Hypoxia — ensure airway open, give high-flow O₂
• Hypovolaemia — IV fluids, control bleeding
• Hypo/hyperkalaemia & metabolic — glucose, electrolytes
• Hypothermia — warm gradually

4 T’s:

• Thrombosis (MI or PE) — consider thrombolysis during CPR
• Tension pneumothorax — needle decompression
• Tamponade (cardiac) — pericardiocentesis
• Toxins — antidotes where available (naloxone, flumazenil)

5️⃣ Clinical Decision-Making in Urgent Care

Frameworks for safe and effective decision-making under pressure

Managing Diagnostic Uncertainty

In urgent care, you often make decisions with incomplete information. The key is managing risk, not achieving diagnostic certainty. Ask yourself: “Could this be life-threatening?” before anything else.

Safety-first approach:

• Rule out serious illness first
• Use clinical prediction tools: NEWS2, Wells score, ABCD²
• Lower threshold in high-risk groups (elderly, immunocompromised, pregnant)
• When in doubt, escalate: senior review, specialist advice, or admission

Common Cognitive Biases

Anchoring Bias:

Fixating on initial impression and ignoring contradictory evidence.

Mitigation: Actively seek disconfirming evidence

Availability Bias:

Overestimating likelihood of recently seen diagnoses.

Mitigation: Consider base rates

Confirmation Bias:

Seeking information that confirms your hypothesis.

Mitigation: Ask “What else could this be?”

Premature Closure:

Accepting diagnosis before fully considering alternatives.

Mitigation: Generate differential list

Structured Decision Framework

1. Information Gathering:

Focused history, targeted examination, point-of-care tests

2. Problem Representation:

Summarise in one sentence (age, sex, key symptoms, red flags)

3. Differential Diagnosis:

Life-threatening causes first, then common causes

4. Risk Stratification:

Use validated tools (NEWS2, Wells, ABCD²)

5. Management Plan:

Immediate actions, investigations, treatment, disposition

6. Safety-Netting:

Expected course, red flags, when/how to seek help

6️⃣ Investigations in Primary Care Urgent Settings

Point-of-care tests and when to use them

Blood Glucose (Capillary BM)

Indications:

• Reduced consciousness (GCS <15)
• Confusion, agitation
• Seizure
• Known diabetes presenting unwell

Interpretation:

• <4 mmol/L: treat hypoglycaemia immediately
• >11 mmol/L: check ketones if diabetic
• >30 mmol/L: urgent hospital referral

Treatment of Hypoglycaemia — NICE CKS:

• Conscious, can swallow: 15-20g fast-acting carbohydrate (e.g., 100-200ml Lucozade, 3-4 glucose tablets)
• Unconscious: glucagon 1mg IM (first-line if no IV access); or glucose 10% IV 100-150ml
• Recheck BM after 15 min; once >4 mmol/L give long-acting carbohydrate

12-Lead ECG

Indications:

• Chest pain (any cardiac features or risk factors)
• Palpitations with haemodynamic compromise
• Syncope, especially if exertional
• Breathlessness (? heart failure, ? PE)
• Suspected arrhythmia
• Suspected electrolyte disturbance
• Reduced consciousness or collapse

Key Abnormalities:

• STEMI: ST elevation ≥1mm (limb) / ≥2mm (chest leads) — call 999 immediately
• AF: irregularly irregular rhythm, absent P waves
• VT: broad complex tachycardia — emergency
• Long QT: QTc >500ms — risk of sudden death

Urine Dipstick

Interpretation:

• Nitrites +ve: suggests bacterial UTI (high specificity)
• Leukocytes +ve: suggests infection (lower specificity)
• Blood +ve: haematuria — investigate if persistent
• Protein +ve: pre-eclampsia (must exclude in pregnancy), nephrotic syndrome, UTI
• Ketones +ve: DKA, starvation, vomiting
• Glucose +ve: diabetes, renal glycosuria

Peak Flow (PEFR)

Interpretation (% of predicted/best):

• >75%: mild exacerbation
• 50-75%: moderate exacerbation
• 33-50%: severe — urgent treatment
• <33%: life-threatening — call 999

Haemoglobin (Point-of-Care)

Rapid assessment of anaemia in:

• Suspected GI bleed
• Heavy menstrual bleeding
• Trauma with suspected blood loss

D-dimer

High sensitivity, low specificity for VTE.

• Only useful if low pre-test probability (Wells score ≤4)
• Negative D-dimer + low Wells score = PE excluded
• If Wells >4: arrange CTPA directly (do not check D-dimer first)
• Can be elevated in: infection, malignancy, pregnancy, surgery — low specificity

CRP (C-Reactive Protein)

Helps differentiate viral vs bacterial infection:

• <20 mg/L: likely viral infection
• 20–100 mg/L: grey zone — use with clinical context
• >100 mg/L: likely bacterial infection; consider antibiotics

CRP does not replace clinical assessment. A high CRP with a well patient, or a low CRP with a very unwell patient, should not override your clinical judgement.

Pregnancy Test

Mandatory in any woman of childbearing age with:

• Abdominal pain
• Collapse or syncope
• Vaginal bleeding

Ectopic pregnancy can rupture with catastrophic haemorrhage even before a period is missed.

Bloods in Urgent Care

Test	Indications	Key Findings
FBC	Infection, anaemia, bleeding	WCC ↑ (infection), Hb ↓ (anaemia)
U&E	Dehydration, renal failure	Creatinine ↑ (AKI), K+ abnormal (arrhythmia risk)
CRP	Infection, inflammation	>100 suggests bacterial infection
Troponin	Suspected ACS	Elevated = myocardial injury
D-dimer	Suspected PE/DVT (Wells ≤4)	Negative excludes PE/DVT
Lactate	Sepsis, shock	>2 mmol/L = sepsis; >4 = severe

Key principle: Most blood tests in urgent care are for hospital assessment. Do not delay referral waiting for results — call ahead and send results with the patient.

7️⃣ Deciding When to Refer or Escalate

Thresholds for hospital admission and emergency referral

Key Principle

When in doubt, refer. It is safer to over-refer than to miss a serious diagnosis. Document your reasoning clearly.

999 Ambulance (Immediate)

• Cardiac arrest, peri-arrest
• Suspected STEMI
• Suspected stroke (FAST positive)
• GCS <13
• SpO₂ <90%, RR >30
• Septic shock
• Anaphylaxis
• Meningococcal sepsis
• Seizure: still fitting after 5 minutes, or recurrent
• Major trauma/severe bleeding

Urgent Hospital Same Day

• NEWS2 score ≥5
• Suspected sepsis
• Acute kidney injury
• Suspected PE (Wells >4)
• Severe asthma not responding
• Acute heart failure
• Suspected DKA
• Acute surgical abdomen
• Suspected ectopic pregnancy

Specialist Referral Urgent

• High-risk TIA — within 24 hours
• Suspected angle-closure glaucoma — same day ophthalmology
• Suspected testicular torsion — same day urology
• Cord compression — same day neurosurgery
• Appendicitis — same day surgery
• DVT — same day anticoagulation clinic

Effective Referral Communication (SBAR)

S - Situation

“I’m calling about a 65-year-old male with suspected STEMI. Central crushing chest pain for 2 hours with ST elevation on ECG.”

B - Background

“History of hypertension. Takes ramipril and atorvastatin. No known allergies.”

A - Assessment

“BP 140/85, HR 95, SpO₂ 96%. ST elevation in II, III, aVF. Given aspirin 300mg and GTN.”

R - Recommendation

“999 called for blue light transfer to cardiac centre for primary PCI. ETA 20 minutes.”

Time as a Diagnostic Tool

Observation with robust safety-netting is appropriate when red flags have been excluded and the patient is stable. This is a legitimate clinical decision, not avoidance of making one.

Safe to observe if ALL of the following:

• No red flags present
• Vital signs normal (NEWS2 0–2)
• Patient clinically stable
• Likely self-limiting condition
• Patient understands warning signs
• Clear follow-up plan documented

Safety-netting for observation must include:

• Expected natural history of the condition
• Specific red flag symptoms to watch for
• When to seek further help (specific timeframe)
• How to access help: 999 / GP / A&E
• Written information if possible

9️⃣ Symptom-Based Differential Diagnoses

Organising differentials around common urgent symptoms

Acute Chest Pain Assessment

Life-Threatening Causes (Don’t Miss)

Acute Coronary Syndrome (ACS)
Central crushing pain, radiation to arm/jaw, sweating, nausea. Risk factors: age, smoking, diabetes, hypertension, family history.
Aortic Dissection
Sudden tearing pain to back, BP difference >20mmHg between arms, pulse deficit.
Pulmonary Embolism
Pleuritic pain, breathlessness, haemoptysis, tachycardia. Risk factors: immobility, surgery, malignancy, pregnancy.
Tension Pneumothorax
Sudden breathlessness, absent breath sounds, tracheal deviation, hypotension. Medical emergency — needle decompression.
Pericardial Tamponade
Beck’s triad: hypotension, raised JVP, muffled heart sounds. Pulsus paradoxus. Causes include malignancy, trauma, pericarditis. Urgent ECHO + pericardiocentesis.

Common Non-Cardiac Causes

Musculoskeletal
Sharp, well-localised, worse with movement/palpation.
GORD
Burning retrosternal, worse after meals/lying flat, relieved by antacids.
Anxiety/Panic Attack
Sharp stabbing, hyperventilation, palpitations.
Costochondritis
Localised tenderness over costochondral junctions, reproduced by palpation.

Immediate Management of Suspected ACS — NICE NG185

Call 999 — blue light to cardiac centre
Aspirin 300mg chewed immediately unless contraindicated (antiplatelet, first-line)
GTN 400mcg spray 1-2 puffs sublingually if systolic BP >90mmHg; repeat after 5 min if pain persists
Morphine 2–5mg IV titrated slowly for pain + metoclopramide 10mg IV (antiemetic) — NICE CKS
12-lead ECG — but do not delay transfer
Oxygen only if SpO₂ <94%
Monitor vital signs continuously until ambulance arrives

ECG Interpretation — STEMI Criteria (Immediate 999)

STEMI requires primary PCI (door-to-balloon <90 min at cardiac centre):

• ST elevation ≥1mm in 2 contiguous limb leads
• ST elevation ≥2mm in 2 contiguous chest leads (V1–V6)
• New left bundle branch block (LBBB) with clinical suspicion of MI
• Posterior MI: ST depression V1–V3 with tall R waves (consider posterior leads V7–V9)

Other ECG red flags requiring immediate action:

• Complete heart block: P waves and QRS dissociated → 999
• VT (broad complex tachycardia): → 999 if haemodynamically unstable
• AF with fast rate: HR >150 + hypotension → urgent admission
• Long QT: QTc >500ms → risk of sudden death, urgent review

Acute Breathlessness Assessment

Moderate

• PEFR 50-75%
• No severe features

Severe

• PEFR 33-50%
• RR ≥25/min
• HR ≥110 bpm
• Unable to complete sentences in one breath

Life-Threatening

• PEFR <33%
• SpO₂ <92%
• Silent chest

Management — BTS/SIGN 158 (2025)

High-flow oxygen (target SpO₂ 94-98%)
Salbutamol 5mg nebulised with oxygen (first-line bronchodilator); repeat every 15-30 min as needed
Ipratropium bromide 500mcg nebulised (add for severe/life-threatening; every 4-6 hours)
Prednisolone 40-50mg orally once daily for 5 days (first-line corticosteroid); or hydrocortisone 100mg IV if unable to swallow
Life-threatening: call 999; IV magnesium sulphate 2g over 20 min (hospital)
Not improving after 1 hour: hospital admission

Discharge Criteria

• PEFR >75% and stable for 1 hour
• SpO₂ >94% on air
• Prednisolone 40mg OD for 5 days prescribed
• Inhaler technique checked and confirmed adequate
• Increase inhaled corticosteroid dose (double usual dose for 2 weeks)
• GP follow-up within 48 hours
• Written asthma action plan provided

Clinical Features of COPD Exacerbation:

• Increased breathlessness beyond day-to-day variation
• Increased sputum volume and/or purulence
• Increased cough
• Upper respiratory tract infection symptoms
• Wheeze and chest tightness

Management — NICE CKS / BTS (2025)

Controlled oxygen (target SpO₂ 88-92% if known CO₂ retainer)
Salbutamol 2.5-5mg nebulised with air (not oxygen if CO₂ retainer)
Ipratropium bromide 250-500mcg nebulised four times daily
Prednisolone 30mg orally once daily for 5 days
Antibiotics if purulent sputum (NICE CKS):
• First-line: amoxicillin 500mg three times daily for 5 days
• Second-line (penicillin allergy or failure): doxycycline 200mg on day 1, then 100mg once daily (days 2-5)
• Alternative: clarithromycin 500mg twice daily for 5 days
Hospital if: acute confusion, SpO₂ <90%, pH <7.35, worsening peripheral oedema, unable to cope at home

Clinical Features:

• Severe breathlessness, worse lying flat (orthopnoea)
• Pink frothy sputum
• Widespread fine crackles on auscultation
• Tachycardia, gallop rhythm (S3), raised JVP
• Peripheral oedema; history of heart failure, MI, valvular disease

Immediate Management

Sit patient upright
High-flow oxygen (target SpO₂ 94-98%)
Furosemide 40-80mg IV (loop diuretic, first-line; double usual oral dose)
GTN 400mcg spray sublingually (1-2 puffs; if BP >100mmHg); consider GTN infusion if severe (start 10mcg/min, titrate up)
Monitor urine output (catheterise if needed)
Consider CPAP if severe hypoxia despite high-flow oxygen (hospital setting)
Call 999 if not improving or BP <90mmHg

Diagnostic Criteria — Resus Council UK 2025 (all 3 must be met):

Sudden onset and rapid progression of symptoms
Life-threatening Airway and/or Breathing and/or Circulation problems
Skin and/or mucosal changes (flushing, urticaria, angioedema)

Note: skin changes may be subtle or absent in 20% of cases.

Immediate Management — Resus Council UK (2021)

Call 999 immediately
Remove trigger if possible (stop drug infusion, remove sting)
Lie flat (or sit up if breathless)
Adrenaline (epinephrine) 500 micrograms IM (0.5ml of 1:1000 solution) into anterolateral thigh (first-line; repeat after 5 min if no improvement)
High-flow oxygen 15L/min
IV fluid bolus 500-1000ml crystalloid if hypotensive
Chlorphenamine 10mg IM or slow IV (antihistamine, adjunct)
Hydrocortisone 200mg IM or slow IV (corticosteroid, adjunct)

Post-Acute

• Observe minimum 6 hours (biphasic reaction)
• Prescribe 2 adrenaline auto-injectors (EpiPen 300mcg adults)
• Written anaphylaxis action plan
• Refer to allergy specialist

Acute Abdominal Pain

Surgical Emergencies (Immediate Referral)

Ruptured AAA:

Sudden severe back/abdominal pain, pulsatile mass, hypotension, collapse. Age >60, male, smoker.

Perforated Viscus:

Sudden severe pain, rigid abdomen, absent bowel sounds, peritonism. History of peptic ulcer disease or diverticular disease.

Bowel Obstruction:

Colicky pain, vomiting, absolute constipation, distension, tinkling bowel sounds. Previous surgery or hernia are risk factors.

Ectopic Pregnancy:

Lower abdominal pain, vaginal bleeding, missed period, shoulder tip pain.

Clinical Features

• Periumbilical pain migrating to RIF (McBurney’s point)
• Anorexia, nausea, vomiting
• Low-grade fever (37.5–38.5°C)
• Rebound tenderness, guarding in RIF
• Rovsing’s sign (pain in RIF when palpating LIF)
• Psoas sign (pain on passive hip extension)

Investigations

• FBC: raised WCC (neutrophilia)
• CRP: elevated (may be normal early)
• Urinalysis: exclude UTI (mild pyuria possible)
• Pregnancy test in women of childbearing age
• Ultrasound if diagnosis uncertain

Management

• Nil by mouth; IV access and fluids
• Analgesia: paracetamol 1g + opioid if needed
• Urgent surgical referral (appendicectomy within 24 hours)
• Antibiotics if perforation: co-amoxiclav 1.2g IV TDS + metronidazole 500mg IV TDS

Clinical Features

• RUQ pain radiating to right shoulder/scapula
• Worse after fatty meals
• Fever, nausea, vomiting
• Murphy’s sign positive (inspiratory arrest on RUQ palpation)
• Tender, sometimes palpable gallbladder
• Risk factors: female, fat, forty, fertile, fair

Investigations

• FBC: raised WCC (neutrophilia)
• LFTs: obstructive pattern if common bile duct stone
• Amylase: exclude pancreatitis
• USS: gallstones, thickened gallbladder wall, pericholecystic fluid

Management (Hospital Admission)

• Nil by mouth; IV fluids
• Analgesia: paracetamol 1g IV four times daily + opioid PRN
• Antibiotics: co-amoxiclav 1.2g IV three times daily; penicillin allergy: ciprofloxacin 400mg IV twice daily
• Urgent surgical referral for cholecystectomy (ideally within 72 hours)

Clinical Features

• Severe epigastric pain radiating to back
• Relieved by sitting forward
• Nausea, vomiting, anorexia
• Cullen’s sign (periumbilical bruising — severe haemorrhagic)
• Grey Turner’s sign (flank bruising — severe)
• Causes: GET SMASHED (Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpion, Hyperlipidaemia, ERCP, Drugs)

Investigations

• Amylase: >3x upper limit of normal (peaks at 24 hours)
• Lipase: more specific than amylase
• FBC, U&E, LFTs (obstructive pattern = gallstone cause)
• Glucose, calcium (hypocalcaemia = poor prognostic sign)
• ABG: oxygenation and lactate

Management

• Nil by mouth
• Aggressive IV fluid resuscitation: Hartmann’s 250–500ml/hr initially
• Analgesia: morphine IV titrated + antiemetic
• Monitor urine output (catheterise)
• Urgent hospital admission (HDU/ITU if severe)
• No routine antibiotics unless infected necrosis suspected

Collapse & Loss of Consciousness

Differential Diagnosis Framework

Cardiovascular:

• Vasovagal syncope
• Postural hypotension
• Arrhythmia
• Aortic stenosis
• PE, acute MI

Neurological:

• Seizure / status epilepticus
• Stroke/TIA
• Subarachnoid haemorrhage
• Vertebrobasilar insufficiency

Metabolic:

• Hypoglycaemia
• Hypoxia
• Dehydration
• Anaemia
• Drug/alcohol intoxication

Red Flags — Immediate Hospital Referral

• Collapse during exertion
• Chest pain or breathlessness
• Palpitations before collapse
• Family history of sudden death <40 years
• Abnormal ECG

• Focal neurological signs (stroke/TIA)
• Severe headache (SAH)
• Prolonged confusion (>15 min post-event)
• Recurrent unexplained collapses
• Injury from fall requiring assessment

Status Epilepticus

Definition:

Seizure lasting >5 minutes, OR two or more seizures without full recovery between them.

Immediate Management:

Call 999 immediately
Protect airway; recovery position if safe
High-flow oxygen during and after tonic-clonic phase
Diazepam 10mg PR (or midazolam 10mg buccal if available) — first-line benzodiazepine in community
Check blood glucose; treat hypoglycaemia if present
Do not restrain the patient

Causes to Consider:

• Known epilepsy (missed medication, intercurrent illness)
• Hypoglycaemia
• Alcohol withdrawal
• Stroke or intracranial bleed
• CNS infection (meningitis, encephalitis)
• Hyponatraemia, other metabolic

After the Seizure:

• Post-ictal confusion is normal — can last 30–60 min
• First seizure: urgent neurology referral
• Do NOT drive until DVLA rules followed

Immediate Assessment Steps

Check responsiveness (AVPU/GCS)
Open airway; check breathing (recovery position if unconscious)
Check pulse and blood pressure (lying and standing)
Measure blood glucose immediately
12-lead ECG — look for arrhythmia, ischaemia, long QT
Neurological examination (focal signs?)
Collateral history: witness account is crucial for collapse

Syncope vs Seizure — Key Differentiators

Feature	Syncope	Seizure
Onset	Gradual (seconds)	Sudden
Posture	Usually upright	Any position
Duration	<20 seconds	1–2 minutes
Colour	Pale, grey	Cyanosed
Movements	Brief jerks possible	Tonic-clonic
Tongue biting	Rare	Common (lateral)
Incontinence	Rare	Common
Recovery	Rapid (<1 min)	Prolonged confusion

8️⃣ Acute Presentations Frequently Seen in Primary Care

Common urgent conditions and their management

Diagnostic Criteria (KDIGO)

• Creatinine rise ≥26 µmol/L within 48 hours
• Creatinine rise ≥1.5x baseline within 7 days
• Urine output <0.5ml/kg/hr for 6 hours

Immediate Management

Stop nephrotoxics: NSAIDs, ACE inhibitors, ARBs, metformin
If dehydrated: IV sodium chloride 0.9% 500ml bolus; reassess
Catheterise if urinary retention suspected
Urgent bloods: U&E, FBC, venous gas (check K+)
Hospital if: K+ >6.5, creatinine >300, oliguria, pulmonary oedema

Severity

• Mild: 5.5-5.9 mmol/L
• Moderate: 6.0-6.4 mmol/L
• Severe: ≥6.5 mmol/L (or any ECG changes)

Emergency Management (K+ ≥6.5 or ECG changes)

Calcium gluconate 10% 10ml IV over 2-5 min (cardiac protection, stabilises myocardium)
Insulin (Actrapid) 10 units + glucose 50% 50ml IV over 15-30 min (shifts K+ into cells)
Salbutamol 10-20mg nebulised (additional K+ shift)
Call 999 — urgent hospital transfer
Stop K+-sparing drugs (ACE inhibitors, ARBs, spironolactone)

Upper GI Bleeding:

• Haematemesis (fresh red or coffee grounds)
• Melaena (black tarry offensive stools)
• Causes: peptic ulcer, oesophageal varices, Mallory-Weiss tear, gastritis
• Risk: NSAIDs/aspirin/alcohol, liver disease

Lower GI Bleeding:

• Bright red rectal bleeding (haematochezia)
• Causes: haemorrhoids, diverticular disease, colitis, colorectal cancer, angiodysplasia

Admit Immediately (999) if:

• Haemodynamic compromise: tachycardia, hypotension, postural drop
• Active brisk haematemesis or heavy melaena
• Signs of shock: pallor, sweating, cold peripheries
• Suspected variceal bleeding (known liver disease)
• Reduced consciousness

Glasgow-Blatchford Score (upper GI bleed):

Score ≥1 = inpatient management needed. Score 0 = consider outpatient.

Immediate Management in Primary Care:

Assess haemodynamics: BP, HR, capillary refill, postural drop
Large-bore IV access x2 if shocked; sodium chloride 0.9% 500ml bolus
Stop NSAIDs and discuss anticoagulation with secondary care
Call 999 if haemodynamically unstable
Urgent same-day medical admission for active stable GI bleed
Age >50 with new rectal bleeding: urgent 2WW colorectal referral if not yet done

Features of Decompensation:

• Increased breathlessness, especially at night (PND)
• Orthopnoea (cannot lie flat)
• Peripheral oedema (new or worsening)
• Weight gain >2kg in 3 days
• Reduced exercise tolerance
• Basal crackles, raised JVP, S3 gallop

Admit If:

• Severe breathlessness at rest
• SpO₂ <90%
• Systolic BP <90 mmHg
• Confusion or reduced consciousness
• Suspected acute coronary syndrome
• Unable to cope at home

Initial Management (while awaiting transfer):

Sit patient upright; high-flow oxygen (target SpO₂ 94–98%)
Furosemide 40–80mg IV (double usual oral dose; first-line) — NICE CKS
GTN 400mcg spray sublingually if systolic BP >100mmHg
Call 999 if not improving; monitoring continuous until ambulance arrives
Review precipitants: infection, medication non-adherence, ACS, arrhythmia

CRB-65 Score

1 point each: Confusion (new), Respiratory rate ≥30/min, Blood pressure systolic <90 or diastolic ≤60, age ≥65

Score 0:

Low risk — consider home treatment

Score 1-2:

Moderate — consider admission

Score 3-4:

High risk — urgent admission

Severity Assessment & Admission Criteria

CRB-65 (community) / CURB-65 (hospital) — admit if score ≥2:

• Confusion (new)
• Respiratory rate ≥30/min
• Blood pressure systolic <90 or diastolic ≤60 mmHg
• 65 = age ≥65 years

Also admit if: SpO₂ <92%, unable to cope at home, or social factors.

Antibiotic Treatment — NICE CKS / BTS (2025)

Low severity (CRB-65 = 0):

• First-line: amoxicillin 500mg three times daily for 5 days

• Penicillin allergy: doxycycline 200mg on day 1, then 100mg once daily for 5 days

Moderate severity (CRB-65 = 1-2):

• First-line: amoxicillin 500mg three times daily + clarithromycin 500mg twice daily for 5 days

• Penicillin allergy: levofloxacin 500mg once daily for 5 days

Antibiotic Treatment — NICE NG109 / CKS (2025)

Lower UTI (women):

• First-line: nitrofurantoin MR 100mg twice daily for 3 days (avoid if eGFR <30)

• Second-line: trimethoprim 200mg twice daily for 3 days (if low resistance locally)

Lower UTI (men):

• First-line: nitrofurantoin MR 100mg twice daily for 7 days

• Second-line: trimethoprim 200mg twice daily for 7 days

Pyelonephritis (mild-moderate, oral):

• First-line: cefalexin 500mg twice to four times daily for 7-10 days

• Second-line: co-amoxiclav 500/125mg three times daily for 7-10 days

• Severe: urgent hospital admission for IV antibiotics

Antibiotic Treatment — NICE CKS (2025)

Mild (Eron Class I — no systemic toxicity, no comorbidities):

• First-line: flucloxacillin 500mg four times daily for 5-7 days (increase to 1g QDS if severe)

• Penicillin allergy: clarithromycin 500mg twice daily for 5-7 days; or doxycycline 200mg on day 1 then 100mg once daily for 5-7 days

Moderate-Severe (Eron Class II-IV):

• Urgent hospital admission for IV antibiotics (flucloxacillin 1-2g IV four times daily)

FeverPAIN Score (1 point each)

Fever in last 24h | Purulence | Attend rapidly (≤3 days) | Severely Inflamed tonsils | No cough or coryza

Score 0-1:

No antibiotics

Score 2-3:

Consider delayed prescription

Score 4-5:

Offer antibiotics

Antibiotic Treatment — NICE CKS (2025)

• First-line: phenoxymethylpenicillin 500mg four times daily for 5-10 days
• Penicillin allergy: clarithromycin 250-500mg twice daily for 5 days

Acute Bronchitis — NICE CKS (2025)

Usually viral. Antibiotics are NOT routinely indicated. Cough may last up to 3 weeks — warn patients.

Management:

• Reassure: self-limiting, cough may last 3 weeks
• Symptomatic relief (honey, adequate fluids, paracetamol)
• Avoid antibiotics unless systemically unwell or high-risk

Consider antibiotics only if:

• Age >65 with one or more of: hospitalisation in past year, diabetic, heart failure, on oral corticosteroids
• Clinically unwell or high-risk
• If used: doxycycline 200mg stat then 100mg once daily for 5 days (NICE CKS)

Management — NICE CKS (2025)

Usually viral and self-limiting within 5–7 days. Antibiotics are NOT routinely indicated.

• Oral rehydration: small frequent sips; ORS sachets if dehydrated
• Continue normal diet when tolerated
• Avoid anti-diarrhoeal agents in children under 12
• Loperamide may be used in adults if no bloody diarrhoea

Signs of Dehydration:

• Dry mucous membranes
• Reduced skin turgor
• Tachycardia, hypotension
• Reduced urine output
• Sunken eyes (children)

Red Flags — Consider Admission:

• Clinical dehydration; unable to tolerate oral fluids
• Blood in stool
• High fever (>39°C)
• Immunocompromised or frail elderly
• Recent foreign travel (typhoid, cholera)

CT Head Indications

Immediate CT (within 1 hour) if any of:

• GCS <13 on initial assessment or <15 at 2 hours
• Suspected open or depressed skull fracture
• Signs of basal skull fracture
• Post-traumatic seizure
• Focal neurological deficit
• More than 1 episode of vomiting

CT within 8 hours if any of:

• Amnesia for events >30 min before impact
• Age ≥65 years
• Dangerous mechanism
• Anticoagulation

X-ray if pain in malleolar zone + bone tenderness at tip/posterior edge of malleolus, OR unable to weight-bear

Sprain Management (PRICE + analgesia)

Protection, Rest, Ice (20 min every 2-3h), Compression, Elevation
Analgesia: paracetamol 1g four times daily + ibuprofen 400mg three times daily (if no contraindications)
Early mobilisation; physiotherapy if not improving at 2 weeks

Red Flags — Urgent MRI & Referral:

• Age <20 or >55 with first episode
• History of cancer
• Fever, night sweats, unexplained weight loss
• Saddle anaesthesia, urinary/bowel retention (cauda equina)
• Progressive neurological deficit
• Thoracic pain
• Trauma

Management (No Red Flags):

• Reassure: most resolve within 6 weeks
• Encourage activity; avoid bed rest
• Analgesia: paracetamol 1g four times daily + ibuprofen 400mg three times daily
• Consider weak opioid if severe (codeine 30–60mg four times daily)
• Physiotherapy referral if not improving at 6 weeks

Wound Assessment:

• Mechanism (clean vs contaminated)
• Depth (superficial, deep, involving structures)
• Neurovascular status distal to wound
• Tendon/nerve function
• Foreign body (glass, wood)
• Tetanus status

Refer to A&E If:

• Neurovascular compromise
• Tendon or nerve injury
• Deep wounds requiring exploration
• Significant tissue loss
• Human or animal bites (high infection risk)
• Wounds >12 hours old (contaminated)

🚨 Primary Care Emergencies — Quick Reference

Know these cold. Know your doses. Know where the equipment is.

Cardiovascular Emergencies

Condition	Key Presentation
Acute Coronary Syndrome	Chest pain, sweating, nausea, breathlessness, sense of doom
Acute Heart Failure	Severe breathlessness, orthopnoea, pink frothy sputum, ankle swelling
Aortic Dissection	Tearing chest/back pain, BP difference between arms, pulse deficits
Cardiac Arrhythmias	Palpitations with chest pain, syncope, or haemodynamic compromise

Respiratory Emergencies

Condition	Key Presentation
Pulmonary Embolism	Sudden breathlessness, chest pain, tachycardia, risk factors
Acute Severe Asthma	Unable to complete sentences, wheeze, PEFR <50%
Pneumothorax	Sudden chest pain, breathlessness, reduced breath sounds one side
COPD Exacerbation	Increased breathlessness, sputum change, confusion, cyanosis

Neurological Emergencies

Condition	Key Presentation
Stroke / TIA	FAST positive: face, arm, speech, time critical
Subarachnoid Haemorrhage	Thunderclap headache, neck stiffness, photophobia, vomiting
Meningitis / Encephalitis	Fever, headache, neck stiffness, rash, altered consciousness
Status Epilepticus	Seizure >5 minutes or repeated seizures without recovery

GI, Infectious & Other Emergencies

Condition	Key Presentation
Acute Abdomen	Severe abdominal pain, guarding, rigidity, peritonism, systemic upset
GI Bleeding	Haematemesis, melaena, shock, postural hypotension
Ruptured AAA	Back/abdominal pain, pulsatile mass, hypotension, collapse
Sepsis	Fever, tachycardia, hypotension, altered mental state, NEWS2 ≥5
Epiglottitis	Stridor, drooling, dysphagia, fever — do not examine throat
Anaphylaxis	Rapid onset, airway swelling, wheeze, hypotension, urticaria
DKA / Hypoglycaemia	DKA: vomiting, ketones, dehydration; Hypo: confusion, sweating
Acute Poisoning	Altered consciousness, specific toxidrome, recent ingestion history
Ectopic Pregnancy	Abdominal pain, missed period, vaginal bleeding, shoulder tip pain

Know Your Emergencies — A GP Training Priority

The GP curriculum is vast, but the risk of harm is highest when emergencies are missed. Learn these first. Know your drug doses. Know where the equipment is before you need it. Know your anaphylaxis protocol. Know your BLS algorithm. These are non-negotiable foundations.

🔴 Dangerous Diagnoses Not to Miss

Red flag conditions requiring immediate recognition and action

Clinical Vigilance

These conditions can present subtly but deteriorate rapidly. Maintain a high index of suspicion. When in doubt, seek senior advice or refer urgently.

Myocardial Infarction — Atypical Presentations

Presentations to recognise:

• Silent MI (common in diabetics and the elderly) — no chest pain
• Epigastric pain mimicking indigestion
• Isolated jaw or arm pain without chest pain
• Breathlessness as the only symptom
• Fatigue or weakness (without chest pain)
• Syncope or near-syncope
• Acute confusion (especially elderly)

Clinical pearls:

• Troponin may be normal in the first 6 hours
• ECG is normal in up to 50% of NSTEMIs
• Women more likely to present atypically
• If in doubt, treat as ACS and refer

Aortic Dissection

Classic triad:

• Sudden tearing or ripping chest/back pain
• BP difference >20mmHg between both arms
• Widened mediastinum on CXR

Risk factors:

• Hypertension (most important)
• Marfan syndrome, Ehlers-Danlos syndrome
• Bicuspid aortic valve
• Cocaine use, 3rd trimester pregnancy

Critical Warning

Do NOT give thrombolysis if dissection is suspected — it will cause catastrophic bleeding. Urgent CT aorta required. Call 999 immediately.

Meningococcal Sepsis

Meningitis Classic Triad (only 44% present with all three):

• Fever
• Neck stiffness
• Altered mental state

Meningococcal Sepsis Signs:

• Non-blanching purpuric rash (late sign — do not wait for it)
• Rapid deterioration (hours)
• Cold hands/feet, mottled skin (early)
• Leg pain, muscle aches (often early)

Immediate Action:

• Benzylpenicillin 1.2g IM/IV STAT (do NOT delay for transfer) — BNF/NICE CKS
• Penicillin allergy: ceftriaxone 2g IV/IM
• Call 999; high-flow oxygen; IV access and fluids if shocked
• Do NOT delay treatment for lumbar puncture
• Inform hospital of suspected meningococcal sepsis

Ruptured Abdominal Aortic Aneurysm

Clinical Features:

• Sudden severe abdominal/back pain
• Pulsatile abdominal mass
• Hypotension, shock, collapse
• Risk factors: age >60, male, smoker

Immediate Action:

• Call 999 immediately
• Large-bore IV access x2
• Permissive hypotension (systolic 80-100 mmHg) — avoid aggressive fluids
• Morphine 2-5mg IV titrated for analgesia
• Transfer to vascular surgery centre without delay

Subarachnoid Haemorrhage

Clinical Features:

• Sudden severe “thunderclap” headache (worst ever)
• Neck stiffness, photophobia, vomiting
• Reduced consciousness
• Sentinel headache in preceding days (30%)

Immediate Action:

• Call 999 — neurosurgical centre
• Paracetamol 1g orally or IV for analgesia (avoid NSAIDs)
• Antiemetic: metoclopramide 10mg IM or IV
• Urgent CT head within 1 hour
• If CT negative but high suspicion: LP after 12 hours (xanthochromia)

Ectopic Pregnancy

Clinical Features:

• Lower abdominal pain (unilateral or bilateral)
• Vaginal bleeding (may be minimal)
• Missed period or irregular bleeding
• Shoulder tip pain (haemoperitoneum)
• Dizziness, syncope, shock if ruptured

Immediate Action:

• Pregnancy test (urine or serum β-hCG)
• If positive + pain/bleeding: urgent gynaecology referral same day
• If shocked: call 999; large-bore IV x2; rapid fluid resuscitation
• Signs of rupture: sudden severe pain, collapse/shock, peritonism, cervical excitation on bimanual, pallor, sweating
• Nil by mouth; group and save (crossmatch if unstable)

Diabetic Ketoacidosis (DKA)

Diagnostic Criteria (JBDS 2023, all 3 required):

• Blood glucose >11 mmol/L (or known diabetes)
• Blood ketones >3 mmol/L (or urine ketones 2+)
• pH <7.3 or bicarbonate <15 mmol/L

Immediate Action:

• Call 999 — medical emergency
• Large-bore IV access; sodium chloride 0.9% 1L over 1 hour
• Do NOT give insulin in primary care (cerebral oedema risk)
• Venous blood gas (pH, bicarbonate, lactate)

Acute Cord Compression

Clinical Features:

• Back pain (thoracic or lumbar)
• Bilateral leg weakness (UMN signs)
• Sensory level on trunk
• Urinary retention or incontinence
• Saddle anaesthesia

Immediate Action:

• Call 999 — spinal emergency
• Dexamethasone 16mg orally or IV STAT if malignancy suspected (to reduce oedema) — specialist guidance
• Urgent MRI whole spine (within 24 hours)
• Neurosurgical/oncology referral

Acute Angle-Closure Glaucoma

Clinical Features:

• Severe unilateral eye pain
• Blurred vision, haloes around lights
• Headache, nausea, vomiting
• Red eye, hazy cornea, fixed mid-dilated pupil
• Hard eye on palpation

Immediate Action:

• Same-day urgent ophthalmology referral
• Analgesia and antiemetic
• Do NOT give topical steroids
• Hospital will initiate: acetazolamide IV, pilocarpine drops, topical beta-blocker
• Definitive: laser peripheral iridotomy (specialist)

Necrotising Fasciitis

Clinical Features:

• Severe pain out of proportion to clinical signs
• Rapidly spreading erythema and swelling
• Skin discolouration (purple, black), bullae, crepitus
• Systemic toxicity (fever, tachycardia, hypotension)

Immediate Action:

• Call 999 — surgical emergency
• High-flow oxygen; large-bore IV x2; aggressive fluid resuscitation
• Broad-spectrum IV antibiotics (hospital to initiate — e.g., piperacillin-tazobactam + clindamycin)
• Urgent surgical debridement is life-saving

Epiglottitis

Clinical Features:

• Rapidly progressive sore throat, severe odynophagia (painful swallowing)
• Drooling — unable to swallow secretions
• Stridor (inspiratory noise = significant airway compromise)
• Muffled “hot potato” voice; patient sitting forward, anxious
• High fever; systemically very unwell
• Now more common in adults (Hib vaccination reduced paediatric incidence)

Immediate Action:

• Call 999 — life-threatening airway emergency
• Do NOT examine the throat — may precipitate complete obstruction
• Keep patient calm and upright; do not distress them
• Oxygen if tolerated; avoid anything that upsets the patient before airway is secured
• Hospital: IV ceftriaxone + definitive airway management by senior anaesthetist

Acute Poisoning / Overdose

Common Toxidromes:

• Opioids: miosis, reduced RR, drowsiness/coma → naloxone
• Benzodiazepines: sedation, ataxia, slurred speech
• Paracetamol OD: initially well; liver failure at 24–72h — always refer
• TCAs: arrhythmias, wide QRS, hypotension, seizures

• Salicylates: tinnitus, hyperventilation, metabolic acidosis
• Stimulants: tachycardia, hypertension, agitation, hyperthermia
• Carbon monoxide: headache, confusion; pulse oximetry unreliable
• Alcohol: ataxia, disinhibition, coma at high levels

Immediate Action:

• ABCDE; call 999 if any compromise or altered consciousness
• Naloxone 400mcg IM/IV for opioid toxicity (repeat every 2–3 min; up to 10mg) — BNF
• 12-lead ECG; blood glucose; renal function
• Paracetamol OD: measure serum level at 4 hours post-ingestion; refer ALL cases regardless of apparent wellbeing
• TOXBASE (www.toxbase.org) or NPIS (0344 892 0111) for antidote/management guidance
• Do NOT induce vomiting

🤒 Sick Day Rules — Advising Patients

What to tell patients about managing their medicines when unwell

When patients with chronic conditions develop acute illness (vomiting, diarrhoea, fever), certain medicines become dangerous. Advising patients proactively on sick day rules prevents avoidable hospital admissions.

What to Tell Patients

If you develop vomiting or diarrhoea, or fever/sweats/shaking:

STOP the medicines listed below (SADMAN)
Restart when you are well (after 24–48 hours of eating and drinking normally)
If in any doubt, contact your pharmacist, GP, or call 111

General advice:

• Rest; drink plenty of sugar-free fluids (≥3 litres/day unless heart failure — then 1.5–2L and weigh daily)
• Maintain normal meal pattern if possible; replace with carbohydrate-containing snacks if not
• Avoid too much caffeine (dehydrating)
• Heart failure patients: if weight gain >2kg in 3 days → call 111 or contact GP

SADMAN — Stop on Sick Days

S — SGLT-2 inhibitors

Canagliflozin, empagliflozin, dapagliflozin (“flozins”) — risk of euglycaemic DKA when dehydrated

A — ACE inhibitors

Ramipril, lisinopril, enalapril, perindopril (“prils”) — cause AKI when dehydrated

D — Diuretics

Furosemide, bendroflumethiazide, bumetanide (“ides”) — worsen dehydration and AKI

M — Metformin

Lactic acidosis risk when dehydrated or acutely unwell

A — ARBs

Losartan, candesartan, valsartan (“sartans”) — same risk as ACE inhibitors

N — NSAIDs

Ibuprofen, diclofenac, naproxen — cause AKI, worsen GI bleeding, worsen heart failure

Sick Day Rules for Patients on Insulin or Diabetes Medication

Key principles:

• Keep taking insulin or diabetes medications even if not eating
• HOWEVER, stop metformin and antihypertensives if dehydrated
• Test blood glucose 4 or more times a day
• Test urine for ketones if blood glucose ≥15 mmol/L (Type 1)
• If ketones positive → contact GP or diabetes team immediately

When to seek urgent help:

• Uncontrolled vomiting — call GP or 111
• Blood glucose >15 mmol/L with ketones ≥2+ in urine
• Unable to keep any fluids down for >4 hours
• DKA symptoms: vomiting, drowsiness, deep breathing, fruity breath

1️⃣5️⃣ Safety-Netting in Urgent Care

Protecting patients when diagnosis is uncertain

What is Safety-Netting?

A strategy to manage diagnostic uncertainty: (1) expected course of illness, (2) specific warning signs, (3) when and how to seek further help.

Three Components of Effective Safety-Netting

1. Expected Course

Explain what should happen if your diagnosis is correct: “Your symptoms should start improving within 48 hours”; “The antibiotics take 2-3 days to work.”

2. Specific Red Flags

Be specific, not vague. “If you develop chest pain or breathlessness, call 999” — NOT “if you feel worse.” Limit to 3-5 key flags.

3. Clear Access Plan

State exactly what to do: “If not improving by tomorrow, call the surgery.” “If [red flag], call 999.” Remove barriers to re-accessing care.

Safety-Netting Pitfalls

❌ Avoid:

• Vague advice: “come back if worried”
• Too many red flags (patient won’t remember)
• Medical jargon
• Not checking understanding
• Failing to document

✅ Best Practice:

• Specific, actionable advice
• 3-5 key red flags maximum
• Plain language
• Ask patient to repeat back key points
• Document in notes; consider written leaflet

What to Look For (specific red flags):

• Severe or worsening symptoms
• New symptoms developing
• Symptoms not improving as expected
• Specific danger signs (e.g. non-blanching rash, severe headache)

How to Access Help:

• 999 for life-threatening emergencies
• 111 for urgent advice
• GP surgery (give contact number)
• Out-of-hours service (give details)
• Written information leaflet (provide if available)

Safety-Netting Documentation Template

Copy this structure into your clinical notes to ensure complete documentation:

Clinical Assessment:

“Patient assessed for [condition]. Examination findings: [findings]. Working diagnosis: [diagnosis]. Differential diagnoses considered: [list].”

Management Plan:

“Advised [treatment/self-care]. Prescribed [medication with dose/duration]. Explained natural history and expected recovery timeframe.”

Safety-Netting Advice Given:

“Advised to call 999 if: [red flag symptoms]. Advised to re-contact surgery if: [specific scenarios]. Advised to attend A&E if: [specific scenarios]. Patient verbalised understanding. Written information provided.”

Follow-Up:

“Routine follow-up in [timeframe]. Patient to contact if not improving. Will review if re-contacts.”

1️⃣4️⃣ Communication Skills in Urgent Care

Effective communication under time pressure

Breaking Bad News (SPIKES)

S - Setting:

Private space; sit down; avoid interruptions. “Let’s find somewhere private to talk. Would you like anyone with you?”

P - Perception:

“What’s your understanding of what’s been happening?”

I - Invitation:

“Would you like me to explain what we’ve found?”

K - Knowledge:

Warning shot first: “I’m afraid the tests show… [pause]. I’m sorry to have to tell you this.” Give in small chunks.

E - Emotions:

Acknowledge and validate; allow silence. “I can see this is very difficult news. Take your time.”

S - Strategy/Summary:

Outline next steps; offer hope where appropriate. “Let me explain what happens next… We’ll make sure you’re supported.”

Difficult Situations

Angry patients:

Stay calm; acknowledge feelings; listen without interrupting; set limits calmly; ensure your safety

Patients refusing treatment:

Explore reasons; address fears; explain consequences; assess capacity; respect decision if competent; document thoroughly

Language barriers:

Use professional interpreter (phone/video); avoid family members; use visual aids; check understanding

Telephone consultations:

Ask red flags explicitly; lower threshold for face-to-face review; robust safety-netting; document “telephone consultation”

Useful Phrases for Challenging Situations

Explaining Diagnostic Uncertainty:

“We don’t have all the answers yet, but here’s what we do know… We’ll investigate further and keep you informed.”

Refusing Inappropriate Requests:

“I understand you’re frustrated, but I can’t prescribe antibiotics for a viral infection because they won’t help and could cause harm. Let me explain why…”

Admitting a Mistake (Duty of Candour):

“I’m sorry, I made an error. Here’s what happened… and here’s what we’re doing to put it right.”

Dealing with Anger:

“I can see you’re very upset. That’s completely understandable. Can you help me understand what’s most concerning you?”

Telephone Triage Safety-Netting Script:

“If you develop [red flag symptoms], call 999 immediately. If you’re not improving in [timeframe], call us back. Do you have any questions?”

1️⃣3️⃣ Ethical and Medico-Legal Issues

Navigating complex ethical dilemmas in urgent care

Four Pillars of Medical Ethics

1. Autonomy

Respecting the patient’s right to make their own decisions. Patient can refuse treatment if they have capacity.

2. Beneficence

Acting in the patient’s best interests. Balance risks and benefits of all interventions.

3. Non-Maleficence

“First, do no harm.” Minimise risks and avoid futile treatment.

4. Justice

Fair distribution of resources and equal treatment regardless of background.

Capacity Assessment — Mental Capacity Act 2005

Key principles: Assume capacity; decision-specific; time-specific; unwise decisions are allowed if patient has capacity.

Two-Stage Test:

Stage 1:

Is there impairment of mind/brain? (dementia, delirium, intoxication, head injury)

Stage 2: Can patient:

Understand, Retain, Weigh up, Communicate the decision?

If lacks capacity:

Make best interests decision; consult family/carers; consider past wishes; choose least restrictive option; document clearly.

Emergency Treatment

In a life-threatening emergency where the patient lacks capacity and time does not allow a full capacity assessment, provide necessary treatment without consent. Document your clinical reasoning clearly.

Medico-Legal Documentation — GMC Good Medical Practice

Essential documentation elements:

• Presenting complaint and duration
• Red flags explicitly asked about and excluded
• Examination findings including vital signs
• Working diagnosis and differentials considered
• Management plan and safety-netting advice given
• Discussions with patient/family; discussions with seniors
• When and how to seek further help

“If it’s not documented, it didn’t happen” — write as if your notes will be read in court.

DNACPR (Do Not Attempt CPR) Decisions

When to Consider DNACPR:

• CPR is unlikely to be clinically successful (advanced frailty, terminal illness)
• CPR is not in keeping with the patient’s expressed wishes
• Patient has capacity and has refused CPR after being informed

How to Have the Conversation:

• Explain what CPR actually involves (realistic outcomes: <20% survival to hospital discharge in community arrest)
• Discuss patient’s values, priorities, and goals of care
• Clarify: DNACPR does not mean “do not treat” or “withdraw care”

Key Legal and Ethical Points:

• DNACPR is a medical decision — not the family’s choice to make
• Must be discussed with the patient if they have capacity
• Consult family/carers (but they cannot veto or consent)
• Does not affect any other treatments
• Must be clearly documented and communicated to all teams
• Review regularly, especially if there is a change in clinical condition

Common Error

Never complete a DNACPR form without a documented discussion. In emergency situations where there is no time, document your reasoning clearly.

🏠 Home Visiting & Care Home Protocols

Safe, structured approach to home and care home visits

When Home Visits Are Indicated

• Medical condition requires attendance but travel would be clinically inappropriate
• Genuinely housebound patients who cannot leave home due to their medical condition
• Terminal / end-of-life care where hospital attendance would be inappropriate
• Acute deterioration where patient cannot safely travel to surgery
• Care home residents where condition requires assessment but transfer is inappropriate

When Home Visits Are NOT Indicated:

• Lack of transport — social reasons alone do not justify home visits
• Convenience — patient preference for home visit when medically able to attend surgery
• Routine monitoring that could be done at surgery
• Minor ailments not requiring immediate assessment

Home Visit Protocol

1. Triage before 11am

Early requests allow proper planning and workload sharing.

2. Gather information first

Symptoms, duration, previous medical history, current medications. Review EMR before leaving.

3. Think ahead

Consider differential diagnoses on the way. What might you need to do when you arrive?

Example — called for swollen legs: Is it one leg or two? One leg → DVT (Wells score, D-dimer), baker’s cyst, cellulitis. Both legs → more likely heart failure (check chest, AF, Pro-BNP, may need diuretics).

4. Safety

Inform colleagues of visit location and expected return time. Lone worker protocols apply.

5. Documentation

Detailed notes, safety-netting advice, follow-up arrangements. Destroy any printed patient data by shredding — never leave in car or bin. It is a serious breach of confidentiality to leave a home visit summary sheet lying around (tearing is NOT enough — use the practice shredder).

Many practices now offer secure electronic access to records on your phone (e.g. Brigid app) — ask your practice about this.

6. Prescriptions

Issue electronically on return to surgery unless urgently needed. There is less chance of error with electronic prescriptions compared to handwritten. Let the patient know you are doing this and when they can collect.

💼 Essential Doctor’s Bag Contents

Emergency Medications:

• Adrenaline 1:1000 (anaphylaxis)
• GTN spray (ACS)
• Aspirin 300mg (ACS)
• Salbutamol nebules (asthma)
• Diazepam PR or midazolam buccal (seizures)
• Morphine (analgesia)
• Atropine (bradycardia)
• Glucagon 1mg (hypoglycaemia)
• Benzylpenicillin 1.2g (meningitis)

Basic Equipment:

• Stethoscope
• BP cuff (manual)
• Thermometer
• Pulse oximeter
• Blood glucose meter
• Urine dipsticks
• Peak flow meter
• Tongue depressors, torch
• ECG machine (if available)

Airway & IV:

• Bag-valve mask
• Oropharyngeal airways (sizes 2, 3, 4)
• Oxygen cylinder + mask
• IV cannulae (14G, 18G)
• Sodium chloride 0.9% 500ml
• Giving sets
• Syringes, needles, gloves

Familiarise yourself with the emergency equipment in your surgery. If it is locked — who has the key? Know this before you need it.

🏥 Care Home & Nursing Home Protocol

Before You Go — Review the Notes:

• Previous consultations for the same presenting complaint
• Last entries from GP, OOH, community nursing
• Discharge summaries and hospital letters
• Outstanding recalls, CDM, blood results
• RESPECT Form and resuscitation status — in place? Does it need completing?
• QOF markers / chronic disease reviews — can you address these while there?

When You Get There — Three Priorities:

1st: Acute Problem

Deal with what you were called for. Always check vitals: BP, HR, Temp, SpO₂.

2nd: Geriatric Giants (MANIC MOLD)

See below — opportunistic review.

3rd: Advanced Care Planning

DoLS, RESPECT form, palliative care register.

The 9 Geriatric Giants — MANIC MOLD

🦵 M — Mobility

Falls, sarcopenia, balance. Stop unnecessary benzodiazepines/antipsychotics. Physio for weak muscles. Reduce opioids if pain allows.

⚠️ A — Elder Abuse

Including self-neglect. Ask patient 1:1: “How are they treating you here?” Check feet — often reveals quality of care.

🍞 N — Nutrition

Check mouth (ulcers, poor dentition, thrush). Ask about oral intake. MUST score if weight falling.

🚽 I — Incontinence

Ask: all the time or sometimes? UTI smell? Dipstick urine. Is patient drinking enough?

🧠 C — Confusion / Cognition

Delirium vs dementia. Consider: infection, pain, constipation, depression. Mini-cog / AMT if needed.

💊 M — Medication Problems

Review and de-prescribe. Reduce polypharmacy. Check compliance and refusals.

🦴 O — Osteoporosis

FRAX score. DEXA scan if appropriate. Falls assessment.

🤗 L — Loneliness

“Often as people age they feel more lonely — are you experiencing that too? How bad is it?” Discuss befriending services, encourage participation in care home community events (e.g. singing sessions). Refer to social prescribing if available.

😔 D — Depression

“You seem a bit down. Are you down in your spirits a lot?” PHQ-2 screen. Antidepressant or behavioural activation if indicated.

Back at the Practice:

• Write up visit and reason for attendance
• Tidy repeat medication list — reduce polypharmacy
• Use clinical templates (ARDENS, EMIS, SystmOne) for CDM, medication review
• Move recall dates; keep recalls to a minimum
• Liaise with community phlebotomy / observation team for follow-up bloods
• Liaise with Community Matrons, Care Coordinators, and District Nurses regarding other issues needing follow-up

End of Life Care at Care Homes:

• Start anticipatory medications if appropriate (Just in Case box)
• Stop unnecessary medications
• Get Palliative Care / Gold Line involved
• Complete DNACPR / RESPECT form — discuss with patient and relatives
• Keep care home staff fully informed

1️⃣1️⃣ Service Organisation in Urgent Care

Understanding the urgent care landscape in the UK

GP Urgent Care Services

Same-Day Appointments:

• Acute illness requiring assessment within hours
• Triage by GP or advanced practitioner
• Face-to-face or telephone consultation

Extended Access Hubs:

• Evening and weekend appointments (PCN level)
• Reduces ED attendance for minor illness

NHS 111

Typical outcomes:

• Self-care advice (40%)
• Primary care appointment (30%)
• Emergency department (15%)
• Ambulance dispatch (10%)
• Other (pharmacy, dental, mental health) (5%)

Urgent Treatment Centres (UTC)

• Minor illness and injury (open ≥12h/day, 7 days)
• Staffed by GPs, nurses, paramedics
• X-ray facilities
• Walk-in, no appointment needed

999 Ambulance Response Categories

• Cat 1: Life-threatening (7-min target)
• Cat 2: Emergency e.g. stroke, chest pain (18-min target)
• Cat 3: Urgent (120-min target)
• Cat 4: Less urgent (180-min target)

GP Out-of-Hours Services

Covers evenings (6:30pm–8am), weekends, and bank holidays. Accessed via NHS 111.

Services provided:

• Telephone advice and clinical assessment
• Face-to-face consultations at OOH base
• Home visits (where clinically indicated)
• Prescriptions (acute, not repeat)

GP Training Note

RCGP requires trainees to spend significant time in OOH settings — not just in-hours duty doctor. Both contribute to UUC capability evidence.

Community Services — GP Referral Options

• District Nurses: Wound care, catheter changes, palliative care, IV antibiotics at home
• Rapid Response / Virtual Ward Teams: Prevent hospital admission for frail elderly; provide same-day review and intervention at home
• Crisis Resolution & Home Treatment Teams (CRHT): Mental health emergencies; can assess and treat at home as alternative to admission
• Paramedic Practitioners: Assess and treat at home; can initiate investigations and refer directly to secondary care
• Pharmacy: Minor illness, emergency contraception, blood pressure checks, urgent supply

1️⃣2️⃣ Multi-Professional Working

Effective collaboration in urgent care teams

Advanced Clinical Practitioners (ACPs)

• Autonomous assessment of undifferentiated presentations
• Can be nurses, paramedics, pharmacists, physiotherapists
• Independent prescribing (if qualified)
• Work within competency framework; escalate when needed

Paramedics in Primary Care

• Urgent home visits for acutely unwell patients
• Advanced life support trained
• ECG interpretation and IV cannulation
• Excellent at recognising deterioration

Clinical Pharmacists

• Medicines reconciliation and medication review
• Antibiotic stewardship
• Independent prescribing (if qualified)
• Expertise in polypharmacy and drug interactions

Principles of Effective MPW

• Mutual respect — value each profession’s expertise
• Clear roles — know scope of practice and when to escalate
• Open communication — use structured handovers (SBAR)
• Shared goals — patient safety first
• Speak up about concerns — it is a professional responsibility

1️⃣6️⃣ Clinical Governance and Learning from Incidents

Quality improvement and patient safety in urgent care

Seven Pillars of Clinical Governance

1. Clinical Effectiveness

Evidence-based practice, NICE guidelines, clinical audit

2. Risk Management

Identifying risks, incident reporting, learning from errors

3. Patient Experience

Feedback, complaints handling, patient involvement

4. Education & Training

CPD, mandatory training, supervision, appraisal

5. Clinical Audit

Measure against standards, implement change, re-audit

6. Information Management

Accurate record-keeping, data security

7. Staffing & Resources

Adequate staffing, skill mix, staff wellbeing

Significant Event Analysis (SEA)

1. Identify

What happened? When? Who?

2. Gather Information

Review records; timeline

3. Analyse

What went wrong? Why?

4. Learning Points

What should we do differently?

5. Action Plan

Specific, measurable actions

6. Follow-Up

Review actions; share learning

Key principles: blame-free culture, openness, focus on systems not individuals, duty of candour.

Quality Improvement — PDSA Cycles

Plan-Do-Study-Act: the iterative approach to improvement. Repeat cycles until aim is achieved.

Plan:

Identify problem, set measurable aim, plan the change

Do:

Implement change on a small scale first

Study:

Collect and analyse data; compare to baseline

Act:

Refine and spread if successful; modify and repeat if not

Clinical Audit Topics for Urgent Care

Suitable topics for GP trainee QI projects:

• Antibiotic prescribing in respiratory infections
• Adherence to sepsis recognition guidelines
• Safety-netting documentation completeness
• Referral appropriateness (urgent vs routine)
• Appropriate use of investigations
• Telephone triage waiting times
• Patient satisfaction with urgent appointments

1️⃣7️⃣ MRCGP Assessment Links

How urgent care maps to MRCGP curriculum and assessments

Applied Knowledge Test (AKT)

Commonly tested urgent care topics:

• Cardiovascular: ACS, heart failure, arrhythmias, PE
• Respiratory: asthma, COPD, pneumonia, pneumothorax
• Neurology: stroke, TIA, meningitis, seizures
• Infections: sepsis, UTI, cellulitis, meningococcal disease
• Metabolic: DKA, hypoglycaemia, AKI, hyperkalaemia

Key guidelines to know:

• NICE NG253 (Sepsis)
• NICE NG128 (Stroke/TIA)
• BTS/SIGN 158 (Asthma)
• Resuscitation Council UK (Anaphylaxis, ALS)

Recorded Consultation Assessment (RCA)

Key competencies assessed in urgent cases:

• Data Gathering: focused history, red flags, SOCRATES
• Clinical Assessment: vital signs, investigations
• Diagnosis: differential diagnosis, pattern recognition
• Management: immediate actions, prescribing, referral
• Safety-Netting: specific, documented, clear access plan
• Communication: empathy, shared decision-making

Top tips:

• Ask red flags explicitly and document them
• Verbalise clinical reasoning
• Safety-net specifically, not vaguely

Workplace-Based Assessments (WPBA)

Case-Based Discussion (CBD)

Choose urgent cases demonstrating clinical reasoning, risk management, ethical dilemmas, multi-professional working, learning from mistakes.

Mini-CEX

Observed urgent consultations: focused history, examination, decision-making, communication under pressure.

Multi-Source Feedback (MSF)

Colleagues assess teamwork in urgent situations, appropriate escalation, professionalism under pressure.

Simulated Consultation Assessment (SCA)

Common urgent presentations in SCA:

• Telephone triage of potentially serious illness
• Acute neurological symptoms (? stroke, ? migraine)
• Unexplained collapse or tachycardia
• Chest pain (risk stratification, safety-netting)
• Acute breathlessness (? PE, ? pneumonia)
• Mental health crisis (suicide risk assessment)

Key skills assessed in SCA urgent cases:

• Rapid focused history taking
• Red flag recognition
• Risk stratification and decision-making
• Clear, specific safety-netting advice
• Communication under pressure

Clinical Observation Tool (COT)

Observed consultations most relevant to urgent care:

• ABCDE assessment of an acutely unwell patient
• Examination of an acute abdomen
• Mental state examination in crisis
• Risk assessment in urgent presentations

DNACPR — for CBD & Ethical Dilemmas:

• DNACPR is a medical decision, not the family’s choice
• Must be discussed with patient if they have capacity
• Does NOT affect other active treatments
• Explain what CPR involves (realistic success rates)
• Discuss patient’s values and priorities
• Must be clearly documented and communicated to all teams
• Review regularly especially if clinical change

💪 You’ve Got This!

Urgent care can feel daunting — but every expert was once a trainee on their first on-call shift. Use this page, trust your training, and always ask for help when needed. That’s not weakness; that’s good medicine.

🧘 Ram’s Mantra — Before Every On-Call

I am okay
I am going to have a good, happy day today
I am going to be kind to all patients and staff, irrespective of how they are
I am going to dance with patients and staff
Today is going to be a good day
And you know it’s going to fly by, so let’s go…

Say all six. Repeat until you believe it and feel it. — Dr Ramesh Mehay

🧠 Think ABCDE first

When in doubt, go back to basics. A systematic approach never fails.

📞 Call early, not late

Escalating early is a sign of clinical wisdom, not a lack of confidence.

📝 Document everything

If it’s not in the notes, it didn’t happen. Safety-net and record it.

🤝 You’re not alone

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“The good physician treats the disease; the great physician treats the patient who has the disease.” — William Osler

Urgent & Unscheduled Care for GPs: Your Essential Guide

Executive Summary — What You Will Learn

📋 What This Page Covers:

📊 Quick Facts at a Glance:

Key Learning Objectives

📥 Downloads & Resources

📥 Downloads

🌐 Web Resources

🧭 Quick Navigation

🧠 Brainy Bites

SEPSIS SIX

FAST Stroke

NEWS2 Triggers

Chest Pain RED FLAGS

🚨 Red Flag Patterns

💪 CASH-A

💊 SADMAN

📋 Data Gathering Pearls

1️⃣ ABCDE Assessment Framework

Look For

Red Flags

Immediate Actions

Inspection

Palpation & Percussion

Auscultation

Life-Threatening Breathing Problems

Immediate Management

Cardiovascular Examination

Shock Recognition

Immediate Management of Shock

AVPU Scale

Glasgow Coma Scale (GCS)

Causes of Reduced Consciousness

Immediate Actions

Full Examination

Temperature Control

Key Findings Not to Miss

2️⃣ Risk Stratification & Scoring Systems

National Early Warning Score 2 (NEWS2)

NEWS2 Parameters

Score 0-4 (Low Risk)

Score 5-6 (Medium Risk)

Score ≥7 (High Risk)

Sepsis Recognition & Management

Sepsis Recognition: Think SEPSIS

Sepsis Six Bundle (Complete within 1 hour) — NICE NG253

Antibiotic Choices — NICE CKS / Local guidelines (confirm locally)

Wells Score for Pulmonary Embolism

Wells Score Criteria

Score ≤4 (PE Unlikely)

Score >4 (PE Likely)

Massive PE (Emergency)

Anticoagulation for Confirmed PE — NICE NG158

Stroke & TIA Assessment

FAST Assessment

TIA Management — NICE NG128

3️⃣ Focused History for Acute Presentations

SOCRATES for Pain Assessment

AMPLE for Background History

Red Flag Questions (Don’t Forget to Ask)

ICE Framework

Remote Assessment — Telephone Triage

4️⃣ Acute Examination Skills for GPs

Vital Signs — The Foundation of Urgent Assessment

Acute Respiratory Examination

Targeted System Examination

Acute Cardiovascular Examination

Mental State Examination in Crisis

4b️⃣ Basic Life Support & Resuscitation Skills

Adult CPR — Resus Council UK 2021

AED Use

Reversible Causes — 4 H’s & 4 T’s

5️⃣ Clinical Decision-Making in Urgent Care

Managing Diagnostic Uncertainty

Common Cognitive Biases

Structured Decision Framework

6️⃣ Investigations in Primary Care Urgent Settings

Blood Glucose (Capillary BM)

12-Lead ECG

Urine Dipstick