Acute Medicine: The acute medical take

• The take: The Acute Medical Unit and the Take | Same Day Emergency Care and Ambulatory Pathways | Frailty Units, Virtual Wards and Hospital at Home
• Risk scores: Risk Scores Used on the Take | Risk Scores at a Glance
• Common presentations: Falls and "Off Legs" | Upper GI Bleeding | Acute Abdominal Pain on the Medical Take | Cellulitis and Skin Infection | Suspected DVT and PE | New Atrial Fibrillation | Urinary Infection and Pyelonephritis
• Ward care: VTE Prophylaxis | Acute Pain and Symptom Control | Handover, Documentation and Discharge
• Revision: The Acute Take at a Glance | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🩺 The acute medical take -page 7 of the Acute Medicine and Resuscitation chapter. Most acute medical patients are not in cardiac arrest -they are older people who have fallen, people with chest pain, breathlessness, a swollen leg, a GI bleed or cellulitis. The skill is to find the sick patient among many who are well, use validated risk scores to decide who can go home safely, and use same day emergency care to avoid unnecessary admission. This page ties the chapter together.
Your four questions for every patient on the take: How sick are they (NEWS2, ABCDE)? What is the most likely diagnosis -and the dangerous one not to miss? Does a risk score support discharge or admission? What does the patient want, and what is their baseline?

The Acute Medical Unit and the Take

• The acute medical unit (AMU) -the front door for adult medical patients referred by the ED, GPs, NHS 111 and ambulance services; typically 24–72 hour stays.
• Royal College of Physicians standards (Acute Care Toolkit; SAMBA audit):
  • Early senior review -all patients seen by a consultant physician within 14 hours of arrival (sooner if unwell) -the NHS seven-day services standard.
  • NEWS2 on arrival; early warning escalation; sepsis screening.
  • Daily consultant review on AMU.
• Clerking -history (including collateral), examination, drug history (medicines reconciliation), baseline function, social situation, treatment escalation plan and resuscitation status, provisional diagnosis and differential, plan.
• Prioritise the list -see the sickest first (NEWS2, sepsis, chest pain, low GCS); delegate; escalate early.
• Post-take ward round -consultant confirms the diagnosis and plan, sets the expected date of discharge and ceiling of care.
• Ambulatory-first thinking -for every patient: "Could this person be managed without an overnight bed?"

Same Day Emergency Care and Ambulatory Pathways

• Same day emergency care (SDEC) -assessment, investigation and treatment on the same day, avoiding overnight admission; patients go home with follow-up or return for results.
• Common SDEC pathways:
  • Suspected DVT -Wells score, D-dimer, ultrasound, anticoagulation.
  • Low-risk PE -PESI or Hestia; outpatient treatment with a DOAC.
  • Low-risk upper GI bleeding -Glasgow–Blatchford score 0–1; outpatient endoscopy.
  • Cellulitis -IV or oral antibiotics; outpatient parenteral antibiotic therapy (OPAT).
  • Chest pain -high-sensitivity troponin pathways; HEART score.
  • New AF -rate control, anticoagulation, echo.
  • Low-risk pneumonia (CURB-65 0–1), headache, syncope (low risk), anaemia (transfusion, IV iron), pleural effusion (aspiration), community-acquired infections.
• Safety -clear safety-netting advice, written information, a route back if worse, results follow-up and GP communication.
• Benefits -patients prefer it; fewer hospital-acquired harms (infection, delirium, deconditioning); frees beds.

Frailty Units, Virtual Wards and Hospital at Home

• Acute frailty services -older people with frailty identified at the front door (Clinical Frailty Scale 5 or more) get early comprehensive geriatric assessment by a multidisciplinary team -reduces admission, length of stay and institutionalisation (see the Medicine of the Older Person chapter).
• Virtual wards (hospital at home) -acute care at home, including in care homes, with remote monitoring (oxygen saturations, heart rate, BP), daily review and home visits -used for frailty, COPD, heart failure, respiratory infection and early supported discharge.
• Urgent community response -two-hour crisis response teams for falls and acute deterioration at home.
• Choosing well -some people are better cared for at home (frailty, dementia, end of life, patient preference); others need hospital (shock, need for imaging or procedures, no support at home).
• Advance care plans and ReSPECT forms help decide what treatment people want and where.

Risk Scores Used on the Take

• Why use them -consistent decisions, safer discharge of low-risk patients, clear communication; they support, not replace, clinical judgement.
• NEWS2 -physiology-based deterioration score (respiratory rate, oxygen saturation, oxygen use, systolic BP, pulse, consciousness or new confusion, temperature) -5 or more urgent review; 7 or more emergency response (see page 1).
• CURB-65 (pneumonia) -Confusion, Urea over 7 mmol/L, Respiratory rate 30 or more, BP (systolic under 90 or diastolic 60 or less), age 65 or more -0–1 home; 2 consider hospital; 3–5 severe (CRB-65 in the community without urea).
• Wells score (DVT and PE) -two-level Wells for DVT (2 or more likely) and PE (over 4 likely); then D-dimer if unlikely, imaging if likely.
• PERC rule -rules out PE without D-dimer when pre-test probability is low (all 8 criteria negative -age under 50, pulse under 100, SpO₂ 95% or more, no haemoptysis, no oestrogen use, no previous VTE, no unilateral leg swelling, no recent surgery or trauma).
• PESI / sPESI and Hestia -PE severity; low-risk PE can be treated as an outpatient.
• Glasgow–Blatchford score (upper GI bleed, before endoscopy) -urea, haemoglobin, systolic BP, pulse, melaena, syncope, liver disease, heart failure -score 0–1 may be managed as an outpatient. Rockall (after endoscopy) predicts rebleeding and death.
• HEART score (chest pain) -History, ECG, Age, Risk factors, Troponin -0–3 low risk.
• CHA₂DS₂-VASc (stroke risk in AF) and ORBIT (bleeding risk -NICE NG196 preferred over HAS-BLED).
• ABCD2 -no longer recommended for TIA triage (NICE) -all suspected TIAs are seen within 24 hours.
• Clinical Frailty Scale -frailty level guides assessment and treatment decisions.
• qSOFA -not recommended for sepsis screening in the UK; NEWS2 used instead.
• GCS and 4AT (delirium) -see page 5.

Risk Scores at a Glance

Falls and "Off Legs"

• "Off legs", "acopia" and "social admission" are not diagnoses -an older person who suddenly can't cope has an acute illness until proven otherwise.
• Common hidden causes -infection (UTI, pneumonia -often without fever), delirium, drugs (new or changed -sedatives, antihypertensives, opioids), dehydration and AKI, electrolytes (sodium, calcium), hypoglycaemia, stroke, MI (silent), heart failure, arrhythmias, GI bleeding, anaemia, fracture (hip, pubic rami, vertebral -check they can bear weight), constipation and urinary retention, hypothyroidism, depression, elder abuse or neglect.
• After a fall -why did they fall (syncope vs trip; see page 4), injuries (head injury on anticoagulants -CT head), long lie (rhabdomyolysis, pressure damage, hypothermia, AKI), can they get up and walk?
• Assessment -full history including collateral, medication review, lying and standing BP, ECG, bloods (FBC, U&E, calcium, glucose, CK, CRP), urine dipstick only if symptoms (unreliable in over-65s), cognition (4AT), walking assessment with physiotherapy.
• Plan -treat the cause; multidisciplinary falls assessment; physiotherapy and occupational therapy; consider frailty unit, SDEC or virtual ward; bone health (fracture risk).

Upper GI Bleeding

• Presentation -haematemesis, coffee-ground vomit, melaena (black tarry stool), shock; a raised urea (blood protein absorbed) supports an upper GI source.
• Causes -peptic ulcer (NSAIDs, aspirin, H. pylori) -commonest; oesophagitis, gastritis; varices (cirrhosis); Mallory–Weiss tear; malignancy; angiodysplasia.
• Resuscitate -ABCDE, two large-bore cannulas, crossmatch, transfuse if haemoglobin under 70 g/L (under 80 with cardiovascular disease) -restrictive transfusion; major haemorrhage protocol if massive bleeding; correct clotting.
• Risk assess -Glasgow–Blatchford -score 0–1 can be discharged with outpatient endoscopy.
• Endoscopy -within 24 hours of admission; immediately after resuscitation if unstable (NICE CG141).
• Anticoagulants and antiplatelets -hold anticoagulants; reverse if major bleeding (vitamin K and prothrombin complex concentrate for warfarin; andexanet alfa or PCC for factor Xa inhibitors per local policy; idarucizumab for dabigatran); continue low-dose aspirin for secondary prevention once bleeding is controlled; discuss clopidogrel with cardiology if recent stent.
• Variceal bleeding (suspected in liver disease) -terlipressin and prophylactic antibiotics before endoscopy; band ligation; TIPS if uncontrolled.
• Non-variceal -endoscopic therapy; PPIs after endoscopy (not before -NICE); interventional radiology or surgery if rebleeding.
• Lower GI bleeding -Oakland score (8 or less -safe discharge); CT angiography if unstable.

Acute Abdominal Pain on the Medical Take

• Medical causes of abdominal pain -DKA, hypercalcaemia, inferior MI, lower lobe pneumonia, pyelonephritis, acute porphyria, sickle cell crisis, adrenal crisis, lead poisoning, herpes zoster (before the rash), constipation, urinary retention.
• Surgical causes not to miss -ruptured AAA (older man, back pain, shock -vascular surgery now), mesenteric ischaemia (AF, pain out of proportion to signs, high lactate -CT angiography), perforation, bowel obstruction, appendicitis, cholecystitis, pancreatitis (amylase or lipase; Glasgow score), ectopic pregnancy (pregnancy test in all women of reproductive age).
• Older people -signs may be subtle; perforation can present with confusion only; threshold for CT is low.
• Tests -FBC, U&E, LFTs, amylase or lipase, CRP, glucose, calcium, lactate (venous gas), ECG, troponin if indicated, urine dipstick and pregnancy test, erect chest X-ray (free air), CT abdomen and pelvis.
• Analgesia early -doesn't mask signs; refer to surgery promptly.

Cellulitis and Skin Infection

• Cellulitis -spreading redness, warmth, swelling and tenderness, usually of one leg; Streptococcus pyogenes and Staphylococcus aureus.
• Bilateral red legs are rarely cellulitis -think venous eczema, lipodermatosclerosis, oedema, contact dermatitis.
• Differentials -DVT (can coexist), gout, ruptured Baker's cyst, erysipelas (raised, well-defined edge -face or leg), necrotising fasciitis.
• Severity (Eron classification) -I: no systemic features; II: systemically unwell or comorbidities; III: significant systemic upset or limb-threatening; IV: sepsis or necrotising fasciitis.
• Treatment (NICE NG141) -flucloxacillin 500 mg–1 g four times daily (oral for mild; IV for severe); clarithromycin, doxycycline or erythromycin in penicillin allergy; co-amoxiclav for facial cellulitis (near the eyes or nose); 5–7 days; mark the edge; elevate the leg; treat the entry point (tinea pedis, ulcers).
• OPAT -IV antibiotics at home or in SDEC (e.g. ceftriaxone, teicoplanin) avoids admission.
• Necrotising fasciitis -pain out of proportion, rapid spread, tense swelling, bullae, crepitus, skin necrosis, anaesthesia over the area, septic shock -emergency surgical debridement; broad-spectrum antibiotics including clindamycin.
• Orbital cellulitis -painful eye movements, proptosis, reduced vision -emergency (ophthalmology and ENT, CT).

Suspected DVT and PE

• Suspected DVT (NICE NG158):
  • Two-level Wells score.
  • DVT likely (2 or more) -proximal leg vein ultrasound within 4 hours; if delayed, D-dimer and interim anticoagulation (e.g. apixaban or rivaroxaban); if scan negative and D-dimer positive -repeat scan at 6–8 days.
  • DVT unlikely (under 2) -D-dimer; if positive, ultrasound.
• Suspected PE:
  • PERC if pre-test probability is low; two-level Wells score.
  • PE likely (over 4) -CTPA immediately (interim anticoagulation if delayed); V/Q scan if contrast allergy or severe kidney impairment.
  • PE unlikely -D-dimer (age-adjusted in over-50s per NICE); if positive, CTPA.
  • Massive PE (shock) -thrombolysis (alteplase); bedside echo if too unstable for CT (see page 4).
• Treatment -apixaban or rivaroxaban first line (DOACs); LMWH in cancer (or DOAC), pregnancy (LMWH), severe kidney failure, antiphospholipid syndrome (warfarin); duration at least 3 months -longer for unprovoked VTE (weigh bleeding risk).
• Outpatient management of low-risk PE (sPESI 0 or Hestia negative) via SDEC.
• Unprovoked VTE -history, examination and basic tests for cancer; don't routinely do CT unless clinical suspicion; thrombophilia testing only in selected cases.

New Atrial Fibrillation

• Look for the trigger -infection, sepsis, alcohol, thyrotoxicosis, MI, PE, heart failure, valve disease, electrolytes, surgery.
• Unstable (shock, syncope, ischaemia, severe heart failure) -synchronised DC cardioversion (see page 2).
• Stable:
  • Rate control -beta-blocker (e.g. bisoprolol) or rate-limiting calcium channel blocker (diltiazem, verapamil -not in heart failure); digoxin if sedentary or in heart failure; aim for resting heart rate under 110 initially.
  • Rhythm control -if onset under 48 hours (or anticoagulated for 3 weeks, or TOE clear) -electrical or pharmacological cardioversion (flecainide if no structural heart disease; amiodarone if structural disease).
  • Treat the cause -sepsis-driven AF often settles with treating the infection.
• Anticoagulation (NICE NG196) -CHA₂DS₂-VASc 2 or more -offer a DOAC (apixaban, rivaroxaban, edoxaban, dabigatran); consider at 1 in men; assess bleeding risk with ORBIT; aspirin is not for stroke prevention.
• Investigations -ECG, TFTs, U&E, magnesium, FBC, LFTs, echocardiogram.
• SDEC -many stable patients go home on rate control and a DOAC with cardiology follow-up.

Urinary Infection and Pyelonephritis

• Don't dipstick urine in over-65s to diagnose UTI -asymptomatic bacteriuria is very common; diagnose on symptoms and signs (UKHSA).
• Treat symptoms, not results -new dysuria, frequency, urgency, suprapubic pain, new incontinence, rigors, new delirium with no other cause; send a urine culture before antibiotics.
• Lower UTI (cystitis) -nitrofurantoin (avoid if eGFR under 45) or trimethoprim (if low resistance risk); women 3 days; men 7 days; pregnancy -nitrofurantoin (avoid at term), amoxicillin or cefalexin (culture-guided).
• Pyelonephritis -loin pain, fever, rigors, vomiting -cefalexin, co-amoxiclav (culture-guided), ciprofloxacin or IV antibiotics (e.g. gentamicin, ceftriaxone) if severe; 7–14 days.
• Urosepsis -sepsis pathway (see page 3); urgent renal ultrasound to exclude an obstructed infected kidney (needs nephrostomy -urological emergency).
• Catheter-associated UTI -change the catheter before taking a sample and starting antibiotics; remove catheters that are not needed.

VTE Prophylaxis

• Assess every medical admission for VTE and bleeding risk on admission and at consultant review (NICE NG89).
• Pharmacological prophylaxis -LMWH (e.g. enoxaparin 40 mg daily -adjust for weight and kidney function) or fondaparinux, for at least 7 days if VTE risk outweighs bleeding risk; unfractionated heparin in severe kidney impairment (eGFR under 15–30).
• Contraindications -active bleeding, bleeding disorders, low platelets (under 50), acute stroke (haemorrhagic, or ischaemic within the first days), already anticoagulated, recent neurosurgery, uncontrolled hypertension.
• Mechanical prophylaxis -intermittent pneumatic compression in acute stroke (CLOTS 3 trial) if immobile; anti-embolism stockings are not recommended for medical patients or stroke (risk of skin damage).
• Reassess after 24 hours and when the clinical situation changes; stop when mobile.
• Hospital-acquired thrombosis is a leading preventable cause of hospital deaths.
• Heparin-induced thrombocytopenia -platelets fall by 50% or more 5–10 days after starting heparin with new thrombosis -stop all heparin; use argatroban or fondaparinux (4T score).

Acute Pain and Symptom Control

• Assess pain -numerical rating scale; PAINAD or Abbey pain scale in dementia or communication difficulties.
• Step up by severity:
  • Paracetamol -regular (1 g four times daily; reduce to 15 mg/kg or a maximum of 3 g/day if under 50 kg, liver disease, malnutrition or frailty).
  • NSAIDs -short courses, with a PPI; avoid in AKI, CKD, heart failure, GI bleeding, older people where possible.
  • Weak opioids -codeine (variable metabolism; avoid in under-12s and breastfeeding), tramadol (seizures, serotonin syndrome, hyponatraemia).
  • Strong opioids -oral morphine (e.g. 2.5–5 mg as needed in frail older people); oxycodone or alfentanil if eGFR is low (morphine accumulates in kidney failure); IV titration for severe pain.
• With opioids -always prescribe a laxative (stimulant plus softener) and an antiemetic as needed; monitor sedation and respiratory rate; naloxone for opioid toxicity (see Clinical Pharmacology chapter).
• Neuropathic pain -amitriptyline, duloxetine, gabapentin, pregabalin (note dependence and respiratory depression with opioids).
• Nausea -match the antiemetic to the cause (cyclizine, metoclopramide, haloperidol, ondansetron); avoid metoclopramide in Parkinson's disease (use domperidone).

Handover, Documentation and Discharge

• Handover -structured (SBAR -Situation, Background, Assessment, Recommendation); face-to-face with the night team; highlight sick patients, outstanding jobs and escalation plans.
• Documentation -date, time, name, role and GMC number; legible; clear plan with ceilings of care and resuscitation status; record discussions with patients and families.
• Treatment escalation plans -decide early (with the patient and family) whether ICU, NIV or CPR is appropriate; ReSPECT form; respects autonomy and avoids crisis decisions.
• Discharge planning starts on admission -expected date of discharge; therapy assessments; social care; medicines reconciliation; transport.
• Discharge summary -diagnosis, key results, medication changes (and why), follow-up, actions for the GP, results pending, safety-netting advice; sent the same day.
• Safety-netting -tell the patient what to look out for, when and how to return.
• Duty of candour -be open and honest with patients when things go wrong (see Ethics and Law).
• Self-discharge -assess capacity; explain risks; record discussion; offer follow-up and treatment to take home; patient may sign a form but it is not mandatory.

The Acute Take at a Glance

Spot the Diagnosis

Exam-style Scenarios

1. A 62-year-old man on naproxen has vomited blood twice and has melaena. Pulse 118, BP 96/60, haemoglobin 82 g/L, urea 18.
Answer: Upper GI bleed -probable peptic ulcer -high risk (Glasgow–Blatchford well above 1).

• ABCDE; two large-bore cannulas; crossmatch; fluids; transfuse if haemoglobin under 70 (under 80 if cardiovascular disease); major haemorrhage protocol if needed.
• Stop naproxen; urgent endoscopy after resuscitation (within 24 hours -immediately if unstable); PPI after endoscopy.
• H. pylori testing and eradication; review aspirin or anticoagulants.

2. A 45-year-old woman has a swollen left calf after a long flight. Wells score 2. Ultrasound is available tomorrow morning.
Answer: Suspected DVT -"likely" on Wells.

• D-dimer and interim anticoagulation (e.g. apixaban) while waiting for ultrasound; SDEC follow-up.
• If the scan confirms DVT -continue the DOAC for at least 3 months (provoked).
• If the scan is negative but D-dimer positive -repeat scan in 6–8 days.

3. An 88-year-old woman from home is "off legs" and more confused for 2 days. She has a positive urine dipstick but no urinary symptoms. Sodium 122, NEWS2 2.
Answer: Acute illness in an older person -delirium with hyponatraemia; the dipstick is unreliable.

• Look for causes -drugs (thiazide, SSRI), chest infection, constipation, retention, pain, fracture; 4AT; collateral history.
• Assess volume status; paired urine osmolality and sodium; stop causative drugs; treat cause.
• Frailty team or CGA; physiotherapy and occupational therapy; consider virtual ward once stable.

4. A 70-year-old man has new AF (rate 140) with a cough and fever. BP 125/80, no chest pain. CURB-65 1.
Answer: Sepsis-related AF with pneumonia.

• Treat the infection (antibiotics, fluids if dry); rate control with a beta-blocker if needed (rate often settles with treatment of the trigger).
• CHA₂DS₂-VASc 1 (age 65–74) -consider anticoagulation (ORBIT for bleeding risk); TFTs, echo.
• Could be managed via SDEC or a short stay if stable.

5. A 55-year-old man with diabetes has a hot, swollen leg and severe pain much worse than the visible redness. He becomes hypotensive within 2 hours.
Answer: Necrotising fasciitis.

• Sepsis pathway -fluids, cultures, lactate; broad-spectrum IV antibiotics including clindamycin.
• Emergency surgical referral for debridement -don't wait for imaging.
• Critical care; repeated surgical review.

Key Points

• Find the sick patient first -NEWS2, ABCDE, sepsis screening; early consultant review (within 14 hours).
• Think ambulatory first -SDEC for DVT, low-risk PE, low-risk GI bleed, cellulitis, chest pain, AF.
• Risk scores support, not replace, judgement -CURB-65, Wells, PERC, sPESI, Glasgow–Blatchford, HEART, CHA₂DS₂-VASc, ORBIT.
• "Off legs" is never a diagnosis -look for infection, drugs, electrolytes, fracture, stroke, delirium.
• Upper GI bleed -resuscitate, restrictive transfusion, Glasgow–Blatchford, endoscopy within 24 hours; terlipressin and antibiotics for varices.
• Medical causes of abdominal pain -DKA, hypercalcaemia, MI, pneumonia; don't miss AAA, ischaemia, perforation, ectopic.
• Cellulitis -usually one leg; flucloxacillin; bilateral red legs are rarely cellulitis; pain out of proportion -necrotising fasciitis.
• Suspected DVT or PE -Wells, D-dimer, imaging, interim anticoagulation; DOACs first line.
• New AF -find the trigger; rate control; anticoagulate by CHA₂DS₂-VASc.
• Don't dipstick urine in over-65s; treat symptoms; scan for obstruction in urosepsis.
• VTE risk assessment on admission; LMWH if appropriate; no stockings for medical patients; IPC in stroke.
• Prescribe laxatives with opioids; oxycodone or alfentanil in kidney failure; avoid metoclopramide in Parkinson's.
• SBAR handover; escalation plans early; discharge planning starts on admission.

Guidelines and Further Reading

• Royal College of Physicians: Acute Care Toolkits; National Early Warning Score (NEWS) 2
• Society for Acute Medicine: SAMBA benchmarking audit; SDEC guidance
• NHS England: Same Day Emergency Care; virtual wards (hospital at home) guidance
• NICE CG141: Acute upper gastrointestinal bleeding in over 16s
• NICE NG158: Venous thromboembolic diseases -diagnosis, management and thrombophilia testing
• NICE NG89: Venous thromboembolism in over 16s -reducing the risk of hospital-acquired DVT or PE
• NICE NG196: Atrial fibrillation -diagnosis and management
• NICE NG141: Cellulitis and erysipelas -antimicrobial prescribing
• NICE NG109 / NG111: Urinary tract infection (lower) and pyelonephritis -antimicrobial prescribing; UKHSA: Diagnosis of UTI
• NICE NG138: Pneumonia (community-acquired) -antimicrobial prescribing
• BNF -for current doses