Urgent and Unscheduled Care

Urgent and unscheduled care tests your ability to recognise and manage emergencies in the primary care setting. This is a high-stakes topic because getting it wrong in practice means delayed treatment and worse outcomes.

Sepsis recognition is critical. The National Early Warning Score 2 (NEWS2) helps identify deteriorating patients, but in primary care, use the NICE guideline NG51 criteria. High-risk features include: systolic BP below 90, heart rate above 130, respiratory rate above 25, SpO2 below 91%, not passed urine in 18 hours, mottled or ashen skin, lactate above 2, and non-blanching rash. If sepsis is suspected: give antibiotics within one hour (if you can), call 999, and start IV fluids if available. Do not wait for blood results.

The acute abdomen requires systematic assessment. Key differentials by location include: right iliac fossa (appendicitis, ovarian pathology, ectopic pregnancy), right upper quadrant (biliary colic, cholecystitis, hepatitis), left iliac fossa (diverticulitis, ovarian pathology), epigastric (peptic ulcer, pancreatitis, MI), and generalised (peritonitis, bowel obstruction, ruptured AAA). Red flags requiring immediate referral include peritonism (guarding, rebound tenderness), haemodynamic instability, and signs of bowel obstruction.

Anaphylaxis management follows Resuscitation Council UK guidelines. IM adrenaline 1:1000 (500mcg in adults) into the anterolateral thigh. Repeat every 5 minutes if no improvement. Position the patient flat with legs raised (or sitting up if breathing difficulty). High-flow oxygen, IV fluids for shock, and antihistamines and hydrocortisone as adjuncts (not first-line). After treatment: observe for at least 6-12 hours (biphasic reactions occur), prescribe two adrenaline auto-injectors, and refer to allergy clinic.

Other medical emergencies in primary care include: meningitis (non-blanching rash, headache, neck stiffness, photophobia, give IM benzylpenicillin before transfer), acute asthma (PEFR below 50% predicted, SpO2 below 92%, unable to complete sentences, give salbutamol nebuliser and oral prednisolone, call 999), and MI (chest pain, sweating, nausea, give aspirin 300mg, GTN, call 999).

Safety netting is the systematic approach to managing diagnostic uncertainty. It involves communicating clearly with the patient about what to watch for, when to return, and what to do if symptoms worsen. Effective safety netting includes specific symptoms to watch for (not just "come back if worse"), a timeframe for follow-up, and a plan for what happens next. Document your safety net advice.

The duty doctor role involves triaging urgent same-day requests, managing acute presentations, and deciding between primary care management, emergency department referral, and 999 transfer. Effective triage requires recognising red flags rapidly and acting decisively.