I was just starting my late cover shift yesterday when the nurse said to me, 'This patient is scoring a 5,' The scores refer to the National Early Warning Score derived from the patient's vital signs and warrants a medical review above a certain cut-off.

'What is she scoring for?' I asked.

'I don't know. It's not my patient. The student was just informing me.'

A quick look through the nursing handover sheet tells me that this patient is being treated for pyelonephritis. She was tachypnoeic, tachycardic and was febrile.

Right. Another quick look through the investigations and charts: she's not had blood cultures and is  on oral antibiotics. 

Right. I will take some blood cultures and escalate her antibiotics to IV. 

***

'Hello, I am one of the doctors on-call. I am here to take some bloods from you, is that okay?

How are you feeling?'

She shook her head while sitting upright.

Torniquet on. Small veins, not visible, not palpable. 

'How is the pain?'

'Still there. It's hard for me to swallow' she finally said. Her voice weak and hoarse.

'Why?' I instinctively asked while still palpating for a vein.

'I just feel my neck is swollen since this morning.'

'Open your mouth for me please'

Right. I cannot see much because the tongue is in the way; the tongue is not swollen I am certain. Chest sounds good and clear. Fine - not angioedema or anaphylaxis. But the neck is swollen and tender, and feels full. 

My torniquet had been on for some time but I still had no luck finding a vein.

***

Something didn't seem right with her but I cannot objectively say how.

She didn't look right; maybe it was the she sat propped up, leaning forward. Maybe it was the soft, low tone of her voice. Maybe it was the fetor of her breath.

'Hello boss, I need you to see this patient with an impending airway obstruction.' I told my registrar.

An hour later, she was transferred to ITU.