Management

“How would you manage this patient?” Is a classic final question consultants use to end the grilling. Of course, the specific management plan will depend on the presenting complaint and likely diagnosis. But here are a few safe, sensible and general things to say. 

Pain relief

Offering immediate pain relief is always a sensible thing to do. It will calm the patient, make them more comfortable and therefore easier to assess. The WHO has a sensible “Pain Ladder” where you start at the lowest level of pain relief quoted and go upwards to adequately manage the pain. 

Step 1: “Non-opioid” (often an NSAID such as ibuprofen) and an “adjuvant” (often paracetamol) then assess pain for improvement. If pain persists, then escalate to step 2.

Step 2: Add a “Weak opioid” (codeine for e.g.) to step 1. If pain persists further, then escalate to step 3.

Step 3: Add a “Strong Opioid” (morphine for e.g.) to step 1 and omit the weak opioid of step 2. 

Fluids 

Another sensible thing to say is “get IV access and start fluids” (provided the patient is unable to orally take in the fluids needed). Simply speaking, fluid management should be split into two categories: replacement or maintenance. 

1.Replacement refers to conditions where the patient shows signs of dehydration such as increased heart rate, low blood pressure and dry mouth etc. In this case, giving 500ml 0.9% sodium chloride (NaCl) over 15 mins IV bolus is a sensible suggestion. Then looking for improvement in HR,BP etc. 

2.Maintenance refers to someone who is unable to take in fluid orally, who requires daily IV fluid to maintain their fluid and ions levels. Typically, an adult requires about 30ml/kg/day of water, and 1mmol/kg/day of essential ions such as sodium (Na) and potassium (K). So, for a 80kg patient, this would mean 2L of water and 80mmol of Na and 80mmol of K. Prescribing something like 1L 0.9% NaCl (+ 40mmol K added) every 12 hours is a sensible thing to say. 

Other things to mention if appropriate are oxygen if O2 sats are low and antibiotics if infection/sepsis is suspected. With regards to sepsis (severe systemic infection), it’s best to reel out the mnemonic: BUFALO.

B=Blood Culture 

U=Urine Output (catheterise)

F=Fluids

A=Antibiotics

L=Lactate

O=Oxygen