Medicine on call

When the staff nurse calls you about a patient on the medical ward at night.

• The deteriorating patient and NEWS2The staff nurse says the NEWS2 is high or the patient "doesn't look right". Go now, assess A–E, treat as you go, and get help early.
• Oxygen and the basic airwayOpen the airway, prescribe oxygen to a target, choose the right device, and don't trust the pulse oximeter more than the patient.
• Low blood pressure on the wardGo now. Lie the patient flat, give a fluid challenge, and work out whether it's sepsis, bleeding, the heart or drugs.
• Low oxygen saturations on the wardSit the patient up, give oxygen to the right target, and find out whether it's the chest, fluid, a clot or the airway.
• Temperature spike on the wardIs this sepsis? Screen, examine for the source, take cultures, and give antibiotics within an hour if septic.
• The confused patient (delirium)New confusion is delirium until proven otherwise. Check the sugar, look for the cause, and calm without drugs first.
• The drowsy patientAirway, sugar, drug chart and pupils. Most drowsy ward patients have a reversible cause you can fix tonight.
• A patient is fittingStart the clock. Protect from injury, check the sugar, give a benzodiazepine at 5 minutes, again at 10, then call for help.
• A patient has fallenLook for the injury, then ask why they fell. Anyone on anticoagulants who hits their head needs a CT head.
• Low blood sugar (hypoglycaemia)Treat first, recheck in 15 minutes, give a longer-acting carbohydrate, then find out why. A low caused by a sulfonylurea can last for a day or more.
• High blood sugar on the wardIs the patient unwell, and are there ketones? That decides between DKA, HHS and just adjusting the regular insulin.
• High blood pressure on the wardRepeat it properly and look for organ damage. If there is none, don't rush to bring it down, and never give sublingual nifedipine.
• Low urine outputCheck the catheter first. Then decide: is the patient dry, septic, bleeding, or are the kidneys failing?
• High potassium (hyperkalaemia)ECG first. ECG changes or potassium 6.5 or more means calcium gluconate to protect the heart, insulin with dextrose to shift potassium, then remove it.
• Prescribing IV fluidsDecide why the patient needs fluid: resuscitation, maintenance or replacement. Then use the weight and the electrolytes to prescribe, and review every day.
• Acute kidney injury (AKI)The creatinine tells you there is a problem. The potassium, the lungs and the acid tell you how dangerous it is. Find out if the patient is dry, blocked or poisoned.
• Electrolytes on the ward: potassium, calcium, magnesium, phosphateTreat the ECG, not just the number. Know the doses for high and low potassium, calcium and magnesium.
• Low sodium (hyponatraemia)How fast it fell matters as much as how low it is. Severe symptoms need 3% saline now. Chronic low sodium must never be corrected too fast.
• Decompensated cirrhosis on the wardTap every patient with ascites on admission, find the trigger, protect the kidneys, and treat encephalopathy with lactulose.
• Pleural effusionUltrasound before every tap. Then decide: transudate or exudate, infected or not, and is it TB or cancer?
• Guillain–Barré syndromeWeakness climbing up from the legs with absent reflexes after an infection. Measure vital capacity, because SpO₂ stays normal until it's too late.