🟦 UNIVERSAL MANAGEMENT FRAMEWORK (For Any System)

Use this structure for cardio, GI, thorax, stomach, skin - any case. Just swap the specific content inside each step.

STEP 1 - Initial Approach (Always Start Here)

"I will perform hand hygiene, introduce myself, confirm patient identity, and assess the ABC - Airway, Breathing, Circulation."

• Check vital signs: BP, HR, RR, SpO2, temperature, GCS
• Establish IV access (two large-bore cannulas if unwell)
• Give supplemental oxygen if SpO2 <94%
• Call for help if the patient is critically unwell

STEP 2 - Resuscitate (If Needed)

"I will resuscitate the patient simultaneously while investigating."

• Fluids: IV crystalloid (0.9% saline or Hartmann's) if haemodynamically unstable
• Blood if haemorrhage (target Hb >8 or >10 in cardiac)
• NBM (nil by mouth) if surgical intervention likely
• Insert urinary catheter to monitor urine output (target >0.5 ml/kg/hr)
• NG tube if vomiting or obstruction

STEP 3 - History & Examination

"I will take a focused history including onset, duration, severity, associated symptoms, and relevant PMH."

• SOCRATES for pain (Site, Onset, Character, Radiation, Associated, Timing, Exacerbating, Severity)
• Past medical history, medications, allergies, surgical history, social history
• Relevant system examination (abdo, chest, cardiac as appropriate)

STEP 4 - Investigations (Tailor to System)

"I will request the following investigations to confirm diagnosis and assess severity."

• FBC - infection, anaemia
• U&E / Creatinine - renal function, electrolytes
• LFTs - liver/hepatic involvement
• CRP / ESR - inflammation/infection
• Coagulation (PT, APTT) - if bleeding or pre-op
• Group & Save / Crossmatch - if surgical
• Blood cultures - if febrile/septic
• Lactate - if sepsis or ischaemia suspected

STEP 5 - Pain Control

"I will provide adequate analgesia using the WHO pain ladder."

• Mild: Paracetamol 1g QDS ± NSAIDs (if no contraindication)
• Moderate: Codeine / Tramadol
• Severe: IV Morphine (with antiemetic)
• Avoid NSAIDs in GI bleed, renal impairment, or if surgery planned

STEP 6 - Antibiotics (If Infection/Sepsis)

"I will prescribe antibiotics after taking cultures, guided by local antimicrobial policy."

• Skin/soft tissue: Flucloxacillin (Staph/Strep); add Metronidazole if anaerobes
• GI/Abdominal: Co-amoxiclav OR Cefuroxime + Metronidazole
• Sepsis (unknown source): Piperacillin-Tazobactam (Tazocin)
• Necrotizing fasciitis: Meropenem + Clindamycin + IV Penicillin (triple therapy)
• Always escalate to Microbiology if no improvement

STEP 7 - Definitive Treatment

"The definitive treatment depends on the underlying cause."

STEP 8 - Peri-operative Management (If Surgery)

"I will prepare the patient for surgery with the anaesthetic team."

• Pre-op: Consent, mark site, anaesthetic review, NBM, TED stockings, LMWH (DVT prophylaxis), pre-op bloods
• Intra-op: WHO surgical safety checklist, correct patient/site/procedure, antibiotics within 60 min of incision
• Post-op: Monitor vitals, urine output, wound, drain output, pain, VTE prophylaxis, early mobilisation

STEP 9 - Monitoring & Reassessment

"I will reassess the patient regularly and escalate if deteriorating."

• Repeat observations every 30-60 min in acute setting
• Use NEWS2 scoring (National Early Warning Score)
• Repeat bloods/imaging if clinical concern
• If no improvement → escalate to senior / ICU referral

STEP 10 - Patient Education & Discharge Planning

"Before discharge, I will counsel the patient on their condition, treatment, and red flags."

• Explain the diagnosis in simple terms
• Medications - purpose, dose, side effects
• Wound care if applicable
• Red flags to return: fever, worsening pain, bleeding, breathlessness
• Follow-up appointment
• Lifestyle: smoking, alcohol, diet, exercise as relevant

Quick Viva Phrase Bank

🟦 MANAGEMENT OF PERFORATION (All Types)

The core principle is the same across all perforations: Stabilize → Investigate → Operate

STEP 1 - Immediate Stabilization (Say This First Every Time)

• Airway - ensure patent, high-flow O2
• IV access - two large-bore cannulas
• IV fluids - aggressive crystalloid resuscitation (0.9% saline / Hartmann's)
• NBM (nil by mouth) immediately
• Analgesia - IV morphine + antiemetic
• Urinary catheter - monitor urine output (target >0.5 ml/kg/hr)
• NG tube - for gastric decompression

STEP 2 - Investigations

STEP 3 - Antibiotics

• GI perforation (gastric/duodenal/bowel): Cefuroxime + Metronidazole OR Co-amoxiclav
• Oesophageal perforation (mediastinitis): Piperacillin-Tazobactam (Tazocin)
• Septic/unclear source: Meropenem ± Metronidazole
• Always escalate to Microbiology if not improving

STEP 4 - Definitive Treatment (Tailor to Site)

STEP 5 - Post-op Care

• ICU / HDU monitoring
• Ongoing IV antibiotics (48-72 hrs, then step down)
• Pain management (PCA morphine or epidural)
• Nutritional support - NG feeding or TPN if prolonged ileus
• Monitor: vitals, drain output, wound, urine output, electrolytes
• DVT prophylaxis: LMWH + TED stockings
• Early physiotherapy and mobilisation

STEP 6 - Treat the Underlying Cause

• H. pylori (peptic ulcer perf): Triple therapy - PPI + Amoxicillin + Clarithromycin x 7-14 days
• Stop NSAIDs (major risk factor for peptic ulcer perf)
• Crohn's/IBD: post-op immunosuppression/biologics
• Malignancy: oncology referral for staging and adjuvant therapy

STEP 7 - Monitoring & Escalation

• NEWS2 scoring every 30-60 min in acute phase
• If deteriorating post-op → re-look laparotomy
• If no improvement on antibiotics → CT to check for collection → drain if needed

STEP 8 - Patient Education

• Avoid NSAIDs and smoking (peptic ulcer)
• Recognize red flags: sudden severe abdominal/chest pain = emergency
• Medication adherence (H. pylori eradication, PPIs)
• Dietary modifications post-surgery
• Follow-up endoscopy if malignancy suspected

Quick Viva Phrase for ANY Perforation

"This is a surgical emergency. I will stabilize the patient with ABCDE, make them NBM, start broad-spectrum IV antibiotics, get an erect CXR and CT, and prepare for emergency surgery. The definitive treatment is [Graham patch / laparotomy + resection / surgical repair] followed by ICU monitoring and treatment of the underlying cause."