Consider me as duty doctor who is fresher
Welcome! I'm Orris, your AI medical assistant. Think of me as your senior colleague available 24/7.
As a fresher duty doctor, here's how I can support you on the ward:
🩺 What I Can Help You With
Clinical Decision Support
- Interpreting symptoms, signs, and investigations
- Differential diagnoses for presentations you're unsure about
- Understanding pathophysiology behind conditions
Management Guidance
- Drug dosing, interactions, and contraindications
- Initial management protocols (sepsis, ACS, stroke, DKA, etc.)
- Fluid management, electrolyte correction
Procedures & Practical Skills
- Step-by-step guidance on common procedures
- Pre/post-procedure care
Investigations
- ECG interpretation
- ABG analysis
- Lab value interpretation
Communication & Documentation
- Clerking structure
- Referral letters
- Breaking bad news frameworks
How to Use Me
Just describe what you're facing — a patient scenario, a drug you're unsure about, a result you need interpreted. Be as specific as you like:
"28F with sudden onset pleuritic chest pain and mild tachycardia — what's my approach?"
"Patient's K⁺ is 6.2. What do I do?"
"I need to start a patient on heparin — what's the protocol?"
What's your first question?
Okay now I want uh to explain me with right protocols and standards followed
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Here is your comprehensive Duty Doctor Protocol Guide — built from emergency medicine textbooks (Rosen's, Tintinalli's, Washington Manual, Bailey & Love's Surgery):
🏥 Duty Doctor Protocol & Standards Guide
1. EMERGENCY PROTOCOLS
🔴 A. SEPSIS — "Sepsis Six" Bundle
(Complete ALL within 1 hour of recognition)
Screen with qSOFA (score ≥2 = high risk):
- Altered mental status (GCS <15)
- Respiratory rate ≥22/min
- Systolic BP ≤100 mmHg
The Sepsis Six — Give 3, Take 3:
| Give 3 | Take 3 |
|---|---|
| ① High-flow Oxygen (target SpO₂ >94%) | ④ Blood cultures ×2 (before antibiotics) |
| ② IV Antibiotics (broad-spectrum within 1 hr) | ⑤ Full blood count + lactate |
| ③ IV Fluid challenge (500 mL crystalloid bolus) | ⑥ Urine output monitoring (catheterise if needed) |
Lactate >4 mmol/L = septic shock → escalate immediately, target MAP ≥65 mmHg with vasopressors if fluids insufficient.
🔴 B. ANAPHYLAXIS — Algorithm
(From Rosen's Emergency Medicine)
Step 1 — Simultaneous Emergency Measures:
- Remove triggering agent
- Supine position (legs elevated unless airway compromise)
- Cardiac monitor + pulse oximetry + BP monitoring
- Large-bore IV ×2 (16–18G preferred)
- Rapid crystalloid: 1000 mL NS in first 5 min (adults); titrate
- Secure airway — be prepared for RSI/surgical airway
Step 2 — First-Line Drug (GIVE IMMEDIATELY):
- Adrenaline (Epinephrine) 0.3–0.5 mg IM into anterolateral thigh (1 mg/mL = 1:1000 solution)
- Repeat every 5–10 minutes as needed
- Paeds: 0.01 mg/kg IM
Step 3 — Second-Line (Never before epinephrine):
- Antihistamine: Diphenhydramine 50 mg IV (adults)
- Bronchospasm: Salbutamol 2.5 mg nebulised
- Steroids: Hydrocortisone 200 mg IV (prevents biphasic reaction — no acute benefit)
Never delay epinephrine for antihistamines or steroids. Observe ≥4–6 hrs after reaction resolves.
🔴 C. STEMI — Reperfusion Strategy
(Washington Manual of Medical Therapeutics)
Upstream Therapy (give while arranging reperfusion):
- Aspirin 300 mg PO (loading)
- P2Y12 inhibitor: Ticagrelor 180 mg or Clopidogrel 600 mg
- Anticoagulation: UFH or LMWH
- Nitrates (avoid if hypotensive or RV infarct)
- Do NOT give morphine routinely — masks ongoing ischaemia
Reperfusion Decision:
| Scenario | Strategy |
|---|---|
| PCI available within 90 min of first contact | Primary PCI (preferred) |
| PCI NOT available within 90 min | Fibrinolysis (within 12 hrs of symptom onset) |
| Symptom onset 12–24 hrs ago, ongoing symptoms | Still offer PCI |
PCI superiority: Better vessel patency (TIMI-3 flow), less reinfarction, less intracranial haemorrhage, improved survival.
Signs of successful fibrinolysis (at 60–90 min):
- Chest pain relief
- ≥50% reduction in ST elevation
- Idioventricular rhythm
🔴 D. ACUTE STROKE — Time is Brain
Key time targets:
- Door-to-CT: ≤25 min
- Door-to-needle (thrombolysis): ≤60 min
- Window for IV tPA: ≤4.5 hrs from symptom onset
- Mechanical thrombectomy: up to 24 hrs (selected patients)
Initial Steps (FAST approach):
- FAST: Face drooping, Arm weakness, Speech difficulty, Time to call
- Immediate non-contrast CT head → exclude haemorrhage
- Glucose check — hypoglycaemia mimics stroke
- Maintain systolic BP <185/110 mmHg before thrombolysis
- NBM until formal swallow assessment
2. WARD ROUND & DOCUMENTATION STANDARDS
The "SOAP" Structure for every patient note:
| Component | What to Write |
|---|---|
| S — Subjective | Patient's complaints overnight/today |
| O — Objective | Vitals (ABCDE), examination findings, investigations |
| A — Assessment | Problem list / diagnosis |
| P — Plan | Investigations ordered, treatments, escalation plan |
Every entry must include:
- Date + Time
- Your full name (print) + signature + GMC/registration number
- Designation (e.g., "FY1 duty doctor")
- A "Safety net" statement — who to escalate to, when
NEWS2 (National Early Warning Score):
| Score | Response |
|---|---|
| 0–4 (Low) | 4–6 hourly monitoring |
| 5–6 (Medium) | Urgent review by duty doctor |
| 7+ (High) | Emergency response / escalate to registrar/consultant |
3. COMMON PROCEDURES
🩺 Peripheral IV Cannulation
(Roberts & Hedges' Clinical Procedures in Emergency Medicine)
- Explain + consent
- Tourniquet above antecubital fossa
- Clean with chlorhexidine swab — allow to dry 30 sec
- Insert cannula bevel-up at 15–30° angle
- Flashback of blood → advance 1–2 mm → advance cannula off needle
- Release tourniquet → remove needle → apply bung/cap
- Flush with 10 mL 0.9% saline — check for swelling (extravasation)
- Secure with transparent dressing + label with date/time
Preferred sites: Antecubital fossa, forearm. Avoid: Flexion creases, infected skin, mastectomy side.
🩺 Arterial Blood Gas (ABG)
- Allen's test (radial artery — check ulnar collateral)
- Clean + anaesthetise skin (1% lidocaine if time permits)
- Palpate radial artery at wrist crease — insert heparinised syringe at 45°
- Allow pulsatile flow to fill syringe (1–2 mL)
- Withdraw, apply firm pressure ≥5 min (10 min if anticoagulated)
- Expel air bubbles → cap + send immediately on ice
🩺 Urinary Catheterisation
- Strict aseptic technique throughout
- Drape patient; clean urethral meatus with antiseptic
- Insert 10 mL lubricant gel into urethra (males — wait 3–5 min)
- Insert Foley catheter gently → advance fully before inflating balloon
- Inflate balloon ONLY when urine draining freely (usually 10 mL water)
- Connect to closed urinary drainage bag
- Document: size, residual volume, date/time
4. PRESCRIBING & MEDICATION SAFETY
The "5 Rights" (minimum standard for every prescription):
| Right | Check |
|---|---|
| ✅ Right Patient | Name, DOB, hospital number |
| ✅ Right Drug | Generic name preferred; check allergies |
| ✅ Right Dose | Weight-based where applicable; renal/hepatic adjustment |
| ✅ Right Route | Oral vs IV vs IM — always use lowest appropriate route |
| ✅ Right Time | Frequency, start date, review date |
Common Prescribing Pitfalls to Avoid:
| Error | Consequence | Prevention |
|---|---|---|
| Decimal point error (e.g., 1.0 → 10 mg) | 10× overdose | Write "1 mg" not "1.0 mg" |
| Unclear "as required" (PRN) dose | Under/overdosing | Always specify max frequency and max daily dose |
| Forgetting renal dosing | Drug toxicity | Check eGFR for antibiotics, opioids, NSAIDs |
| Transcription errors on handover | Wrong drug continued | Reconcile medications at every handover |
| Allergy not checked | Anaphylaxis | Check drug chart AND ask patient every time |
High-Risk Drugs — Extra Vigilance Always:
- Insulin, heparin/LMWH, opioids, digoxin, warfarin, methotrexate, potassium infusions
5. ESCALATION — Know When to Call for Help
Immediately escalate if:
• NEWS2 ≥7 at any time
• Any patient you are worried about (trust your instinct)
• Airway compromise
• Systolic BP <90 despite fluid resuscitation
• GCS drop >2 points
• New onset chest pain + ECG changes
• Lactate >4 mmol/L
Golden rule as a fresher: If in doubt, shout. It is always better to escalate early than late. Your registrar/consultant would rather be called unnecessarily than called too late.
Quick Reference Card
| Emergency | First Drug | Dose |
|---|---|---|
| Anaphylaxis | Adrenaline IM | 0.3–0.5 mg (1:1000) |
| Sepsis | IV antibiotics + fluids | Within 1 hour |
| STEMI | Aspirin + P2Y12 | 300 mg + 180 mg |
| Hypoglycaemia | Dextrose 50% IV | 50 mL (or Glucagon 1 mg IM) |
| Seizure | Lorazepam IV/IM | 4 mg (adult) |
| PE | Heparin + CTPA | UFH bolus + CTPA confirm |
Which of these areas would you like to go deeper on? I can walk through any specific scenario, drug calculation, or protocol step-by-step.
Take me to step by step cases details
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Excellent data gathered. Now presenting all five major cases in full step-by-step clinical format:
🏥 Step-by-Step Clinical Cases — Duty Doctor Edition
🔴 CASE 1: SEPSIS
The Patient Arrives
"65-year-old male, nursing home resident. Brought in confused, febrile 39.2°C, BP 88/60, RR 24, SpO₂ 93% on air. Urine looks cloudy. Family says he's been 'off' for 2 days."
Step 1 — Recognise It (qSOFA)
Screen immediately at bedside:
| qSOFA Criterion | This Patient |
|---|---|
| Altered mental status (GCS <15) | ✅ Confused |
| RR ≥22/min | ✅ RR 24 |
| SBP ≤100 mmHg | ✅ BP 88/60 |
Score: 3/3 → Presumed Sepsis / Septic Shock. Act NOW.
Step 2 — Call for Help
- Inform your registrar/consultant immediately
- Activate sepsis pathway if your hospital has one
- Move patient to resus/HDU
Step 3 — The Sepsis Six (within 60 minutes, simultaneously)
TAKE 3:
- 🩸 Blood cultures ×2 (peripheral; before antibiotics — do NOT delay antibiotics waiting for this)
- 🩸 FBC, U&E, LFTs, CRP, coagulation, lactate (lactate is critical — >2 mmol/L = sepsis, >4 = septic shock)
- 🚽 Urinary catheter — monitor urine output (target >0.5 mL/kg/hr)
GIVE 3:
- 💧 IV fluids — 500 mL crystalloid bolus (Hartmann's preferred over NS); reassess after each bolus
- 💉 IV antibiotics — broad-spectrum within 1 hr (e.g., Piperacillin-Tazobactam 4.5g IV + Gentamicin for urosepsis; always check local policy)
- 🫁 Oxygen — high-flow via non-rebreather mask; target SpO₂ >94%
Step 4 — Reassess at 30 minutes
| Target | Goal |
|---|---|
| MAP | ≥65 mmHg |
| Urine output | >0.5 mL/kg/hr |
| Lactate | Falling by ≥10% |
| SpO₂ | >94% |
If BP not responding after 1–2 L fluids → start Noradrenaline (vasopressor, via central or peripheral line initially; target MAP ≥65)
Step 5 — Ongoing Monitoring
- Repeat lactate at 2 hours — aim for normalisation to <2 mmol/L
- Cultures guide de-escalation of antibiotics at 48–72 hrs
- Daily reassessment: fluid balance, organ function (renal, liver, coagulation)
Pitfall: Do NOT delay antibiotics waiting for cultures. Every hour of delay in antibiotics increases mortality by ~7%.
🔴 CASE 2: ANAPHYLAXIS
The Patient
"22-year-old female. 10 minutes after penicillin IV in the ward — suddenly flushed, throat tightening, BP drops to 70/40, RR 28, generalised urticaria. Nurse calls you urgently."
Step 1 — Recognise It
Classic triad: Rapid onset + Skin/mucosal changes + Airway/BP/cardiovascular compromise
Step 2 — STOP the Trigger
- Stop the penicillin infusion immediately
- Do NOT remove IV cannula (you'll need it)
Step 3 — Call for Help + Position
- Shout for help / crash team
- Lay patient flat, legs elevated (unless airway compromise — then sit up)
- Prepare for airway management (have airway trolley ready)
Step 4 — ADRENALINE FIRST (no delays)
Adrenaline 0.5 mg IM into anterolateral thigh (1:1000 = 1 mg/mL → give 0.5 mL)
- Repeat every 5 minutes if no improvement
- This is the ONLY life-saving drug — give it before everything else
Step 5 — Resuscitate
- High-flow O₂ via non-rebreather mask
- IV fluids — 1000 mL 0.9% NaCl STAT (several litres may be needed)
- Cardiac monitoring + pulse oximetry
Step 6 — Second-Line Drugs (after adrenaline)
| Drug | Dose | Route | Purpose |
|---|---|---|---|
| Chlorphenamine | 10 mg | IV/IM | H1 antihistamine — itch/urticaria |
| Ranitidine/Famotidine | 40 mg | IV | H2 antihistamine |
| Hydrocortisone | 200 mg | IV | Prevents biphasic reaction (no acute benefit) |
| Salbutamol | 2.5 mg nebulised | Inhaled | If bronchospasm present |
Step 7 — Monitor for Biphasic Reaction
- Observe minimum 6–12 hours after reaction resolves
- Biphasic (return of symptoms without re-exposure) occurs in ~5–20%
- Before discharge: prescribe EpiPen ×2, allergy band, allergy referral, alert on drug chart
🔴 CASE 3: STEMI
The Patient
"58-year-old male, smoker, diabetic. Sudden onset central crushing chest pain radiating to left arm, sweating, started 45 mins ago. ECG shows ST elevation in leads II, III, aVF. BP 110/70."
Step 1 — 12-Lead ECG Immediately
- Inferior STEMI (II, III, aVF) → suspect Right Coronary Artery occlusion
- Do a right-sided ECG (V4R) → if ST elevation = RV infarct → avoid nitrates and aggressive diuresis
Step 2 — Call Cardiology NOW
- Activate the cath lab / PPCI pathway within minutes of diagnosis
- Door-to-balloon target: ≤90 minutes
Step 3 — Dual Antiplatelet Loading (while awaiting PCI)
| Drug | Dose |
|---|---|
| Aspirin | 300 mg PO (chew, don't swallow whole) |
| Ticagrelor | 180 mg PO (or Clopidogrel 600 mg if Ticagrelor not available) |
Step 4 — Anticoagulation
- UFH (Unfractionated Heparin) bolus: 60–70 units/kg IV (max 5000 units) — cardiology will guide
- Or LMWH if fibrinolysis planned
Step 5 — Supportive Measures
- O₂ only if SpO₂ <94% (hyperoxia is harmful in STEMI)
- GTN spray (2 puffs sublingual) — only if SBP >90 and NO RV infarct
- Analgesia — IV morphine 2.5–5 mg titrated (cautiously — may mask symptoms)
- IV antiemetic (metoclopramide 10 mg)
- IV access ×2, continuous monitoring
Step 6 — If PCI NOT available within 90 min → Fibrinolysis
- Tenecteplase (weight-based IV bolus) or Alteplase
- Check absolute contraindications first: prior haemorrhagic stroke, active bleeding, recent surgery, uncontrolled hypertension
- Signs of reperfusion success at 60–90 min: chest pain relief, ST normalisation ≥50%, reperfusion arrhythmia
- If failed → rescue PCI urgently
🔴 CASE 4: DIABETIC KETOACIDOSIS (DKA)
The Patient
"19-year-old known T1DM. Brought in vomiting, Kussmaul breathing, drowsy. RBS 28 mmol/L, ketones 5.2, pH 7.1, HCO₃ 9, K+ 3.8."
DKA Diagnostic Criteria (all three required):
- Blood glucose >11 mmol/L (or known diabetes)
- Ketonaemia ≥3 mmol/L or ketonuria ≥2+
- Acidosis: pH <7.3 or HCO₃ <15 mmol/L
Step 1 — IV Access + Bloods
- FBC, U&E, blood glucose, blood ketones, ABG, blood cultures, urine dip
- VBG acceptable for monitoring (faster)
Step 2 — IV Fluid Resuscitation (most important initial step)
| Time | Fluid |
|---|---|
| 0–60 min | 1 L 0.9% NaCl over 1 hour |
| 1–2 hrs | 1 L 0.9% NaCl over 2 hours |
| 2–4 hrs | 1 L 0.9% NaCl over 2 hours |
| 4–8 hrs | 1 L 0.9% NaCl over 4 hours |
| 8–12 hrs | 1 L 0.9% NaCl over 4 hours |
When glucose falls to <14 mmol/L → switch to 10% dextrose alongside saline to allow continued insulin without hypoglycaemia
Step 3 — Fixed Rate Insulin Infusion (FRIII)
- 0.1 units/kg/hr of IV Actrapid (short-acting insulin)
- Do NOT give bolus insulin
- Do NOT start if K+ <3.5 mmol/L — replace potassium FIRST
Step 4 — Potassium Management (critical)
| K+ Level | Action |
|---|---|
| K+ <3.5 mmol/L | Do NOT start insulin. Replace K+ urgently, recheck |
| K+ 3.5–5.5 mmol/L | Add 40 mmol KCl per litre of fluid |
| K+ >5.5 mmol/L | No potassium supplementation; monitor closely |
DKA causes total body potassium depletion even if serum K+ is normal/high initially. Insulin drives K+ intracellularly — dangerous drop expected.
Step 5 — Monitoring Targets
| Time | Check |
|---|---|
| Hourly | Blood glucose + ketones + GCS |
| 2-hourly | VBG (pH, HCO₃, K+) |
| 4-hourly | U&E |
Resolution criteria (all three):
- Blood ketones <0.6 mmol/L
- pH >7.3
- Bicarbonate >18 mmol/L
Step 6 — Transition to Subcutaneous Insulin
- When eating and drinking + resolution criteria met
- Give SC insulin 30–60 min before stopping IV infusion
- Find and treat precipitant: infection, missed insulin, new diagnosis
🔴 CASE 5: ACUTE ISCHAEMIC STROKE
The Patient
"72-year-old hypertensive female. Sudden onset right-sided weakness + slurred speech 2 hours ago. GCS 13. BP 190/110. BM 7.2."
Step 1 — FAST Assessment + Time Stamp
- Face, Arm, Speech, Time — document exact onset time or last seen well
- Every minute of delay = ~1.9 million neurons lost
Step 2 — Immediate Investigations (all within 15 min)
- Non-contrast CT head — exclude haemorrhage (looks white = blood)
- FBC, coagulation, glucose, U&E, group & save
- 12-lead ECG (AF as cause?)
- If CT clear → discuss thrombolysis with stroke team
Step 3 — Thrombolysis Decision
IV Alteplase 0.9 mg/kg (max 90 mg) — 10% as bolus, rest over 60 min
Eligible if:
- Ischaemic stroke confirmed (no haemorrhage)
- Onset <4.5 hours ago
- No contraindications (recent surgery, anticoagulants, BP not controlled)
Must control BP first: target <185/110 mmHg before giving tPA
Step 4 — Contraindications to Thrombolysis (check every time)
- Prior haemorrhagic stroke at any time
- Intracranial surgery/head trauma in last 3 months
- Active internal bleeding
- Platelet count <100,000
- On warfarin with INR >1.7 or NOAC within 48 hrs
- BP >185/110 despite treatment
Step 5 — Supportive Care
- NBM until formal SALT (speech and language therapy) swallow assessment
- Do NOT lower BP aggressively unless >220/120 (or pre-thrombolysis)
- Blood glucose: treat if <4 or >11 mmol/L
- Antipyrexia if febrile (fever worsens infarct)
- Aspirin 300 mg (via NG/PR if dysphagia) — start 24 hrs after thrombolysis, or immediately if no thrombolysis
Step 6 — Thrombectomy Window
- For large vessel occlusion → mechanical thrombectomy up to 24 hours (selected patients)
- Discuss with stroke team urgently
🧠 Quick Mental Framework for ANY Emergency
ABCDE → Stabilise first, diagnose second
A — Airway (patent? need adjunct?)
B — Breathing (rate, SpO₂, auscultate)
C — Circulation (HR, BP, cap refill, IV access, fluids)
D — Disability (GCS, pupils, glucose)
E — Exposure (temperature, rashes, injuries, signs)
Then: Recognise → Resuscitate → Reassess → Refer
Which case would you like to go deeper on — drug calculations, monitoring charts, or a more complex variant of any of these? I can also present cases for PE, acute pulmonary oedema, hyperkalaemia, or upper GI bleed next.
Some of the basic diseases to diagnose and how to investigate and manage them step by step with proper drugs dosages wt fluids rate wt will the complication wt i shud cross check befr drugs ,how to deal with trauma rta cases deeps cuts wounds wt suturing shud be done wt material is used at antibiotics i shud write for them,and few daiganoses like UTI,DKA,CLD with ascites ,any pain abdmomen cases,renala calculi cases ,evrytng basic diseases steps i need to follow just explain it in discipline way consider ur self as my senior consultant and ur guiding me to understand how to deal with it
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