Conditions commonly seen at the

medical front door

People may soon find themselves involved in the care for individuals with general medical
conditions and they may not have done that for many weeks/months/years - this document is
not going to make someone into a general medical registrar overnight. However it should
provide a reasonable framework to build upon and should be a helpful first step in the upskilling
we are all currently doing.

The most up to date version of this guide of guidelines will always be available at
bit.ly/Guide-of-guidelines

Comments, questions and criticism can be sent to me - jjhilton@gmail.com

To paraphrase John Green paraphrasing Robert Frost:

The only way out is through. The only way through is together.

Jon Hilton - Acute internal medicine and intensive care medicine registrar ST4

Obstetric medicine on the acute take

Gastroenterology
Abnormal liver function tests
Decompensated liver failure
Paracetamol overdose
Ulcerative colitis
Acute upper GI bleeding

Respiratory
Pneumothorax
Exacerbation of chronic obstructive pulmonary disease
Asthma
Community acquired pneumonia
Community acquired pneumonia in Covid-19 patients
Respiratory support in patients suspected or confirmed to have COVID-19

1
 Pulmonary Embolism
Non-invasive ventilation
High flow nasal oxygen

Cardiology
Cardiac arrest
Hypotension and fluid resuscitation
Chest pain
Supraventricular tachycardia
Atrial fibrillation
Bradyarrhythmias
Syncope
Acute Heart failure
Hypertensive urgency and emergency

Elderly care
Delirium
Urinary tract infection [UTI]
Assessment of a patient who has fallen
Medication review in the older frail patient

Renal
Acute kidney injury
Hyperkalaemia
Acute upper urinary tract infections

Neurology
Stroke
Transient ischaemic attack
Meningitis
Subarachnoid haemorrhage
Epilepsy - Status
Epilepsy - First Fit
Acute management of patients with Parkinson’s

Infectious diseases and HIV medicine

Malaria
Herpes zoster // shingles
Pneumocystis jiroveci pneumonia [PCP]
Post-exposure prophylaxis [PEP]

Endocrinology

2
 Diabetic ketoacidosis [DKA]
Hyperosmolar hyperglycaemic syndrome [HHS]
Hyponatraemia
Hyercalcaemia
Addisonian crisis
Thyrotoxic crisis // Thyroid storm
Hypothyroid crisis // Myxoedema coma

Haematology
Deep vein thrombosis [DVT]
Blood products
Blood transfusion reaction

Rheumatology
Septic arthritis
Temporal arteritis // Giant cell arteritis [GCA]
Suspected methotrexate toxicity

Palliative care
Care planning
Symptomatic relief

Psychiatry
Assessing capacity and Mental Capacity Act
Patients who do not wish to stay in hospital

Obstetric medicine on the acute take1

Always ask about the current and previous pregnancies:

● Gestational age?
● Single or multiple?
● Any current obstetric issues? Scans normal?
● Any previous pregnancies?
○ Any problems during or after?
○ What was the mode of delivery?

Some examination findings will be physiologically different in pregnancy and some won’t. A
systolic murmur, bounding pulse and presence of a S3 heart sound can all be normal. Any

1
Dr Charlotte Frise - @obstetricmedic

3
abdominal or uterine tenderness is a red flag. Blood pressure >140/90mmHg is concerning and
reading should be repeated in 30 minutes, any blood pressure of >160/100mmHg represents
severe hypertension, Obstetric registrar should be informed and urgent antihypertensive
management is needed.

Red flag examination findings include:

● Vaginal bleeding
● Vaginal discharge/fluid
● Reduced fetal movements
● Hypertension +/- proteinuria
● Abdominal pain or signs of labour

Don’t worry about the radiation from a chest x-ray, it’s around 140g of Brazil nuts and less than
the background radiation from a weekend in Cornwall.

VTE is a leading cause of death in pregnancy and postpartum period - VTE prophylaxis is critical.

4
Gastroenterology
Abnormal liver function tests2

Decompensated liver failure

Decompensated cirrhosis is a medical emergency with a high mortality. Effective early

interventions can save lives and reduce hospital stay3. The standard package includes:

● Blood cultures
● Ascitic tap - sending samples for WCC, culture and albumin
● Intravenous Pabrinex 2 pairs three times a day
● Intravenous albumin [20% Human Albumin solution] at 1.5g per kg
● Chlordiazepoxide if individual is at risk of alcohol withdrawal symptoms
● Venous thromboembolism prophylaxis is critical as patients with liver disease are at a high
risk of VTE

2
2017 British Society of Gastroenterology Guidelines on the management of abnormal liver blood tests
3
British Society of Gastroenterology decompensated cirrhosis care bundle - First 24 hours

5
If the individual has known varices, presents with a GI bleed or there is a suspicion of varices then
intravenous terlipressin 2mg four times a day should be considered.

If prothrombin time is prolonged, consider intravenous vitamin K 10mg once only

Paracetamol overdose

Paracetamol overdose [intentional or unintentional] is a common presentation seen on the acute

medical unit.

Criteria for hospital assessment:

● Ingestion in context of self-harm

● Symptomatic patients - abdominal pain, jaundice etc
● Ingestion of 75mg/kg or more over a period of one hour or less
● Time of ingestion is uncertain but dose ingested is above 75mg/kg

Management of paracetamol toxicity is clearly documented in the ToxBase guidelines.

King's college criteria for acute liver transplant -

● pH <7.3
● or all three of
○ INR > 6
○ Creatinine >300
○ Grade III or IV encephalopathy

Ulcerative colitis

Truelove and Witt’s classification can be used to determine the severity of an ulcerative colitis
flare.

6
Initial standard management package includes:

● Steroids
○ IV Hydrocortisone 100mg every six hours
○ PR Hydrocortisone 100mg in 100ml 0.9% Sodium Chloride twice a day [Via Foley
catheter]
● Prophylactic low molecular weight heparin
● Intravenous fluids as often intravascularly depleted
● Abdominal x-ray to rule out toxic megacolon
● Erect chest x-ray to rule out subdiaphragmatic air and to review for lung lesion incase
rescue infliximab is required

7
Acute upper GI bleeding4

4
2019 British Society of Gastroenterology Summary AUGIB Care bundle

8
Refeeding syndrome5

Is a life threatening cluster severe electrolyte abnormalities which occur when malnourished
individuals receive inappropriately high calorie intake.

Level of risk Patient has...

Moderate risk ❖ Little or no nutritional intake for more than 5 days

High risk One or more of:

● BMI less than 16
● Unintentional weight loss of 15% or more in last 3-6 months
● Very little nutritional intake for more than 10 days
● Low levels of potassium, phosphate or magnesium prior to feeding

Two or more of:

● BMI less than 18.5
● Unintentional weight loss of 10% or more in last 3-6 months
● Those with very little intake for more than 5 days
● A history of alcohol dependence or receiving prescribed
medications such as insulin, chemotherapy or diuretics

Very high risk ★ BMI less than 14

★ Negligible intake for greater than 15 days

Individuals identified as high or very high risk should be offered intravenous Pabrinex two vials
three times a day for at least two days, stepping down to Vitamin B co-strong and Multivitamin
afterwards. Wherever possible, emergency feeding regimens should be discussed with the
nutrition team prior to starting.

For those individuals we identify as being at risk of refeeding, we should monitor their potassium,
magnesium, calcium, phosphate, renal function and liver function tests on a daily basis until
stable.

5
RBH Junior Doctors Gut Guide

9
Replacing potassium // Hypokalaemia

For a confirmed serum potassium above 2.5mmol/L in a stable patient who can take oral
medications, potassium effervescent tablets - Sando K 2 tablets three times a day is our preferred
option.

For a serum potassium below 2.5mmol/L or those who can’t take oral medications, 1000ml
intravenous 0.9% sodium chloride with 40mmol to run over four hours [or eight if concerned
about fluid burden] is our only option.

Replacing phosphate // Hypophosphataemia

For a confirmed serum phosphate greater than 0.32mmol/L in a stable patient who can take oral
medications, 1 or 2 effervescent phosphate tablets three times a day is our preferred option.

For a serum phosphate less than 0.32mmol/L or in a patient who is symptomatic or can’t take oral
medications, 100mls of phosphate polyfuser should be given over 6 - 12 hours and then the rest
of the polyfuser discarded. This equates to 20mmol phosphate

Replacing magnesium // Hypomagnesaemia

For a confirmed serum magnesium greater than 0.5mmol/L in a patient with mild or no symptoms
who can take oral medications, 1 sachet of magnesium aspartate can be given dissolved in 200ml
of water - this equates to 10mmol of magnesium and can be repeated up to five times a day.

For a serum magnesium less than 0.5mmol/L or a patient with severe symptoms or who can’t
take oral medications, magnesium sulphate 20mmol (5g) in 500ml 0.9% sodium chloride should
be given over 2.5 - 5 hours.

Respiratory
Pneumothorax

Management of pneumothorax is dependent on whether it is a primary or secondary

pneumothorax and the size of the pneumothorax.

10
A primary spontaneous pneumothorax [PSP] is one which occurs when an individual has
otherwise healthy lung parenchyma. A secondary spontaneous pneumothorax [SSP] is one which
occurs in an individual with underlying lung disease such as COPD.

The size of a pneumothorax is measured at the level of the hilum, less than 2cm is considered
small and greater than 2cm is considered large. 6

Exacerbation of chronic obstructive pulmonary disease

The key aspects of management for an exacerbation of COPD are maximising medical therapies
to avoid the need for non-invasive ventilation7.

The standard package includes:

6
BTS Management of spontaneous pneumothorax
7
https://www.nice.org.uk/guidance/ng115/chapter/Recommendations#managing-exacerbations-of-copd

11
 ● Regular salbutamol nebulisers 2.5mg four times a day and PRN up to every 4
hours
● Regular ipratropium nebulisers 500 micrograms four times a day and suspend
regular long acting antimuscarinic [such as tiotropium] if patient is already taking
one
● Regular oral prednisolone 30mg once a day
● Send sputum for culture
● Oxygen prescription, if at risk of carbon dioxide retention their target should be 88
- 92%, if they are not then their target should be greater than 94%

Asthma

Inpatient management of an asthma exacerbation is guided by symptoms at initial presentation,

the standard package will include:

● Regular salbutamol nebulisers 2.5mg every 6 hours and PRN

● Oral prednisolone 30-40mg daily until recovery, minimum 5 days
● Supplemental oxygen to achieve target SpO2 94-98%

For patients who show poor response to salbutamol or with acute severe or life-threatening then
regular ipratropium nebulisers 500microgram every 6 hours should be added.

A single dose of magnesium sulphate [1.2-2g IV infusion over 20 minutes] can be considered in
patients with acute severe asthma who show a poor response to salbutamol.

12
8

Referral to intensive care should be made for any patient:

● Requiring ventilatory support

● With acute severe or life-threatening asthma who is failing to respond to therapy -
○ Deteriorating peak expiratory flow
○ Persisting or worsening hypoxia
○ Hypercapnia
○ ABG showing low pH
○ Exhaustion or poor respiratory effort
○ Drowsiness, confusion or altered conscious state
○ Respiratory arrest

Community acquired pneumonia

The CURB 65 score provides guidance about mortality from a community acquired pneumonia
and guides antibiotic therapy9. The presence of any of the following scores 1 points: Confusion,
Urea >7, Respiratory Rate >30, Systolic BP <90 or Diastolic <60, Age >65.

8
BTS/SIGN British Guideline on the Management of Asthma
9
Royal Berkshire Hospital MicroGuide

13
 CURB Score Standard therapy Penicillin allergy

0 -1, Mild Oral Amoxicillin 1g TDS Oral Doxycycline 200mg loading, then
100mg twice a day

2, Moderate Intravenous Benzylpenicilin 1.2g 6 Intravenous Teicoplanin 10mg/kg 12

hourly and oral Doxycycline 200mg hourly for the first three doses, then
loading, then 100mg twice a day every 24 hours and intravenous
Clarithromycin 500mg 12 hourly

> 3, Severe Intravenous Benzylpenicillin 1.2g 4 Intravenous Teicoplanin 10mg/kg 12

hourly and intravenous Clindamycin hourly for the first three doses, then
1.2g 6 hourly every 24 hours and intravenous
Clindamycin 1.2g 6 hourly

However CURB score can under represent the severity of pneumonia in younger patients and the
SMART-COP can be used to predict the need for intensive respiratory or vasopressor support.

Community acquired pneumonia in Covid-19 patients10

CURB Score Standard therapy Penicillin allergy

0 -1, Mild Oral Amoxicillin 1g TDS or Oral Doxycycline 200mg

Co-Amoxiclav 625mg TDS in loading, then 100mg twice a
people with chronic lung day
disease

2, Moderate Oral Amoxicillin 1g TDS and Oral Doxycycline 200mg

Doxycycline 200mg loading, loading, then 100mg twice a
then 100mg twice a day day and oral co-trimoxazole
960mg twice a day

> 3, Severe Intravenous Ceftriaxone 2g Intravenous Teicoplanin

once a day +/- Clindamycin if
known to have influenza or
use of intravenous drugs.
10mg/kg 12 hourly for the first
three doses, then every 24
hours +/- Clindamycin if
known to have influenza or
use of intravenous drugs.

10
RBH MicroGuide

14
Respiratory support in patients suspected or confirmed to have COVID-1911

Continuous positive airway pressure [CPAP] is the preferred method of support for a patient who
is suspected or confirmed to have COVID-19 and a hypoxic respiratory failure. Suggested initial
settings are 10 cm of water and 60% oxygen. Our target peripheral oxygen saturations would be
94 - 96% or 88 - 92% in an individual at risk of developing hypoxic hypercapnic respiratory failure.

Bilevel positive airway pressure [BiPap] is the preferred method of support for a patient who is
suspected or confirmed to have COVID-19 and a hypoxic hypercapnic respiratory failure. Our

11
NHS England and NHS Improvement - Guidance for the role and use of non-invasive respiratory support
in adult patients with coronavirus (confirmed or suspected)

15
target peripheral saturation would be 88 - 92% with inspiratory and expiratory pressure
appropriate for the patient.

High flow nasal oxygen [HFNO] is not advocated in patients with COVID-19 due to lack of efficacy,
high oxygen flow use and infection spread.

CPAP, BiPap and HFNO are all considered to be aerosol generating procedures by Public Health
England guidance and therefore airborne/droplet precautions for personal protective equipment
should be adhered to.

Pulmonary Embolism12

If a pulmonary embolism is suspected, the use of the two-level PE Wells score should be used to
estimate the clinical probability. A patient who has a likely clinical probability then an immediate
CTPA should be performed, or they should receive therapeutic dose low molecular weight
heparin if the CTPA can not be performed within the hour.

The simplified PESI can indicate which people with a PE or suspected PE can be managed via an
ambulatory pathway.

Non-invasive ventilation

NIV is a therapy which is indicated in acute hypercapnic respiratory failure [when pO2 is low and
pCO2 is high] for people with COPD, neuromuscular disease or chest wall deformity13.

12
NICE clinical guideline CG144 - Venous thromboembolic diseases
13
BTS/ICS Guidelines for the Ventilatory Management of Acute Hypercapnic Respiratory Failure in Adults

16
Best practice for the initiation of NIV includes:

● Advance care planning should NIV be ineffective at reversing the acute hypercapnic
respiratory failure.
● Chest x-ray to exclude pneumothorax, although this should not delay initiation in cases
where severe acidosis is present.
● Blood gas measurement before initiation and at regular intervals afterwards to guide
therapy.

17
High flow nasal oxygen

14

14
RBH Guidelines for the use of Nasal High Flow Oxygen Therapy in Adults – GL690

18
Cardiology
Cardiac arrest15

15
Adult Advanced Life Support Resuscitation Council (UK) 2015 Guidelines

19
For a person who is confirmed to have or is suspected to have COVID-19 the current advice [as of
18th March 2020] is that CPR should not be started until staff have donned a gown, eye
protection, gloves and FFP3 mask [or alternative if they have not passed fit testing]16.

Hypotension and fluid resuscitation

Fluid management is an important aspect of inpatient care, sometimes we forget that intravenous
fluids are a drug. Balanced crystalloid such as Plasma-late or Hartmann’s would be preferred over
“normal” saline as there is nothing normal about 0.9% sodium chloride17.

Our goal of fluid therapy is to achieve a mean arterial pressure [MAP] of greater than 65mmHg18
and recent evidence shows that in people aged over 65 years a target of 60mmHg is non-inferior
to 65mmHg19.

Generally speaking, we want to give as little intravenous fluid as possible, an initial 500ml fluid
bolus can indicate if a patient will be fluid responsive. If there are concerns about fluid overload a
more cautious 250ml bolus can be used.

Hypotension does not always equate with hypovolaemia - if a patient does not respond to initial
fluids look hard for an alternative cause and call critical care if repeated boluses are required to
maintain an appropriate MAP.

Chest pain

Many patients presenting with chest pain are managed entirely by the Emergency Medicine team
and direct liaison with Cardiology. However patients may be referred to the general medical take
from the Emergency Department due to being deemed as “high risk”. The Emergency
16
Statements on COVID-19
17
SALT-ED Trial
18
Surviving Sepsis Campaign
19
Effect of Reduced Exposure to Vasopressors on 90-day Mortality in older critically ill patients with
vasodilatory hypotension

20
Department uses a combination of the HEART score, clinical presentation and initial high
sensitivity troponin to risk stratify patients presenting with potential non-ST elevation myocardial
infarction.

20

20
Chest Pain in Adults ED Guideline GL1114

21
At any point if a patient enters the red zone, they will be referred to medicine.

21

21
Troponin results interpretation GL546

22
Supraventricular tachycardia22

Narrow being less than 120ms and wide being greater than 120ms.

22
2019 European Society Cardiology - Management of patients with SVT

23
Atrial fibrillation23

Atrial fibrillation [AF] is a heart rhythm characterised by an irregularly irregular rhythm where there
is a loss of P waves on ECG. It has five patterns:

● First diagnosed AF, not witnessed before and irrespective of duration or severity
● Paroxysmal AF, self-terminating runs of AF can be up to 7 days in length
● Persistent AF, lasting longer than 7 days
● Long-standing persistent AF, continuous AF for >1 year where a rhythm control control
plan has been adopted
● Permanent AF, accepted by patient and physician, rhythm control not pursued.

Atrial fibrillation with a fast ventricular rate [“Fast AF”] requires acute heart rate control:

23
2016 European Society of Cardiology guidelines for the management of atrial fibrillation

24
AF is a prothrombotic condition and a common cause of stroke. Anticoagulation decisions should
be guided by patient choice, CHA2DS2-VASc score to estimate benefit and HAS-BLED score to
estimate risk.

For patients who have been in AF for longer than 48 hours [which should be assumed if there is
no definitive time of onset] cardioversion should not be attempted due to the high stroke risk.

25
Bradyarrhythmias

26
Syncope24

Syncope is a transient loss of consciousness secondary to cerebral hypoperfusion - classical

features are rapid onset, short duration and spontaneous complete recovery.

Individuals who present with syncope and only have low-risk features could be released from
hospital with outpatient Cardiology follow up. Otherwise, admission to hospital for diagnostic
investigations is strongly recommended.

Diagnostic tests include:

● Carotid sinus massage is indicated in individuals >40 and is diagnostic if a ventricular

pause lasting longer than 3 seconds and/or a fall in systolic of >50mmHg is induced.
● Orthostatic challenge is diagnostic for orthostatic hypotension if there is a sustained fall in
systolic BP of 20mmHg or more or in diastolic BP of 10mmHg or a decrease in systolic BP
to below 90mmHg. However, orthostatic hypotension can occur in the absence of
symptoms and therefore may not always be the cause of syncope.
● Cardiac rhythm monitoring should be used in individuals where there is a suspicion of
arrhythmic syncope.

24
2018 European society of Cardiology Guidelines for the diagnosis and management of syncope

27
In all patients presenting with syncope, re-evaluate the need for any anti-hypertensive
medications.

Acute Heart failure25

Acute heart failure is the rapid worsening of chronic heart failure or onset of new heart failure.
Management is often dependent on the presentation of the patient and how they fit into one of
four clinical profiles.

25
2016 European Society of Cardiology guidelines for the diagnosis and treatment of acute and chronic
heart failure

28
Diuretic of choice in acute heart failure is intravenous furosemide, the dose should be the lowest
possible to achieve diuresis. In individuals already on oral furosemide, the IV dose should be at
least equal to that.

Vasodilator of choice in acute heart failure is often a glyceryl trinitrate infusion which is titrated to
avoid hypotension. Vasodilators work in acute heart failure by decreasing venous tone
[optimising preload] and arterial tone [decreasing afterload].

Digoxin can be considered in individuals who have a rapid ventricular rate [greater than 110] in
addition to their acute heart failure.

29
30
Hypertensive urgency and emergency26

Hypertension is a common problem for many individuals but only a small fraction of those need
hospital admission.

Individuals with a blood pressure of 180/120mmHg or higher require same day hospital review if
any of the following are present:

● Signs of retinal haemorrhage or papilloedema

● New onset confusion
● Chest pain or signs of heart failure
● Acute kidney injury

Presence of these symptoms are suggestive of accelerated hypertension, also known as

malignant hypertension27.

Clinical presentation Timeline and targets First-line treatment

Malignant hypertension Over several hours reduce Labetalol

MAP by 20-25%

Hypertensive encephalopathy Immediately reduce MAP by Labetalol

20–25%

Acute coronary event or Immediately reduce SBP to Glyceryl trinitrate

acute heart failure <140 mmHg

Eclampsia and severe Immediately reduce SBP to Labetalol and magnesium

pre-eclampsia <160 mmHg AND DBP to <105 sulfate. Consider emergency
mmHg delivery

26
Hypertension in adults: diagnosis and management NICE guideline [NG136] Published date: August 2019
27
2018 European Society of Cardiology Guidelines for the management of arterial hypertension

31
Elderly care
Delirium28 29

Delirium occurs in roughly 20% of adult acute general medical patients, particularly higher in
certain patient groups. The 4-AT should be used to identify patients with probable delirium. CT
head is not routinely required although it should be considered if an individual displays new focal
neurology, reduced level of consciousness, recent falls, head injury or any current anticoagulation
therapy.

Much of the management of delirium is non-pharmacological, firstly at reducing the risk and then
resolving potential causes.

● Ensure individual is orientated and has their glasses and/or hearing aids
● Promote sleep hygiene
● Early mobilisation
● Optimising pain control
● Promoting optimal hydration and nutrition
● Regularisation of bladder and bowel function
● Provision of supplemental oxygen, if appropriate
● Regular medications should be reviewed and possible causative medications should be
suspended.

Pharmacological restraint should only be used in the aggressive agitated individual where all
other options have been exhausted. Older people will often have multiple co-morbidities and
careful considerations should be made regarding choice and dose of any sedative agents.

Generally speaking, haloperidol 500 micrograms is a reasonable starting point and is the safest
option. Alternatively if the individual is known to have a long QT interval in which case 500
microgram of lorazepam although benzodiazepines are associated with an increased risk of falls
and fractures in the older population.

There are case reports detailing that delirium can be a presenting symptom of COVID-19.
Standard non-pharmacological measures to treat delirium may not be possible in isolation
environments - isolation may even cause delirium.

28
SIGN 157: Delirium
29
Coronavirus: Managing delirium in confirmed and suspected cases

32
Urinary tract infection [UTI]3031

UTI is the most common infection in elderly adults aged over 65 years, it is the most common
source of Gram-negative bacteria blood-stream infections in long term care facilities such as care
homes, nursing homes and residential homes.

A diagnosis of UTI in an older person should not be made using a urine dip test - the presence of
positive leucocytes or nitrites has a positive predictive value of 45% for UTI. Smell of urine can
not be used to diagnose a UTI.

In an older individual a diagnosis of UTI should be made using clinical evaluation:

New onset dysuria or any two of the following:

● New onset delirium

● New fever
● New onset frequency or urgency
● New suprapubic discomfort
● Acute haematuria
● Loss of diabetes control

Assessment of a patient who has fallen32

Important questions to ask:

● How did you fall? What exactly happened?

● How many falls have you had in the last year?
● Where were you when you fell?
● Do you get dizzy if you stand up quickly? Do you feel like the room is spinning?

Perform an examination with a focus on:

● Bony injury - important not to miss fracture or dislocations

● Heart rhythm and rate including 12-lead ECG
● Lying and standing blood pressure
● Peripheral sensation
● Peripheral power
● Visual field and acuity assessment
● Gait assessment

30
Investigation of suspected urinary tract infection in older people
31
RBH Antimicrobial prescribing guidelines for management of urinary tract infection in elderly GL1167
32
British Geriatrics Society - Patients at risk of falls and fractures

33
For patients who are on treatment dose anticoagulation a CT head will likely be indicated,
especially in an unwitnessed fall.

Medication review in the older frail patient33

Over time, many patients accumulate a number of prescribed medications but not all medications
are essential as an individual becomes older or their functional baseline declinces. When
reviewing regular medications, a reasonable course of action would be to assume a patient is on
no medications and consider which medications would be of significant benefit to start.

The American Geriatrics Society produced the Beers Criteria which provides guidance on which
medicines carry the largest number of side effects and therefore should be stopped wherever
possible.

The anticholinergic burden is one of the biggest factors inducing detrimental side effects in older
patients. Anticholinergic properties can induce confusion, dizziness and falls. The ACB Calculator
can be used to determine the total anticholinergic burden of all medications prescribed, can
provide the relative score for each individual medication and provide alternatives with a lower
anticholinergic burden.

Many medications prescribed confer a risk reduction when taken for 5, 10 or 15 years. If a person
has a life expectancy lower than the time taken to receive a benefit it may be appropriate to
consider stopping that medication.

Renal
Acute kidney injury34

A diagnosis of acute kidney injury [AKI] is made using the Kidney Disease Improving Global
Outcomes [KDIGO] criteria. AKI is defined as any of the following:

● Increase in serum creatinine by 26.5 within 48 hours

● Increase in serum creatinine to 1.5 times baseline
● Urine volume less than 0.5ml/kg/hour for 6 hours

Once AKI has been identified it is important that a documented review of all medications is
performed and any potentially causative medications suspended. Many drug doses need to be
adapted due to altered pharmacokeinetics in AKI.

33
American Geriatrics Society 2019 Updated Beers Criteria for potentially inappropriate medication use in
older adults
34
2019 The Renal Association Acute Kidney Injury guideline

34
AKI is often multi-factorial, potential causes include:

● Reduced fluid intake or increased fluid loss

● Sepsis
● Obstruction of urinary tract
● Drugs such as NSAIDs, ACEi/ARB, diuretics, statin, PPI, chemotherapy

All individuals diagnosed with an AKI should have their urea and electrolytes measured at least
daily. In individuals where there is no immediately apparent cause for AKI or in those who are not
responding as expected then a urine dip [for blood and protein] and an ultrasound of their renal
tract should be performed.

35
Intravenous fluid administration should be guided by haemodynamic status.

35

35
RBH Management of Acute Kidney Injury EMA077

36
Hyperkalaemia

37
Acute upper urinary tract infections

Upper urinary tract infections and pyelonephritis are characterised by fever, loin/flank pain and
chills. For men and non-pregnant women gentamicin36 is the main antibiotic of choice, doses at
7mg/kg initially [or 2mg/kg if GFR less than 30 or deemed high risk for AKI]. For pregnant women
we instead use aztreonam at a dose of 2g every 8 hours37. Antibiotic choice should be reviewed
when cultures and sensitivities are known.

If there is no initial response to antibiotic therapy within the first 48 hours then we could consider
a CT scan to investigate for possible pyonephritic abscess.

36
RBH Microguide
37
RBH Microguide

38
Neurology
Stroke38

Non-contrast CT head should be performed immediately for any patient presenting with a
suspected acute stroke if any of the following apply:

● Indications for thrombolysis or thrombectomy

● On anticoagulant treatment
● A known bleeding tendency
● GCS of less than 13
● Unexplained progressive or fluctuating symptoms
● Papilloedema, neck stiffness or fever
● Severe headache at onset of stroke symptoms

Individuals who present within 4 and a half hours of onset of stroke symptoms who have no signs
of haemorrhage on their CT are eligible for thrombolysis.

Patients with an acute ischaemic stroke receive 300mg aspirin as initial management for the first
two weeks and then a decision is made regarding the most appropriate antiplatelet agent to
remain on long term.

Venous thromboembolism prevention is maintained with the use of intermittent pneumatic

compression.

Transient ischaemic attack39

A TIA is any focal neurological deficit which resolves spontaneously within 24 hours without
intervention. In individuals presenting with a suspected or confirmed TIA aspirin 300mg is the
initial management for the first two weeks and then a decision is made regarding the most
appropriate antiplatelet agent to remain on long term. CT head is not required, unless there is an
alternative diagnosis that CT could detect. Specialist assessment in the TIA clinic should be
arranged.

38
Stroke and transient ischaemic attack in over 16s, NICE 2019, NG128
39
Stroke and transient ischaemic attack in over 16s, NICE 2019, NG128

39
Meningitis40

40
RBH Management of Meningitis in Adults GL1087

40
Subarachnoid haemorrhage41

Epilepsy - Status42

Convulsive status epilepticus is defined as a continuous generalised tonic clonic [GTC] seizure or
a high frequency of GTC seizures which does not allow recovery in between. The priority is to
stop the seizures.

Always perform a blood glucose measurement and if hypoglycaemia is present administer 1ml/kg
of 20% glucose.

Benzodiazepines are an important therapy, Lorazepam 4mg given as an intravenous bolus is the
first line therapy while a formal anticonvulsant is arranged.

41
RBH Suspected Subarachnoid Haemorrhage - EMA019
42
NICE Guideline CG020, RBH Emergency Management of adult convulsive status epilepticus EMA020

41
Levetiracetam is often the anticonvulsant started, it is well tolerated, can be uptitrated quickly,
has a minimal side effect profile and has a 1:1 conversion ratio between oral and intravenous.
Levetiracetam is dosed at 25mg/kg and infused over 15 minutes.

If an individual continues to display seizure activity or has not regained full consciousness then a
rapid sequence induction and general anaesthesia should be performed.

Epilepsy - First Fit43

There are a wide list of differentials which present with a transient altered awareness - e.g.
cardiogenic syncope, TIA, migraine, non-epileptic attack disorder, metabolic disturbances.

Patients who are deemed to be safe to be released from hospital should be referred to the First
Fit clinic.

43
RBH Management of a first seizure in adults - EMA018

42
Acute management of patients with Parkinson’s44

When converting oral medications to a topical Rotigotine patch the OPTIMAL calculator is very
useful.

Infectious diseases and HIV medicine

Malaria45

Malaria is one of the most commonly seen tropical diseases in the UK, the presenting signs and
symptoms can be relatively non-specific. A diagnosis of malaria should be considered in all
feverish adults who have visited a malaria-endemic area.

Optimum diagnostic procedure is examination of thick and thin blood films which can detect and
speciate the malarial parasites.

44
RBH Guidelines for management of patients with Parkinson’s - GL730
45
UK Malaria treatment guidelines 2016 - Journal of Infection

43
Uncomplicated P. falciparum malaria should be treated with artemisinin combination therapy
[Riamet].

Severe falciparum malaria or infections with a parasite count of more than 2% should be treated
with intravenous artesunate.

Severe or complicated malaria is a medical emergency and can precipitate acute respiratory
distress syndrome, disseminated intravascular coagulation, acute kidney injury, seizures and also
severe intercurrent bacterial infections.

Herpes zoster // shingles46

Herpes zoster is an itchy painful rash confined to one dermatomal distribution. Serious
complications can include meningitis, encephalitis and myelitis. A rash involving the tip, side or
root of the nose indicates the nasociliary nerve is involved which is a prognostic factor for
subsequent eye inflammation and permanent corneal denervation - this requires urgent
ophthalmic review and oral antivirals are indicated. Likewise, any visual symptoms or an
unexplained red eye should prompt urgent ophthalmology input.

Aciclovir has been shown to be effective in reducing severity and duration of pain, speed up
recovery and reduce the risk of post-herpetic neuralgia. Antiviral treatment is most effective if
started as soon as possible after the onset of the rash - although treatment can still be
considered u[ to 1 week after the onset of rash if there is a high risk of severe shingles in older or
immunocompromised people or those who have severe pain.

Patients with shingles should not be cared for by anyone who is or could be pregnant.

Pneumocystis jiroveci pneumonia47 [PCP]

PCP is a pneumonia which can occur in immunosuppression patients. In an individual with HIV it
would be considered an AIDS defining illness.

High dose co-trimoxazole is the drug of choice. Oral co-trimoxazole has good bioavailability and
oral route is preferred as the dose required results in a large quantity of intravenous fluid
administration.

If an individual is intolerant or allergic to co-trimoxazole then a combination of clindamycin and

primaquine can be considered after discussion with a consultant medical microbiologist.

46
NICE CKS Shingles
47
BNF Treatment summary for Pneumocystis pneumonia

44
Post-exposure prophylaxis [PEP]48

British Association for Sexual Health and HIV [BASHH] suggest that PEP is considered when
transmission risk is between 1 in 1,00 and 1 in 10,000.

The first-line regimen is Truvada and Raltegravir for 28 days. Treatment should start as soon as
possible after exposure but can be considered up to 72 hours.

Comprehensive sexually transmitted infection screening should be offered as well as at two

weeks post-exposure.

Individuals should be encouraged to attend local sexual health clinics.

Endocrinology
Diabetic ketoacidosis [DKA]49

DKA is a life-threatening condition with a mortality of around 0.5%. The main causes of mortality
in adults include severe hypokalemia, acute respiratory distress syndrome and co-morbid status
such as pneumonia, myocardial infarction and sepsis.

Diagnostic criteria:

● Blood ketones equal or greater than 3 mmol/L or significant ketones in urine indicated by
2+ on standard urine dipsticks
● Blood glucose greater than 11 or known diabetes mellitus
● Venous pH less than 7.3 and/or bicarbonate less than 15 mmol/l

A fixed rate intravenous insulin infusion [FRIII] is used to suppress ketogenesis, reduce blood
glucose and correction of electrolyte disturbance. The FRIII rate is calculated as 0.1 units/kg body
weight per hour.

If the blood glucose level drops below 14 mmol/L intravenous 10% glucose should be
administered to avoid hypoglycaemia and permit continuation of FRIII to suppress ketones. This
will often be infused in addition to the resuscitative intravenous fluid. Due to insulin inducing
shifting of serum potassium an intravenous potassium infusion will be required to maintain a
normal serum potassium level.

48
BASHH Guidelines Post-Exposure Prophylaxis following sexual exposure
49
Joint British Diabetes Societies Inpatient Care Group - Management of Diabetic Ketoacidosis in Adults

45
Individuals who are already using a long acting subcutaneous insulin [e.g. Lantus, Levemir or
Tresiba] should continue to receive their regular long acting insulin at their usual dose.

If the individual has a reduced GCS, severe acidosis or does not improve within the initial hour of
management then consider involving the ICU/Critical care team.

Intravenous access can be tricky in individuals presenting with DKA due to their hypovolaemic
state, it is not uncommon to require definitive access [PICC, midline, CVC] to facilitate the critical
intravenous infusions they require.

DKA is a prothrombotic state and VTE prophylaxis is critical.

Hyperosmolar hyperglycaemic syndrome [HHS]50

A precise definition of HHS does not exist but there are characteristic clinical features which
differentiate it from other high blood sugar states such as DKA:

● Hypovolaemia
● Blood sugar greater than 30mmol/L without ketones over 3, pH over 7.3, bicarb over 15
● Osmolality usually 320mosmol/kg or more

Mainstay of therapy is intravenous fluid replacement and we should be aiming to achieve a

positive balance of 3 - 6 litres within the 12 hours and it can take up to 72 hours to entirely
resolve biochemical abnormalities.

50
Joint British Diabetes Societies Inpatient Care Group - Management of hyperosmolar hyperglycaemic
state in adults with diabetes

46
Initial fluid replacement regimen could look like:

1. 1000ml 0.9% sodium chloride over 1 hour

2. 1000ml 0.9% sodium chloride over 2 hours
3. 1000ml 0.9% sodium chloride over 4 hours

With supplemental potassium replacement as required to ensure serum potassium remains

between 3 and 5.2 mmol/L. We should expect an initial rise in serum sodium, in isolation this is
not an indication for hypotonic solutions.

Osmolality can be calculated as 2x serum sodium + glucose + urea, this should be calculated on a
regular basis to monitor the response to therapy.

HHS is a prothrombotic condition and VTE prophylaxis is critical.

Hyponatraemia51

Hyponatraemia is classified in terms of biochemical severity, time of development and presenting

symptoms.

Biochemical - Sodium level Time Symptoms

Mild = 130-135 mmol/L Acute less than 48 hours Moderate - nausea, confusion,
headache

Moderate = 125 - 129 mmol/L Chronic documented to have Severe - Vomiting,

lasted longer than 48 hours or cardiorespiratory distress,
Profound = <125 mmol/L if the time of onset is unclear Seizures, GCS <8, abnormal
and deep somnolence

51
European Society of Endocrinology - Clinical practice guideline on diagnosis and treatment of
hyponatraemia

47
48
For patients with severe symptoms In the first hour of management, irregardless of acute vs
chronic, give 150ml of 3% hypertonic sodium chloride over 20 minutes. After 20 minutes their
sodium should be checked again and a further infusion of hypertonic sodium chloride could be
considered.

Hyercalcaemia52

A calcium level of less than 3 in an asymptomatic patient does not usually require urgent
correction.

Patients which present with abdominal pain, anorexia, vomiting, constipation, confusion, polyuria,
polydipsia, tiredness, muscle weakness, dysrhythmia, weight loss, renal failure or renal stones will
require further investigations and management.

Essential investigations include:

● Blood - renal profile, parathyroid hormone, Vit D, full blood count, ESR, albumin, adjusted
calcium, phosphate, magnesium, liver function tests and protein electrophoresis
● Chest x-ray
● ECG
● 24 hour urinary calcium

Indications for urgent treatment include:

● Serum calcium greater than 3.5mmol/L

● Drowsiness/confusion
● Hypotension
● Severe abdominal pain

52
RBH Hypercalcaemia - EMA002

49
Addisonian crisis53

Suspect adrenal insufficiency/crisis in people with known Addison’s disease or other pituitary axis
pathology, a patient presenting with low sodium and high potassium, a patient with significant
postural hypotension, a patient receiving steroids admitted with an acute illness.

The clinical presentation of adrenal insufficiency includes:

53
RBH Acute Adrenal Insufficiency/Addisonian Crisis - EMA001

50
 ● acute abdominal pain,
● weight loss,
● hyperpigmentation,
● nausea/vomiting/diarrhoea,
● hypotension,
● drowsiness/confusion
● fatigue/lethargy/coma

The immediate treatment is an intravenous bolus of Hydrocortisone 100mg. It should then be

continued with 100mg hydrocortisone every 6 hours for at least 24 hours.

The next step is to identify the underlying cause which can include infection, myocardial
infarction, trauma and this could be a first presentation of Addisons disease.

Thyrotoxic crisis54 // Thyroid storm

Thyrotoxic crisis is a clinical diagnosis supported by biochemical diagnostics. The

Burch-Wartofsky Point Scale can be used to determine the severity and guide management.

Life-threatening thyrotoxicosis is a rare disorder with mortality rates in the region of 8-25%. A
multimodal approach is recommended with:

● Betablockers such as oral Propranolol 80mg TDS

● Anti-thyroid drug such as oral Propylchiouracil 200mg TDS
● Corticosteroid therapy such as intravenous Hydrocortisone 200mg bolus

Hypothyroid crisis // Myxoedema coma

Hypothyroid crisis is a medical emergency which usually is seen in patients with known
hypothyroidism. Often these individuals will have had a break in their treatment or will be
presenting with another illness such as stroke or pneumonia.

Free thyroxine will be low or undetectable, TSH will usually be extremely high.

Clinical findings can include:

● Altered mental status - lethargy, delirium or coma

● Hypothermia
● Bradycardia and often low output cardiac failure

54
2016 American thyroid association guidelines for diagnosis and management of hyperthyroidism and
other causes of thyrotoxicosis, as endorsed by European Society of Endocrinology

51
 ● Low sodium or low glucose are common.

The standard treatment package includes:

● Intravenous levothyroxine
● Intravenous hydrocortisone
● Supportive measures such as fluids, passive rewarming, correcting electrolyte imbalances
and avoiding hypoglycaemia

Haematology
Deep vein thrombosis [DVT]55

An individual presenting with signs or symptoms of a DVT should be assessed using the DVT
Wells score. If the two-level DVT Wells score indicates a DVT is likely then a proximal leg vein
ultrasound scan should be carried out. In individuals where a DVT is unlikely a D-dimer should be
performed to assist with diagnosis.

If there will be a delay of 4 hours or greater before obtaining the ultrasound then a treatment
dose of low molecular weight heparin should be administered.

Once a diagnosis of proximal DVT has been made the next step is to decide on an anticoagulant.
In many people this will be a non-vitamin K oral anticoagulant but there are groups of people
where warfarin will be indicated and some may need to stay on low molecular weight heparin if
they will require urgent procedural interventions.

Blood products56

Red blood cells57 should be prescribed as single unit transfusions for adults who do not have
active bleeding - with follow up clinical assessment to determine if additional red blood cells are
required. For routine administration a red blood cell transfusion should usually run over 90 - 120
minutes, rapid transfusion may be appropriate in the management of major haemorrhage.

There is strong evidence recommending a haemoglobin threshold of 70 g/l in general adult

critical care population58. The British Society of Haematology have created this flowchart to assist
with arriving at an individualised transfusion threshold:

55
NICE Venous thromboembolic diseases: diagnosis, management and thrombophilia testing CG144
56
The administration of blood components: a British Society for Haematology Guideline
57
The administration of blood components: a British Society for Haematology Guideline
58
Transfusion Requirements In Critical Care (TRICC) study

52
59

Indications for irradiated blood products:

● Recipients of allogeneic haemopoeitic stem cell transplantation for the first 6 months after
conditioning chemoradiotherapy and then lifelong if they develop chronic graft vs host
disease or further immunosuppressive treatment is required.
● All adults with Hodgkin lymphoma at any stage of the disease should have irradiated
blood products for life.

Platelet transfusions are typically administered over 30-60 minutes per adult therapeutic dose
[also known as a “pool of platelets”]. Threshold values for therapeutic platelet transfusions are
determined by the Modified World Health Organization bleeding score which ranges from Grade
1 [least severe] to Grade 4 [most severe] - for example haematemesis is Grade 2, whereas
bleeding with moderate haemodynamic instability is Grade 3.

59
British Society for Haematology Guidelines on the management of anaemia and red cell transfusion in
adult critically ill patients

53
British Society for Haematology guidelines60 make the following recommendations regarding
platelet count thresholds and procedures:

● Platelets greater than 20 for an ultrasound guided CVC inserted by an experienced

clinician
● Platelets greater than 40 for a lumbar puncture

In severe bleeding we should maintain the platelet count above 50 and consider activating a
major haemorrhage protocol.

Fresh-frozen plasma [FFP] and cryoprecipitate are typically administered at 10-20ml per kilo per
hour, although it is important to remember that the time frame needs to be short enough to
ensure the transfusion is completed within 4 hours of removal from temperature-controlled
storage.

60
British Society for Haematology Guidelines for the use of platelet transfusions

54
Blood transfusion reaction61

For adults who appear to be experiencing an anaphylactic reaction to a blood product

transfusion we follow the Resuscitation Council (UK) guidelines62.

61
British Haematology Society Guideline on the investigation and management of acute transfusion
reactions
62
Resuscitation Council (UK) Anaphylaxis algorithm

55
56
Rheumatology
Septic arthritis63

Whenever an individual presents with a swollen, tender, erythematous warm joint septic arthritis
must be considered in the differential. If left untreated the joint can quickly become destroyed by
the infective process.

63
BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults

57
Temporal arteritis // Giant cell arteritis [GCA]64

Giant cell arteritis is a large vessel vasculitis which is a medical emergency and requires
immediate treatment, GCA can induce blindness or stroke.

A diagnosis of GCA can be difficult to make and should be guided by signs, symptoms and acute
phase markers65. Signs and symptoms include:

● Jaw claudication
● Diplopia
● Prominent, enlarged, tender temporal arteries

A normal ESR or an ESR less than 50 indicate that GCA is unlikely, however an elevated ESR of
above 100 does not automatically confirm the diagnosis. The gold standard investigation is a
temporal artery biopsy.

Standard initial steroid dose for GCA is in the region of 40 - 60mg oral prednisolone.

Suspected methotrexate toxicity66

Methotrexate [MTX] is used to treat a number of rheumatological conditions, it interferes with

synthesis of DNA, RNA and proteins by competitive inhibition of many enzymes reliant on folic
acid.

MTX side effect Presenting symptoms Action required

Methotrexate pneumonitis Cough, dypnoea, fever, Stop methotrexate

hypoxia, CXR consolidation,
ground glass appearances on
HRCT, Eosinophilia
Consider ICU and pulsed
methylprednisolone. If
evidence of marrow
suppression administer folinic
acid.

Marrow suppression Neutropaenia Stop methotrexate.

Thrombocytopaenia Give folinic acid
Pancytopaenia

Methotrexate hepatitis Otherwise unexplained Strop methotrexate

hepatitis Exclude other causes

Methotrexate mucositis Severe mouth ulceration Stop methotrexate

64
British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis: executive
summary
65
Does this patient have temporal arteritis? - JAMA 2002
66
RBH Suspected Methotrexate Toxicity EMA062

58
 Give folinic acid
Check platelet count
Exclude herpes and thrush

Methotrexate should always be stopped in the following situations:

● Diarrhoea and vomiting

● Any severe infection with WBC >13
● Severe viral upper respiratory tract infection
● Recent use of co-trimoxazole or phenytoin
● Acute kidney injury

If in doubt - stop methotrexate

Folinic acid rescue is mandatory in cases of severe marrow suppression and is often used in
cases of pneumonitis and hepatitis although the evidence is less certain with those indications.

Palliative care
Care planning67

It is vital that advance care planning is undertaken for all acute hospital admissions, ideally during
the initial admission process and definitely at the initial consultant review when an explicit
decision should be made.

There will be some patients for whom attempting CPR is inappropriate, for example, a patient
who is at the end stage of a terminal disease. In these circumstances CPR would not restart the
heart and breathing of the individual and there should not be attempted. A healthcare
professional has no legal duty to give a person a treatment that they judge to have no reasonable
chance of success, or to be clinically inappropriate, including CPR.

A Treatment Escalation Plan should be documented for all patients - this will indicate which
therapies are and are not appropriate. When there is ambiguity which therapies may be
appropriate then discussions with senior physicians and/or intensivists should be had.

Symptomatic relief68

Our standard package of prescriptions for symptom control at end of life is:

67
RBH Deterioration Patient and Resuscitation Policy - CG080
68
Berkshire Adult Palliative Care Guidelines - GL110

59
 ● Opioid for pain and/or breathlessness such as Morphine 2.5mg subcutaneous or oral on a
PRN basis up to every 4 hours
● Benzodiazepine for anxiety and panic such as Lorazepam 0.5mg sublingual or oral on a
PRN basis up to twice a day
● Alternatively, Haloperidol at a dose of 0.5mg subcutaneous on a PRN basis up to every 2
hours
● For nausea and/or vomiting we use Metoclopramide 10mg subcutaneous on a PRN basis
up to every 8 hours
● For respiratory secretion burden we use Hyoscine butylbromide subcutaneous on a PRN
basis up to every 4 hours.

Specific COVID-19 Palliative Care advice69

Breathlessness:

69
NHS England and NHS Improvement - Clinical guide for the management of palliative care in hospital
during the coronavirus pandemic

60
Cough:

Delirium:

61
Fever:

Psychiatry
Assessing capacity and Mental Capacity Act70

Although capacity will rarely be assessed without medical input capacity is not a medical concept
but a legal one and as such the standard of proof when capacity is in doubt is that of civil law i.e.
on the balance of probabilities.

Capacity is dynamic and may change over time and patients may be capacitous at some times
and for some choices but not at other times or for other choices. If someone was capacitous
yesterday that does not mean they are today and the opposite is also true - if someone was not
capacitous yesterday they might be today.

I work in England and therefore my knowledge of this topic reflects the law in England. I know
that the law *is* different in Scotland but I don’t know *how* it is different.

70
RCPsych Mental Capacity and the law

62
The basics:

● All adults are presumed to be capacitous.

● All adults should be encouraged and enabled to make their own decisions by being given
the help and support he or she needs to make an express a choice.
● Assessments should only be carried out where there is legitimate doubt about a patient’s
capacity and should not be carried out simply because a patient disagrees with a clinician.
● Criteria from Mental Capacity Act 2005 [MCA] are used to assess capacity but it is a
general clinical skill and should not be left for psychiatrists.
● Decisions made on behalf of people without capacity should be made in their best
interests, giving priority to achieving what they themselves would have wanted.
● Decisions made on behalf of someone else should be those which are “least restrictive of
their basic rights and freedoms”.

The test of capacity - Can the patient...

● comprehend and retain the information given to them?

● weigh in the balance information such as to make a considered decision?
● communicate that decision?

There is no time limit on retaining the information - being able to only retain the relevant
information for a short period does not prevent someone from being capacitous.

Any preceding or current diagnosis may affect a person’s capacity BUT doctors must assess
capacity with reference to the formal test of capacity. Non-co-operation with an assessment of
capacity does not mean a patient is incapacitous.

How to maximise capacity:

● Appropriate timing and location

● Treating inhibiting conditions
● Diagrams
● Educational models
● Videos and audio
● Translators and interpreters
● Adequate time

If a patient is found to not have capacity then treat in the patient’s best interests on the basis of
“necessity” - think holistically and do not limit yourself to best medical interests. If there is
someone who can be an advocate for the patient [such as someone with lasting power of

63
attorney], find them. If there is no one then consider the use of an IMCA - independent mental
capacity advocate. Most of all, document all assessment findings and rationale for decisions.

If a patient is deemed to lack capacity regarding discharge destination or timing then they may
be detained - the mechanism to do so is called a deprivation of liberty safeguard [DOLS]. A DOLS
does not allow for treatment against someone’s will, although if a patient lacks capacity regarding
treatments then the authority to give that treatment comes from the MCA

The unconscious patient:

● With unconscious patients the doctrine of necessity is used to allow emergency

treatment.
● Emergency to be interpreted conservatively - to avert immediate danger or risks.
● Treatment given must be in the patient’s best interests.
● Treatment following self-harm is covered by this.

Patients who do not wish to stay in hospital71

One of the main concerns when an individual wishes to leave hospital against medical advice is if
the individual has capacity to understand the implications and risk of coming to harm. There are
three broad categories of patients wishing to leave hospital against medical advice:

● Adult patient with capacity to make the decision to self-discharge against medical advice -
they are free to leave
● Adult patient who lacks capacity - further consideration as to whether discharge is in the
patient’s best interests is required
● Adult patient with evidence of an acute mental disorder where there is a risk of further
decline or harm to the patient or others - discussion should be had with local mental
health team and consideration for a possible Mental Health Act Assessment

It is vital to complete clear documentation of the discussions surrounding a patient wishing to

leave hospital against medical advice. Key parts to include are:

● Information provided about potential consequences

● Follow-up plans and options for reassessment if there is further decline

It is critical that the patient’s GP be informed of the hospital attendance and the mode of
discharge.

71
Medical Protection - Dealing with patients who want to self-discharge

64