Consultant-Style Bedside Case Presentation
Template for DM Critical‐Care Finals
The outline below is examiner-tested. Copy it once, then populate the blanks with any ICU patient—post-op bowel obstruction, septic shock, or (in today’s worked example) a decompensated COPD patient who has just crossed the NIV-to-invasive-ventilation threshold.
| Section | Key Content | |
|---|---|---|
| 1 | Identification / Biodata | Name, age, sex, admission number, primary surgical date |
| 2 | Chief Complaints | Symptom + duration, in patient’s own words |
| 3 | History of Present Illness | Chronology, progression, red-flag events, interventions |
| 4 | Past Medical & Surgical History | Chronic diseases, prior operations, allergies |
| 5 | Medication & Social History | Current drugs, habits, functional baseline |
| 6 | Provisional Diagnosis (Based on History Alone) | One concise sentence stating your most likely diagnosis and its pathophysiological basis, before any examination findings |
| 7 | General Examination | First-look description, device audit, hydration/perfusion |
| 8 | Detailed Vital Signs | Heart rate, blood pressure (method, MAP, trend), RR, SpO₂/FiO₂, temperature, advanced haemodynamics |
| 9 | Systemic Examination | CVS, Respiratory, Abdomen, Renal, Neurological, etc. |
| 10 | Problem List | Ordered by acuity, one line each |
| 11 | Differential Diagnoses (Post-Examination) | Ranked list, each linked to a specific supporting / refuting sign |
| 12 | Investigations | Completed results, pending tests with rationale |
| 13 | Management Plan | Problem-action pairs, targets, monitoring strategy |
| 14 | Clinical Course & Response | Trend table or graph since admission |
| 15 | Prognosis & Communication | Anticipated trajectory, family updates, consent issues |
1 Identification / Biodata
“Mr R.K., 68-year-old male, UHID 221184, admitted 9 July 2025 to Medical ICU, bed 3.”
2 Chief Complaints
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Worsening breathlessness 3 days
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Increased wheeze 2 days
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Altered sensorium 4 hours
3 History of Present Illness
| Date / Time | Event |
|---|---|
| 6 Jul | Gradual increase in cough and purulent sputum; home nebulised salbutamol–ipratropium with poor relief. |
| 8 Jul, 22:00 | Dyspnoea escalated (mMRC 4); came to ED. SpO₂ 82 % RA, RR 34. |
| 8 Jul, 23:30 | ABG: pH 7.25, PaCO₂ 78 mmHg, PaO₂ 54 mmHg on 6 L O₂. Started NIV (PS 12, PEEP 5, FiO₂ 0.4). |
| 9 Jul, 05:00 | Tachypnoea persisted, GCS 13 → 9, repetitive apnoeic spells. |
| 9 Jul, 05:30 | Intubated; volume-controlled ventilation (VT 6 mL kg⁻¹ IBW, PEEP 6, FiO₂ 0.5). |
No chest pain, haemoptysis or pedal oedema. No recent travel.
4 Past Medical & Surgical History
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COPD GOLD D (post-bronchodilator FEV₁ 38 %) – 15-pack-year smoker, quit 2018
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Type 2 diabetes, hypertension, dyslipidaemia
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No previous intubations; no thoracic surgery
5 Medication, Allergy & Social History
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Home: Aclidinium–formoterol DPI, PRN salbutamol MDI, metformin, telmisartan, rosuvastatin
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No drug allergies
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Ex-smoker, no alcohol, independent ADLs baseline
6 Provisional Diagnosis – History-Based
“Acute exacerbation of COPD with type-II (hypercapnic) respiratory failure, now failing non-invasive ventilation and requiring invasive mechanical ventilation.”
(Note: This is declared before any examination findings.)
✱ Professional Bedside Etiquette
Why here?
The history is complete and you are physically approaching the patient for examination; this is the natural point to state how you ensure courtesy, consent and cultural sensitivity before any touch.
CIVIC Mnemonic — Five Micro-Steps for Every Encounter
| Letter | Action | Example Script |
|---|---|---|
| C – Connect | Greet, use patient’s preferred name, maintain eye-level contact. | “Good morning, Mr Kumar.” (eye-level at bedside) |
| I – Introduce | State your name, role, and purpose. | “I’m Dr Mehta, the critical-care resident on duty today. I’d like to perform a routine check.” |
| V – Verify Identity & Understanding | Confirm patient ID and comprehension of current situation. | “Could you please confirm your birth date? Do you recall why the breathing tube is in place?” |
| I – Inform & Invite Consent | Describe each examination step and ask permission. | “I will listen to your chest and check your abdomen—may I proceed?” (Pause for assent or nod.) |
| C – Continue to Communicate | Narrate what you’re doing, reassure, and summarise findings in simple terms before leaving. | “You may feel the stethoscope—it’s cold. … All set, thank you. Your lungs sound clearer than yesterday.” |
Key Examiner Pearl:
Mentioning this CIVIC routine demonstrates adherence to NABH/JCI patient-rights standards and underscores your commitment to respectful, informed care—qualities evaluators look for beyond pure clinical acumen.
7 General Examination
| Aspect | Observation |
|---|---|
| Appearance & Mental State | Intubated, lightly sedated, responds to pain; RASS -2 |
| Hydration & Perfusion | Warm peripheries, capillary refill 2 s |
| Skin & Mucosae | No pallor/cyanosis; mild pedal oedema +1 |
| Lines & Devices | 8.0 mm ETT @ 22 cm incisors; VCV; R-IJ CVC day 1; Lt radial arterial line; Foley |
| 24-h Input / Output | IV 1.8 L; enteral feeds 200 mL; urine 1.2 L; NG 60 mL |
8 Vital Signs (Detailed)
8.1 Heart Rate
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Value: 116 beats min⁻¹
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Rhythm: Sinus tachycardia, occasional PVCs (telemetry)
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Volume & Character: Bounding peripheral pulse; pulse pressure 68 mmHg (wide)
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Interpretation: Tachycardia likely multifactorial—β-agonists, hypoxaemia, early sepsis screen pending
8.2 Blood Pressure
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Measurement: Invasive – Lt radial (zeroed mid-axillary)
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Current Reading: 158/90 mmHg → MAP 113 mmHg
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Trend: Stable over last 6 h (MAP 100-115) without vasopressors
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Perfusion Correlation: Urine output 0.8 mL kg⁻¹ h⁻¹; serum lactate 1.4 mmol L⁻¹
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Clinical Comment: Hypertensive relative to baseline; monitor for dynamic hyperinflation effects on preload
8.3 Respiratory
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RR (ventilator-set / spontaneous): 18 / 2 min⁻¹
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Mode & Settings: VCV; VT 420 mL (6 mL kg IBW), PEEP 6, FiO₂ 0.45, Ti 0.9 s
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Pressures: Ppeak 28, Pplat 20 cmH₂O
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Gas Exchange: ABG 30 min post-intubation – pH 7.28 | PaCO₂ 72 | PaO₂ 88 | HCO₃⁻ 33 (FiO₂ 0.45) → P/F ~ 195
8.4 Oxygen Saturation
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SpO₂ 94 % on listed ventilator settings
8.5 Temperature
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Core (bladder) 37.8 °C; diurnal curve rising 0.3 °C since midnight
(Include CVP, ScvO₂, if being monitored.)
9 Systemic Examination (Key Findings)
| System | Examination |
|---|---|
| Cardiovascular | S₁S₂ normal; no murmurs; JVP 4 cm H₂O; peripheral pulses symmetrical |
| Respiratory | Equal chest expansion; prolonged expiration; scattered wheeze; no crackles; percussion resonant; trachea midline |
| Abdomen | Soft, non-tender; liver span 12 cm; normative bowel sounds |
| Renal | Foley patent; no flank tenderness |
| Neurological | Sedated but localises pain; pupils 3 mm bilateral, brisk |
| Musculoskeletal / Skin | No pressure injuries; good cuff pressure control |
10 Problem List (with Abbreviated Plans)
| # | Problem | Immediate Action |
|---|---|---|
| 1 | Hypercapnic respiratory failure (PaCO₂ 72) | Optimise ventilation: check auto-PEEP, extend Te, consider PC-SIMV; target pH > 7.25 |
| 2 | Worsening AECOPD likely infective | Empirical IV piperacillin-tazobactam + azithromycin; send sputum & blood cultures |
| 3 | Haemodynamic stress tachycardia | Control agitation, review bronchodilator dosing, maintain euvolaemia |
| 4 | Risk of ventilator-associated dynamic hyperinflation | Flow-volume loop monitoring; bedside auto-PEEP check q4 h |
| 5 | Mild hyperthermia | Rule out pneumonia; chest radiograph ordered; antipyretics if > 38.5 °C |
(Continue with investigations, full management bundle, course, prognosis, as per sections 11-15 of the master outline.)
11 ABCDE–Oriented Management Plan
(Insert immediately after the “Problem List.” Examiners appreciate seeing your actions mapped to the universal resuscitation sequence used in every critical-care crisis.)
| Component | Immediate Objectives | Concrete Actions for This COPD Example |
|---|---|---|
| A Airway | • Ensure a patent, secure airway.• Verify tube position and protection against aspiration. | • Confirm 8.0 mm ETT at 22 cm; bilateral chest rise, capnography waveform present.• Cuff pressure 22 cm H₂O (target 20-25).• Oral care q4 h; head-of-bed 30 °. |
| B Breathing | • Optimize ventilation to correct hypercarbia without causing auto-PEEP.• Maintain adequate oxygenation (SpO₂ 92-96 %). | • VCV: VT 6 mL kg⁻¹ IBW, RR 16, PEEP 6, FiO₂ 0.45.• Check flow–time loop for air-trapping; extend Te to 0.8 s if auto-PEEP > 5 cm H₂O.• Daily readiness screen for pressure support trial. |
| C Circulation | • Maintain MAP ≥ 65 mmHg and euvolaemia.• Detect arrhythmia or dynamic hyperinflation-related hypotension early. | • Continuous invasive BP via Lt radial line; MAP trending 110-115 mmHg without vasopressor.• Balanced crystalloid at maintenance 1 mL kg⁻¹ h⁻¹; CVP trending 8-10 cm H₂O.• ECG monitoring for PVC burden; electrolytes K⁺ > 4 mmol L⁻¹, Mg²⁺ > 2 mg dL⁻¹. |
| D Disability (Neurologic / Sedation) | • Achieve target sedation (RASS -2 to -3) to synchronise ventilator while permitting periodic neurologic checks.• Prevent delirium. | • Midazolam infusion 0.05 mg kg⁻¹ h⁻¹ titrated; daily sedation pause planned at 08:00.• Analgesia: fentanyl bolus 1 µg kg⁻¹ q30 min PRN.• CAM-ICU screen each shift; early mobilisation once haemodynamically stable. |
| E Exposure / Environment | • Identify systemic or hidden pathology (skin, lines, temperature).• Implement infection prevention and pressure-area care. | • Full skin inspection: no pressure injuries, left sacrum at-risk—turn q2 h.• Core bladder temperature 37.8 °C—antipyretic plan if > 38.5 °C.• Sputum and blood cultures drawn prior to first antibiotic dose.• Stress ulcer and DVT prophylaxis active (pantoprazole 40 mg IV OD; enoxaparin 40 mg SC OD). |
Mnemonic refresher: “Airway first, then ventilate, perfuse, think brain, uncover everything.”
Including ABCDE in your oral or slide presentation reassures examiners you approach every ICU emergency systematically.
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12 Investigations — Comprehensive & Prioritised
A clear “what, why, and when” structure convinces examiners that every test you order directly informs a therapeutic decision. Divide the section into (A) Point-of-Care / Bedside and (B) Laboratory & Imaging. Quote today’s results and flag the action trigger for any pending study.
12-A Point-of-Care / Bedside Tests
| Test & Timing | Latest Result | Rationale | Action Threshold |
|---|---|---|---|
| Arterial Blood Gas (ABG) • Admission, then q2 h until stable | 30 min post-intubation: pH 7.28 / PaCO₂ 72 mmHg / PaO₂ 88 mmHg / HCO₃⁻ 33 mEq L-¹ / Lactate 1.4 mmol L-¹ (FiO₂ 0.45) | Quantifies hypercapnia, guides ventilator titration, detects lactic acidosis | pH < 7.25 or PaCO₂ ↑ > 10 mmHg → adjust RR/Te or escalate to ECMO discussion |
| Continuous End-tidal CO₂ (capnography) | 43–47 mmHg (square waveform) | Confirms ETT patency, tracks ventilation–perfusion changes | Sudden drop to ≤20 mmHg → rule out accidental extubation / PE |
| Bedside Lung Ultrasound (BLUE protocol) | Bilateral A-profile with absent B-lines; no pleural effusion | Differentiates hyperinflation from consolidation; rules out pneumothorax post-intubation | B-profile or consolidation → adjust antibiotics, consider chest CT |
| Focused Cardiac Ultrasound (FoCUS) | Good LV contractility; RV not dilated; IVC 1.8 cm, <50 % collapse | Screens for cor-pulmonale, guides fluid strategy | New RV strain → lower PEEP, evaluate for PE |
| Bladder Pressure (ACS screen) q8 h | 9 mmHg (25 mL instilled) | Vigilance for abdominal compartment in dynamic hyperinflation | ≥20 mmHg + organ dysfunction → decompress, re-evaluate ventilation |
| Glucose (capillary) hourly while on insulin drip | 148 mg dL-¹ | Prevents hypo-/hyper-glycaemic neuroimpact | <110 or >180 mg dL-¹ → titrate insulin |
12-B Laboratory, Microbiology & Imaging
| Domain | Test | Result (Date/Time) | Significance for This Patient | Next Step* |
|---|---|---|---|---|
| Haematology | CBC | Hb 12.8 g dL-¹, WBC 14 × 10⁹ L-¹ (78 % N), Plt 260 × 10⁹ L-¹ (09 Jul 07:00) | Leucocytosis supports infective AECOPD | If WBC > 18 × 10⁹ → broaden sepsis work-up |
| Coagulation | PT 14.2 s / INR 1.18; aPTT 31 s | Baseline before LMWH | INR > 1.5 → delay tracheostomy, correct | |
| Biochemistry | Urea 36 mg dL-¹; Cr 1.0 mg dL-¹; Na 138, K 4.1, Mg 1.9 mg dL-¹ (q12 h) | Guides fluid, electrolyte & arrhythmia risk | K < 4.0 or Mg < 2.0 → replace | |
| Inflammatory Markers | CRP 68 mg L-¹; PCT 0.42 ng mL-¹ | Trend with therapy; moderate rise consistent with bacterial trigger | CRP ↑ or PCT > 0.5 → re-cultures, imaging | |
| Microbiology | Endotracheal aspirate Gram stain – G- bacilli; Culture pending (sent 09 Jul 05:40) | Etiology & de-escalation | Culture ⬆ > 48 h – re-assess empiric cover | |
| Blood cultures × 2 sets | No growth at 24 h | Rule out bacteraemia | Positive → adjust antibiotics per antibiogram | |
| Urine culture | Awaiting | Screen catheter UTI | — | |
| Radiology | Portable CXR (09 Jul 07:30) | Hyperinflated fields, no infiltrate, ETT 3 cm above carina | Placement confirmation, baseline lung status | New infiltrate → consider VAP, CT chest |
| Chest CT (planned if P/F < 150 or new lung signs) | — | Identify pneumonic changes, barotrauma | Trigger CT if P/F falls below threshold | |
| Others | Sputum AFB / GeneXpert if risk factors | — | Exclude TB in chronic COPD | — |
*“Next Step” means the pre-agreed action or threshold that will prompt escalation, ensuring every investigation has a management link.
Key Principles to Voice During the Exam
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Every test must alter management. Quote the exact decision node (e.g., “If PaCO₂ remains > 80 mmHg despite maximal settings, I will discuss ECCO₂R with the team.”).
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Trend over time > single value. Show you follow kinetics of CRP, lactate, and ABGs, not isolated results.
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Link to organ-support strategy. E.g., FoCUS findings dictate fluid vs vasodilator approach; lung ultrasound tailors PEEP.
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Mention stewardship. State that microbiology results will be reviewed at 48 h for antibiotic de-escalation.
Presenting investigations in this disciplined, reason-for-every-request manner tells the board you practise resource-efficient, evidence-based critical care.
13 Management Plan — Structured in ABCDE Format
(Problem → Action → Target)
| Component | Immediate Actions | Monitoring & Adjustment | End-Point Target |
|---|---|---|---|
| A Airway | • Confirm 8.0 mm ETT @ 22 cm, cuff 20–25 cm H₂O.• Oral suction q2 h; 30° head-up. | Capnography waveform; oral cavity inspection. | Secure, patent airway without micro-aspiration. |
| B Breathing | • VCV: VT 6 mL kg⁻¹ IBW, RR 16, PEEP 6, FiO₂ 0.45.• Passive elongation of expiratory time (Ti 0.9 s) to minimise auto-PEEP.• Bronchodilators: salbutamol 2.5 mg + ipratropium 0.5 mg via MDI–spacer q4 h; IV methyl-prednisolone 40 mg q12 h. | • ABG q2–4 h.• Auto-PEEP manoeuvre q6 h.• Lung US daily for B-lines/consolidation. | pH ≥ 7.32 and PaCO₂ ≤ 60 mmHg; SpO₂ 92–96 % on FiO₂ ≤ 0.4; absence of auto-PEEP > 5 cm H₂O. |
| C Circulation | • Maintain euvolaemia: balanced crystalloid 1 mL kg⁻¹ h⁻¹ guided by FoCUS (IVC & LV filling).• No vasopressor at present; start noradrenaline if MAP < 65 mmHg after fluid optimisation.• Correct lytes: K⁺>4, Mg²⁺>2. | IBP trace + hourly urine; daily Lactate; FoCUS if MAP trend drops. | MAP ≥ 65 mmHg, UO ≥ 0.5 mL kg⁻¹ h⁻¹, Lactate < 2 mmol L⁻¹. |
| D Disability / Drugs | • Sedation: Midazolam 0.05 mg kg⁻¹ h⁻¹ (RASS -2).• Analgesia: Fentanyl 25 µg h⁻¹ ± PRN bolus.• Avoid excessive β-agonist and theophylline that can worsen tachycardia. | RASS each shift; daily sedation hold; CAM-ICU screen; blood glucose hourly (insulin infusion). | RASS -2 to -1; pain NRS < 3; glucose 140-180 mg dL⁻¹. |
| E Exposure / Everything Else | • Empiric antibiotics: Piperacillin-tazobactam 4.5 g q6 h + Azithromycin 500 mg OD pending cultures.• DVT: Enoxaparin 40 mg SC OD.• GI: Pantoprazole 40 mg IV OD.• Skin: turn q2 h; pressure mapping.• Nutrition: start trophic EN 20 mL h⁻¹, advance to 25 kcal kg⁻¹ d⁻¹.• Physiotherapy: passive ROM ×2/day. | Culture report at 48 h for de-escalation; calorie count daily; skin audit every shift. | Negative cultures or narrowed cover; no pressure injuries; caloric goal reached within 72 h. |
14 Clinical Course and Response (first 24 h snapshot)
| Time | Intervention / Event | Objective Data | Observed Response |
|---|---|---|---|
| 05 : 30 | Intubation, VCV initiated | Pre-ETT ABG: pH 7.21 / PaCO₂ 82 / PaO₂ 68 | SpO₂ rose to 96 %; HR fell from 126 to 116 bpm |
| 06 : 00 | Post-ETT ABG | pH 7.28, PaCO₂ 72, PaO₂ 88 (FiO₂ 0.45) | CO₂ trending ↓ 10 mmHg; pH improving |
| 06 : 30 | First antibiotic dose (TZP + AZ) | WBC 14 × 10⁹ L⁻¹, CRP 68 mg L⁻¹ | Sepsis bundle < 1 h; temp plateaued 37.8 °C |
| 07 : 30 | Baseline CXR | Hyperinflated lungs, ETT tip 3 cm above carina | Tube position confirmed; no consolidation |
| 10 : 00 | Auto-PEEP check | 4 cm H₂O | Acceptable; no ventilator changes |
| 12 : 00 | ABG trend | pH 7.30, PaCO₂ 68, PaO₂ 92 (FiO₂ 0.40) | Met target FiO₂ down-step; P/F ≈ 230 |
| 14 : 00 | Family meeting (SPIKES) | Daughter informed; documented. | Anxiety reduced; agreed plan-of-care |
| 15 : 00 | Readiness-for-weaning screen | Criteria not met—PaCO₂ still > 65 | Continue full support; reassess next morning |
Key Trajectory: Gradual CO₂ clearance (-14 mmHg in 9 h), FiO₂ down-titrated, haemodynamics stable without vasopressors.
15 Prognosis & Communication
15-A Prognosis
| Factor | Current Status | Implication |
|---|---|---|
| APACHE II | 20 | Predicted ICU mortality ≈ 25 % |
| COPD baseline | GOLD D, FEV₁ 38 % | High 1-yr exacerbation risk |
| Ventilator progress | PaCO₂ falling; no dynamic hyperinflation | Likely extubatable within 48–72 h if trend continues |
| Comorbidities | DM, HTN—controlled | Do not worsen short-term outlook |
| Anticipated complications | VAP, barotrauma, critical-illness myopathy | Preventive bundles in place |
15-B Family Meeting Conducted with SPIKES Protocol
| Step | Execution |
|---|---|
| S – Setting | Quiet counselling room; consultant + bedside nurse present; mobile phones silenced. |
| P – Perception | Asked: “Can you share what you understand about your father’s breathing problem?” Daughter believed ventilation worsened his lungs. |
| I – Invitation | Confirmed she wanted full medical detail, delivered slowly. |
| K – Knowledge | Warned of seriousness, then explained: “COPD lungs couldn’t clear CO₂; the ventilator is supporting him while antibiotics treat the infection.” Used simple language, no jargon. |
| E – Emotions/Empathy | Daughter tearful, angry at machine. Response: “I can see how frightening this feels. It’s normal to look for reasons. Be assured the tube is life-support, not a cause of harm.” Allowed silence; offered tissue. |
| S – Strategy & Summary | • Outlined next 48-h goals: trend CO₂, daily weaning screen, infection control.• Promised structured updates at 09 h and 18 h; direct nurse line 24 h.• Documented full-code status; daughter verbalised understanding and agreement. |
Documentation:
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Time 14 : 00; attendees; emotional cues; questions answered; agreed plan.
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Note filed in EMR and flagged for multidisciplinary review.
Planned Follow-Up:
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Next formal meeting in 48 h or sooner if clinical status changes.
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Social worker referral offered for emotional support.
Bottom Line for the Examiner
A management plan rooted in ABCDE, a data-driven daily course chart, and a structured SPIKES conversation together demonstrate (1) organised resuscitation thinking, (2) continuous outcome evaluation, and (3) empathetic, protocol-based communication—exactly what modern critical-care practice demands.
The same skeleton works for any ICU case; only the content changes. Populate the headings methodically, pair every problem with an action, and quote current numbers with confidence.
Present like this and you speak the language consultants respect—and examiners reward.
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