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CALLED.TO.SEE.PATIENT v1.1
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By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
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Table of contents Page
Prologue 3
General Advice 5
General Medicine 11
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Cardiology 20
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Respiratory Medicine 35
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Neurology 41
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Renal/Electrolytes 45
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Gastroenterology 63
Endocrinology
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Geriatric Medicine 75
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Palliative Medicine 81
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Haematology/Oncology 88
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Miscellaneous 93
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KTPH 95
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By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
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This book is dedicated to:
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Foreword
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It gives me great pleasure as the program director of the
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NHG-AHPL Internal Medicine Residency Program, to write
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the foreword for this booklet entitled Called To See Patient
(CTSP), which embodies the work and tremendous effort of
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the pioneer batch of our Internal Medicine residents.
wished then, that there was a manual that will provide tips to
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survive the call and the day, and also guidance for the
management of acute conditions.
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By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
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progresses in future years. I would like to commend the
residents on the great effort and thoughts which went into the
writing of this booklet. I would also like to thank the Internal
Medicine faculty from Tan Tock Seng Hospital, Khoo Teck
Puat Hospital and National Neuroscience Institute for their
unfailing guidance and support.
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Dr. Koh Nien Yue
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Program Director
NHG-AHPL Internal Medicine Residency Program
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Disclaimer
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This booklet serves as a brief general guide to the
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management of acute conditions commonly encountered in
the ward. It is not meant to be exhaustive and the reader i
should use the standard reference text for further reading.
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Every patient and situation may differ; hence the information
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By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
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General Advice On Call
PRE-CALL:
- Get enough SLEEP the night before. Extremely impt
- Psych up! Easier said than done though; pre-call
depression has been known to afflict hapless HOs up to 1
WEEK before the call itself. Think about the wonderful
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sleep youll get post-call (if you get to go post-call)
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- Confirm which level youre covering, get the numbers of
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your MOs and contact them early to ask them how they
want to work (e.g. SMS or call? Contact them for new
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cases or clerk first?)
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- Get your call room early and changed
- HAVE AN EARLY DINNER. Best time to eat is around 5 to
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6pm when most primary teams are still around and the
calls dont really start flooding in yet
- Get HANDOVERS from your friends. Impt things to note i ne
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down: DIL patients, bloods/ECGs/blue letters etc to trace
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- Scout the wards for empty beds. Can also look at BMU bed
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ON-CALL:
- Got time sleep, got food eat, got water drink.
- Learn to PRIORITISE. You may be overwhelmed by the
sheer amount of work esp during the first few calls, but if
you sieve out whats impt and deal with those first, things
become much more manageable.
- In rough order of priority:
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1. Patient COLLAPSE
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2. Urgent passives/patient complaints
3. New cases (generally try to see before your MO)
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4. Tracing labs/investigations and acting on them
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5. Time sensitive bloods (e.g. cardiac enzymes)
6. Procedures (IDCs, plugs). More urgent if: ARU x long
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time with high RU/PVRU, plugs for dopamine etc
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7. Non-urgent passives (cough syrup, sleeping pills,
change med order in eIMR, etc.) i
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8. Updating/speaking with relatives
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for scopes)
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- When giving meds/ordering investigations/taking blood:
Check its the correct patient!! Always check sticky label +
order form
- Taking GXMs: Sign BOTH the sticky label and order form.
Indicate on sticky label date and time the blood was taken
- Learn how to dispatch your own bloods using the tube
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system
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- Dont dismiss complaints like headache and giddiness.
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Always check BP and neurology (dont miss ICH!!)
- Simple investigations like CBG, SpO2, ECGs can be
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performed quickly and potentially yield impt information wrt
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patient complaints.
- Try to trace all labs/ECGs youre asked to review
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document in case notes as appropriate
- CVM actives are taken care of by MOs but you should help
out with taking blds for the new patients. If you need help
with CVM passives should call the CVM MO.
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
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Always carry a few add-test form and KY gel with you
Useful to carry green (heparin) for BOHB, toxicology, and
grey (floride) tubes for lactate with you not all wards
stock and may need for acute emergencies
Carry coins with you for a quick coffee/coke break at the
vending machines
Save phone numbers into your work phone as you work
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it makes future work easier because you do not have to
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call 0 (for operator) and wait
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Accompanying DIL patients down for scans/procedures
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know at least what the resus status is and ensure
appropriate equipment is available (e.g. drugs, fluids,
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working IV plug available) if for active and unstable may
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want to carry defibrillator for continuous ECG monitoring,
ensure O2 tank has enough O2 to last the journey. Help to
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push the heavy beds (the Ah-Mahs and nurses will
appreciate it)
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2. Diet
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Fluids N/S, D/S, premix etc etc.
NBM, feeds, soft diet, full diet
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Type/therapeutic (Dieticians realm): e.g. low salt, low fat,
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DM, non-milk, low purine, renal, high protein
Consistency (STs realm)
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o Solids: easy chew, soft moist, blended
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o Fluids: thin, nectar, honey, pudding, NGT
o NGT feeding usually over 6-8 shares (e.g. 200ml x 6 i
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+ 50ml H2O flushes)
Types: Ensure, glucerna, nephro etc.
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POST-CALL:
- HAND-BACK sick patients you encountered overnight esp
those that should be seen by the primary team early in the
AM round
- Also be sure to HAND-BACK any significantly abnormal
lab/imaging results, esp if asked to trace them overnight
- Try to grab a quick breakfast before AM rounds start
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- Post-call (ie leave by 1pm or so) privilege has now become
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more common for HOs unlike in the good (bad) old days.
Responsibility must however be borne when exercising this
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privilege. Be sure to finish up ALL your morning round
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changes and handover appropriately before you saunter off
home.
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- It can be of tremendous learning value to re-visit some of
your interesting admissions/passives over the next few
days when time is available. Diagnoses may change, signsi ne
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may develop, cases will evolve. You may even end up
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General Medicine
A. SEPSIS/SPIKE FEVER
CTSP: new case sepsis, or inpt spike fever
Definition: True fever is > 38 C
Low Grade fever: query significance (exception: elderly,
immunosuppressed, dialysis pts, persistent >37.2 (E) or
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37.5 (R) may be significant); Non-infectious fever: drugs,
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RAI dz, tumour, DVT/PE, CNS insult etc
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Approach: Differentiate isolated fever (have time) from sepsis
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(urgent) and severe sepsis/shock (emergency)
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SIRS: At least 2 of : T>38.5C or <35.0C; HR >90; RR
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>20 or PaCO2 of <32; WBC >12K or <4K or >10% bands
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Sepsis = SIRS + proven OR suspected infection (Non-
septic sirs = burn, pancreatitis, large PE etc) i
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Severe Sepsis = Sepsis + organ dysfxn (mottled skin, low
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Find Source:
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(Cdiff, GE), Joint (Septic jt), Abd (peritonitis / perf gut), HBS
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device
Travel/contact/exposure hx
Recent antibiotics & treatment by e.g. GP
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If existing inpt case reason for adm, last septic w/u,
current Abx regime, old culture data, standing orders from
primary team, r/o fever vs sepsis (see above)
o If pt well (fever but not septic) and w/u done within 4
days, usu no need to repeat septic w/u. May repeat
blood cx x2 if T>38 and still no diagnosis. Also no need
to escalate Abx on night call can wait for primary
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team to decide CM
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o If patient has new/worsening sepsis, repeat w/u (unless
done within 24-48 hours), escalate abx
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Rule of thumb: can never be too many blood cultures done if
source / diagnosis not confirmed.
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PE
Vitals, GCS, SpO2; Ensure pt not in shock (check tissue i
and organ perfusion)
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Look for source: front, back, cavity (oral / PR), plug
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stool for ova/cyst/parasite if(+)travel hx. KIV CDiff in all
(prior abx or not).
- Wound swabs never helpful (actually harmful b/c
confusing). Should ONLY swab if pus seen from draining
sinus. All others: do not swab (await deep biopsy by GS /
IR).
- Line sepsis draw bld from line AND periphery. If
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differential time to positivity >120 min (line 1 , then periph)
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highly suspect line source. If unstable remove line send
tip for c/s, do periph c/s x2.
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Mx
- KIV Isolate: Airborne (TB, measles, chickenpox, unknown
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severe resp. illness), droplet (influenza, mumps, rubella,
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meningococcal meningitis until 24 hrs abx), contact
- REFER ARUS-C for empirical antibiotic guidelines i
- Remember to adjust Abx for renal function
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Aspiration: IV / PO Augmentin
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IF UTI pt unstable, suspect pyelonephritis,
perinephric/prostate abscess etc; start IV cefazolin plus
gentax1, do imaging (US, CT)
Line sepsis (e.g permanent catheter), prosthetic septic
joint: IV vancomycin
Cellulitis, native septic joint: IV cefazolin
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B. GIDDINESS/SYNCOPE
Rule out hypoglycaemia and uncontrolled hypertension
Determine if there was syncope/LOC or not
Syncope:
- Rule out seizures (need not be GTC; can be atonic
seizure)
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o preictal (aura/palpitations/pallor), ictal (GTC, loss of
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continence, biting of tongue, veering of eyes) and post-
ictal (drowsiness, Todds paralysis)
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- True syncope - transient LOC of few seconds with
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spontaneous recovery
- Ensure no HI, contusion, # (if fragility # over typical sites
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eg. radius, hip, VB, ?coexistence of osteoporosis); then
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consider the following causes:
o CVS: Arrhythmias or LVOTO eg. AS/HOCM i
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o Neuro: CVA/TIA
o Postural hypotension: dehydration, blood loss, BP
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o Vasovagal
o Situational e.g. cough, pain, micturition (e.g.
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Giddiness:
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o Dysequilibrium: Parkinsons disease, cervical
myelopathy, peripheral neuropathy
o Presyncope (approach as per syncope)
o Non-specific giddiness eg. from hyponatremia/
psychiatric causes (e.g. anxiety)
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Dix-Hallpike maeuveur and otoscopy for vertigo
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Orders
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Fall precaution
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Postural BP monitoring
FBC, UECr (depending on Na/K KIV 8am cortisol), cardiac
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enzymes, CBG monitoring
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ECG
X-rays of areas suspected #s +/- BMD i
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KIV CT head, MRI/MRA
Treatment depends on cause - KIV ENT referral for
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C. DELIRIUM
Aka AMS, CTSP re: pt confused, behaviourial change
Confusion Assessment Method (CAM)
Acute onset and fluctuating course AND
Inattention AND
Disorganised thinking OR
Altered level of consciousness
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Causes
Medications (e.g Antidepressants, pain meds,
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anticholinergics. Anti-parkinsonism)Exercise caution when
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prescribing COUGH MIXTURES, PAIN MEDICATIONS,
SLEEPING PILLS
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Metabolic ( hypo/hyperglycemia, thyroid conditions,
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electrolytes
Infx (sepsis, pneumonia, meningitis)
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CVA/ICH
Acute coronary syndromes
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ARU/Constipation
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Pain (Be cautious with pain meds, if need for opoids, KIV
low dose e.g. PO tramadol 25mg BD PRN and titrate)
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confused (e.g. climbing and falling out of bed
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Note: May get calls for the elderly being unable to sleep,
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requesting for sleeping pills or coughing elderly requesting for
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cough mixture
Advise on S/E e.g. AMS, ARU (piriton)
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Encourage sleep hygiene
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KIV substitutes (e.g. fluimucil instead of cough syrup)
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D. COLLAPSE/MEGACODE RESUS
i.e. patient found unresponsive, pulseless, no BP
See patient IMMEDIATELY, contact MO/Reg ASAP
Find out if patient has any resus status if none = DIL-
active until proven otherwise
Usually there will be chaos (Try to) stay calm and
assume the leadership position until someone more senior
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arrives. Listen to the senior nurses they have more
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experience than you. After which, be vigilant, listen to
instructions and help out wherever appropriate (i.e. dont
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switch off)
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Start BCLS Start CPR, get E-trolley
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Attach ECG leads (not 12-lead) watch for cardiac rhythm
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on defibrillator and shock PRN i.e. ACLS
Start bag-valve-mask with 100% O2 i
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Ask for stat CBG
Set 2 large bore IV lines +/- draw all 4 tubes/ABG
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medications given
+/- help to update family
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Cardiology
A. CHEST PAIN
Ask over the phone vitals, how bad is the pain? SoB?
Sweaty? 12-lead ECG, BP on both arms, O2 if hypoxic, serve
GTN if PRN order available
Life-threatening causes
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Cardiac: ACS AMI/NSTEMI/UA, aortic dissection
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Respi: PE, tension pneumothorax
GI: perf viscus (e.g. perf peptic ulcer, esophagus)
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Eyeball the patient
Read through the case-notes quickly (e.g. look for risk factors
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for IHD) and look at the ECG
abdomen, calves/LL
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ABG (if unstable, desat or respiratory distress)
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B. ACUTE CORONARY SYNDROMES
CTSP re: chest pain/SoB, trace ECG, trace CEs
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Assess and stablise ABCs
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Supplemental O2 if pt hypoxic, keep SpO2 >95%
Focussed hx and PE: Assess for left heart failure,
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hemodynamic compromise, baseline neurologic function
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(to watch signs of ICH later)
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FBC, UECr, PT/PTT/INR, cardiac enzymes, GXM
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S/L GTN 0.5mg up to x 3
PO aspirin 300mg STAT + 100mg OM (if no i
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contraindications e.g. recent major GI bleed, ICH)
Beta-blockers e.g. bisoprolol 1.25-2.5mg, atenolol 25mg
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reactive airway dz
IV morphine 2-4mg slow Q5-15mins
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90mins)
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C. ACUTE DECOMPENSATED HEART FAILURE
CTSP re: SoB, new case: fluid overload
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causes of symptoms ARDS (e.g. pneumonia),
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neurogenic (e.g. CVA)
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Identify ppt factors
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Cardiac: ACS, arrhythmias (e.g. AF), progression of CCF
Non-cardiac: severe hypertension, renal impairment,
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anaemia, hypo/hyperthyroidism, fluid/diet indiscretion, non-
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compliance, iatrogenic (e.g. fluid resus, bld transfusion)
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ECG e.g. T wave inversions, LVH, Q waves
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CXR
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Rx
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ABCs
Supplemental O2 as required if hypoxic keep SpO2 >92-
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D. HYPERTENSION
CTSP re: BP >180/120
Differentiate HTN urgency (w/o end organ damage) vs
HTN emergency (w/ end organ damage)
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CVS: AMI/APO/Aortic dissection
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Renal: AKI
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Quick assessment
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Symptoms e.g. chest pain, blurring of vision, headache,
nausea/vomiting, confusion
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Signs - Assess ABCs, vitals and recheck manual BP (on
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both limbs), review BP trend, GCS, neuro exam, JVP,
lungs for creps, pedal edema, peripheral pulses, i
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fundoscopy for papilloedema
ECG, blds (e.g. UECr, cardiac enzymes) +/- CT brain, CT
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aortogram
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complications
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E. HYPOTENSION
CTSP re: BP low
Exclude SHOCK i.e. end organ damage from any cause
(commonly hypovolemic, septic, cardiogenic; also
obstructive, anaphylactic, neurogenic)
Ask other vital signs, GCS, usual BP trend, resus status
over the phone
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Order a fast drip i.e. 500ml over 15-30mins over the
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phone and see the pt ASAP/early
Look through case notes looking particular for hx of CCF,
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ESRF (i.e. risk factors for fluid overload)
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If pt unstable or doesnt respond to fluid challenge, inform
senior
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Evaluation Hx (chest pain, SoB), PE (include assess fluid
status, DRE) i
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Ix (as indicated)
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ECG + CEs
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Mx
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Hrly para+SpO2
Strict I/O (insert IDC or at least urosheath)
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F. TACHYCARDIA
CTSP re: HR >100-120
Ask for other vitals, ABCs, GCS, usual trend of HR
If unstable, see immediately + ask for E-trolley/defibrillator +
inform senior
If pt stable, see pt soon + ask for ECG
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Assess for underlying cause, common causes:
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Fever, pain
Hypovolemia/shock from various causes (e.g. sepsis),
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anaemia
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Cardiac e.g. Fast AF, atrial flutter, SVT, VT/VF may be
ppt by cardiac or non-cardiac causes
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Pulmonary embolism
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Hyperthyroidism, hypoglycemia, electrolyte abnormalities
Drugs (e.g. caffeine, salbutamol nebs, smoking) i
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Anxiety/Panic attack
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Mx of fast AF
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Can be either too fast (e.g. multiple PVCs, fast AF) or too
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slow (e.g. sinus pause, sinus bradycardia, heart blocks)
Check pts vitals, GCS and for any symptoms, ask for a 12
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lead ECG
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If unstable or symptomatic inform senior
If stable
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o Read through case notes to find out WHY pt is on
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telemetry (e.g. recent NSTEMI, severe hypokalemia)
o Look for ischemia on 12-lead ECG (may be missed on i
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telemetry)
o Continue Mx - e.g. correct electrolytes
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G. DVT/PE
Hx Unilateral LL swelling, pain, tenderness, erythema
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Bedridden for >3 days or major surgery within past 1
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4 weeks
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Localized tenderness in deep vein system 1
Swelling of entire leg 1
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Calf swelling >3cm other LL measured 10cm below 1
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tibial tuberosity
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Pitting edema greater in symptomatic leg 1
Collateral non-varicose superficial veins 1
Active Ca or Ca treated within 6 months
Alternative diagnosis more likely (e.g. cellulitis,
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Bakers cyst)
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FBC, PT/PTT/INR, D-dimer (to rule out if pt is low risk on
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Wells score)
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Mx
S/C clexane 1mg/kg BD (! Bleeding, low Hb)
Prevention! TED stockings etc.
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KIV IVC filter if not candidate for clexane (low Hb, high fall
risk etc, but will not relief local symptoms)
Hx/PE
High index of suspicion SoB, tachycardia, chest pain,
DVT symptoms, relatively clear lungs
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Wells Score for PE
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Findings Points
Symptoms of DVT 3
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No alternative dx that better explains dz 3
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Tachycardia >100 1.5
Immobilization 3 days or surgery in prev 4 weeks 1.5
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Prev hx of DVT/PE 1.5
Presence of hemoptysis
Presence of Ca i ne 1
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*Probability: 7pts high; 2-6 mod; 1 low
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ECG + CE
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Mx
If unstable Inform senior, ABCs, transfer pt to HD/ICU,
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H. ACLS protocols
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Respiratory Medicine
A. SHORTNESS OF BREATH/DESATURATION
CTSP pt c/o SoB, pt desaturated on VM50%
Generally should see ASAP
Over the phone - vitals (SpO2 especially!!), patients
general condition, any other concurrent symptoms
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Important (life-threatening) causes:
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Cardiac: AMI, APO, ADHF/CCF, arrhythmias, tamponade
Pulmonary: Pneumothorax, PE, Pneumonia (maybe
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aspiration??), COPD/asthma attack, pleural effusion
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GI: BGIT, ascites
Symptomatic anemia, shock (e.g. hypovolemic)
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Metabolic: Acidosis (e.g. DKA), Poisons (e.g. salicylates),
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thyrotoxicosis
Others: anaphylaxis w/ bronchospasm, GBS, myasthenia
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More benign causes (but still must be addressed):
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ARU, constipation??
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Hx
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PE
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CXR
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Supplemental O2 (95%, 90-92% in COPD pts)
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Supplemental O2 devices and est. FiO2
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INO2 up to ~40% - max 4-6L
VM - 24-50%
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Non-rebreather mask (NRM) 60% (2 valve leaflets are
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taken off), 80%, 100%
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Treat underlying cause (i.e. SpO2 100% on 100% NRM
means nothing if the underlying cause is not addressed) -
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e.g. fluid resus, lasix for APO (Note: Giving nebs to pt with
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ratio.
o PaO2/FiO2 < 300: acute lung injury
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B. ACUTE EXACERBATION OF COPD
CTSP new case, SoB in existing cases
Acute exacerbation = acute increase in symptoms beyond
normal day-to-day variation (cough frequency and severity,
sputum volume and character/purulence, SoB)
Ppt factors: infection viral (1/3 to 2/3 of cases), bacterial
(1/3 to of cases), environmental factors, non-compliance
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to meds, unknown
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Consider other causes of SoB e.g. PE, pneumonia,
pulmonary edema/CCF, asthma, bronchiectasis, PTX
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Other points LTOT at home? Prev intubations/ICU adm,
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social Hx
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Staging on lung function test: FEV1/FVC<0.7 AND
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Stage 1 FEV1 >80% predicted
Stage 2 FEV1 50-80% predicted i
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Stage 3 FEV1 30-50% predicted
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Rx
O2 aim SpO2 >92% (For pts with chronic T2RF with or
without LTOT SpO2 >88% may suffice), PAO2 >60mmhg
w/ Venturi mask (more precise control of FiO2) or INO2
(more comfortable)
FiO2 by INO2 = 21 + Ax4 (where A=No. of L of O2)
(Very rough estimate - dependent on RR of patient)
y c
Nebs salbutamol:ipratropium:N/S (1:2:1) stat and Q4-6H.
en
Up to 2 stat nebs can be given to break bronchospasm.
PO prednisolone 30mg 1/52 or IV hydrocortisone 100mg
id
6hrly (if unable to tolerate orally)
es
Mucolytics (e.g. fluimicil) no evidence but can be given
for symptom control
R
Antibiotics (e.g. augmentin/klacid) if increase sputum
ne
purulence + SOB or increase sputum volume
KIV NPPV (e.g. pH <7.33, pCO2 >50 and patients i
ic
clinically worsen eg increasing drowsiness despite Mx) or
intubation if severe (inform senior if patient unwell or does
ed
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
38
C. ACUTE EXACERBATION OF ASTHMA
CTSP new case, SoB in existing cases
Assess severity of attack - !!ALERT using accessory
muscles, speak in words/short phrases, inability to lie
down, profound diaphoresis, AMS, failure to improve w/
initial Mx, cyanosis, rising pCO2
Exclude ddx of SoB e.g PTX, pneumonia, CCF/APO
y c
en
Asthma control test: In past 4 weeks
Points
id
1 2 3 4 5
es
1. How often asthma limited activity at work or home
All the Most of Some of A little of None of
R
time the time the time the time the time
2. How often SoB
>1x/day 1x/day 3-6x/wk 1-2x/wk None i ne
ic
3. Wake up at night or earlier than usual
ed
controlled what e
te
Ix
N
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
39
Peak flow (seldom used as pt not always able to cooperate
drop of 20% from normal/personal best =exacerbation,
drop of >50% = severe exacerbation)
Rx
O2 keep O2 >92-95%
Nebs salbutamol: N/S (1:3 stat and every 4 to 6Hly
y c
depending on severity. Up to 3 stat nebs can be given to
en
break bronchospasm if no contraindications. Beware of
higher freq of nebs in the elderly).
id
+/- add ipratropium nebs (i.e. 1:2:1)
es
PO prednisolone 30mg OM or IV hydrocortisone 100mg
6Hly (if unable to tolerate orally)
R
Reassess pt frequently PRN to monitor response
ne
KIV IV MgSO4 2g over 20mins
KIV intubation if severe (inform senior if patient unwell or
i
ic
does not respond to initial Mx)
ed
M
al
rn
te
In
G
H
N
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
40
Neurology
A. CEREBROVASCULAR ACCIDENT (CVA)
CTSP: critical abnormal CT/MRI head result, acute
neurovascular syndrome
Ascertain time of onset: within 4.5 hours of onset, inform
NL stat as pt may be for IV thrombolysis (<6hours can offer
y
IA thrombolysis, <8hours consider MERCI/TREVO) barring
c
contraindications
en
Determine handedness
Examine patient for focal neurology congruent to site of
id
CVA, AFib /mitral stenosis /prosthetic heart valves /CCF
es
stigmata of IE (all of which may suggest cardioembolic
source), carotid bruit
R
ne
Orders
Hrly paras, CLC monitoring, call Dr if GCS drop >2 (see i
ic
below), NBM + IV NS 2L/day unless CCF/renal impairment
(risk of asp), IN O2 if SaO2<90%
ed
2DEcho CM
H
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
41
If hemorrhagic CVA: Keep SBP ~140-150mmHg with PO
amlodipine, consult senior for NSD intervention
If ischaemia CVA: if no BGIT, history of active PUD or low
Hb/plts, load with PO aspirin 300mg stat and subsequently
100mg OM; otherwise, start PO clopidogrel 75mg OM,
(some given PO simvastatin/atorvastatin 80mg stat); omit
BP meds and allow permissive hypertension unless SBP
y c
>220mmHg/DBP >120mmHg or hypertensive
en
encephalopathy/crisis
id
Fall in GCS or deterioration in neurological status consider:
es
hypoglycemia, electrolyte imbalance, infection (UTI,
aspiration pneumonitis), hypotension, arrhythmia, AMI,
R
hyperviscosity syndrome and complications of CVA
ne
(cerebral edema, hemorrhagic conversion, new CVA,
progression of thrombosis, post- ictal state, obstructive
i
hydrocephalus). Consider decompression craniectomy if
ic
<48 hours from onset for malignant MCA infarction.
ed
M
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
42
B. SEIZURES
CTSP pt having seizures - ?active or aborted
y c
(give IM/IV 2.5mg diazepam for GRM pts due to low volume
en
of distribution and lower hepatic metabolism)
id
Document seizure type (generalized/partial;
es
complex/simple), duration and number of seizures, aborted
spontaneously or by BZDs/AEDs
R
ne
Causes
Known epileptic: non-compliance, intercurrent illness, sleep
i
deprivation, recent change in meds, drug interactions
ic
reducing [AED] AND also causes listed below
ed
Orders
Insert IV cannula (may need for further meds)
te
When to be concerned
rd
- 3 seizure within 30min
- seizure lasts >5 min, or recurrent seizures with no recovery
y c
of consciousness in between (status epilepticus) escalate
en
to MO to consider NL referral and to start loading with IV 18-
20mg/kg phenytoin infusion (must monitor HR, RR, BP. Max
id
rate is 50mg/min)
es
Also consider phenytoin if there is a known CNS problem (eg.
R
st
Meningitis, SOL in brain) & this is pts 1 seizure discuss
ne
with MO
i
*Pt should become more alert post-ictally in a few hours; if
ic
not consider neuroimaging or flumazenil if more than one
ed
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
44
Renal/Electrolytes
A. CLERKING NEW RENAL CASES
Things to note for ESRF patients
Reason for ESRF? - e.g. DM nephropathy, HTN, GN
Follow-up with?
RRT since when? What type of RRT HD, PD, transplant?
y
If HD:
c
o HD where, which days? - e.g. NKF AMK Ave 1 1,3,5
en
o HD which vascular access e.g. AVF, Perm cath, AVG
if perm cath date when it was inserted
id
o Last dialysis when completed? (usually 4 hrs)
es
o Latest dry weight
R
- If PD:
ne
o For how long?
o CAPD or APD? What regime? i
ic
o Care-giver?
o PD book available usual UF? Missed exchanges?
ed
- If transplant:
al
renal function?
H
y c
o Hypotension/giddiness during dialysis whether
en
high intradialytic weight gain, shortened dialysis
times, problems with dialysis
id
o Always assume cardiac event if patient presents with
es
SOB or low BP if on regular dialysis.
o Other medical conditions e.g. pneumonia
R
ne
DO NOT TAKE BLOOD FROM PERM CATH! (OR THE
RENAL TEAM WILL KILL YOU) i
**esp when writing blue letters may need to call dialysis
ic
centre for more details re: any issues during dialysis e.g.
ed
encephalopathy)
+/- Metabolic acidosis (pH less than 7.1)
+/- Certain alcohol and drug intoxications
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
46
B. ACUTE KIDNEY INJURY
- May be called for rising Cr trend, NPU or low urine output,
AMS, fluid overload symptoms (SoB etc)
- Assess ABCs, mental status, vitals
- Differentiate acute vs chronic
y
Assess for causes
c
Pre-renal (decreased renal perfusion) - Shock (Sepsis,
en
Dehydration), Uncontrolled HTN etc.
Renal - ATN, GN, AIN, drugs
id
Post-renal obstruction
es
Orders
R
Reverse reversible causes (e.g. IV hydration for
ne
dehydration, Insert IDC for obstruction)
Review medications take off nephrotoxic medications i
ic
(e.g. ACE-Is/ARBs)
ed
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
47
C. LOW URINE OUTPUT/URINE CATHETERS
If NPU > 12hrs do random RU
Assess patients fluid status
y c
patients, otherwise can try potting patient, CIC if recurrent
en
RU <150ml watch or pot patient
id
If difficult catheterization, try different sizes, nelaton
es
catheter but careful not to create false track Sometimes a
larger IDC may be easier to insert as the tip is firmer
R
ne
Document IDC insertion indicate if there were difficulties
with catheterization i
ic
Assess for common causes of ARU constipation, UTI,
ed
BPH +/- order Ix (e.g. UFEME, urine c/s) and Mx (e.g. clear
M
bowels)
al
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
48
If clots or sediments present and unable to get smooth
flow, change to a 3-way catheter and perform manual
bladder washout (MBWO) until urine clear and flow smooth
KIV continuous bladder washout (CBWO)
If all else fails, refer uro urgent KIV suprapubic
catheterization
y c
If NPU + no bladder + dehydrated = hypovolemia
en
Look through I/Os
Fluid challenge (e.g. 500ml N/S over 1-4hrs)
id
Watch for urine output
es
R
i ne
ic
ed
M
al
rn
te
In
G
H
N
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
49
D. HYPERKALAEMIA
Vital signs, order ECG, CBG and hyperK protocol
Exclude spurious result (e.g. hemolysis) KIV repeat
K 6-6.5:
o IV soluble insulin 5-10U with IV dextrose 50% 40ml
SLOW over 5 mins
y c
o D50 can be omitted if CBG>18, KIV dextrose drip if
en
CBG<6 or patient at risk of hypogly
o PO/PR resonium STAT and tds x 1/7
id
o Stop all medications tt can increase K (e.g.
es
ACE/ARB, K drip)
o CBG q1 hr x 6H (12H if renal failure)
R
o Keep hrly para till resolution
ne
o Repeat K and ECG in 4 hours
patient is on digoxin
o Close monitoring with telemetry bed
al
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
50
E. HYPOKALAEMIA
Look for symptoms and complications: constipation,
muscle weakness, muscle cramps, rhabdomyolysis,
arrhythmias. Watch for respiratory muscle weakness if
hypokalaemia is severe.
Check medications. Beware of digoxin toxicity in the
presence of hypokalaemia (Keep K 4)
c y
Look for possible source of loss: GI (e.g. diarrhea), renal
en
(e.g. diuretics)
Look for possible causes of intracellular shift: insulin
id
therapy, hyperthyroidism, beta 2 agonist therapy
es
Check BP - if high, may need to consider: Hypertension
with diuretic use, Conns, RAS, Hypercortisolic states
R
Check blood for magnesium, bicarbonate and creatinine
ne
kinase (if muscle aches, weakness)
Check ECG for U waves (V4-6), ST depression, T
i
ic
inversion, large/wide P wave, increased QT interval,
ectopics, arrhythmia
ed
M
Other Considerations
N
PREPARATION K (mmol)
Span K 0.6 gram 8
Mist KCL 10 ml 13.4
y
Potassium Citrate 10 ml 28
c
Potassium Citrate 1 tablet 10
en
IV 7.45% KCL 10 ml 10
IV KH2PO4 10 ml 10
id
es
If symptomatic/K<2.5/ECG changes:
R
Replace 3 cycles pre-mixed KCl (10 mmol of KCL in 100
mls normal saline), then recheck symptoms/ECG/K 2 hrs
later
Rate of replacement should not be more than 10 i ne
ic
mmol/hour
ed
Correct hypomagnesaemia
te
If asymptomatic/K>2.5:
In
Correct hypomagnesaemia
N
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
52
F. HYPERNATREMIA
Represents a deficit of water in relation to sodium stores,
which can result from a net water loss (majority of cases) or a
hypertonic sodium gain.
Causes
c y
en
Hypervolemic Euvolemic or
Hypertonic saline, Hypovolemic
id
Cushings,
es
Hyperralodsteronism
R
ne
Extra-renal GI, skin loss
i
ic
Renal loss
ed
nephrogenic)
al
rn
Management:
1. Correct underlying cause
G
cy
used only if there is significant hypotension from
en
dehydration.
id
INFUSATE Na (mmol/l)
es
Dextrose 5% 0
0.45% NaCl 77
R
0.33% NaCl/Dextrose 5%/10mmol KCl 56
Body Water + 1)
al
y c
Caution if pt has CCF or CKD (!fluid overload)
en
Monitor the serum sodium closely and adjust the volume and
id
rate of infusate accordingly.
es
R
i ne
ic
ed
M
al
rn
te
In
G
H
N
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
55
G. HYPONATREMIA
Approach to Severe Hyponatremia
- Exclude errors in collecting the blood sample, especially in
a well patient with an extremely low serum Na+. Exclude
pseudohyponatremia: hyperglycemia, hyperproteinemia
or hyperlipidemia
- Determine if patient has symptoms attributable to
y c
severe hyponatremia
en
- Determine the acuity or chronicity of the hyponatremia
as this determines the severity of symptoms and the
id
appropriate rapidity to which the hyponatremia should be
es
corrected
R
At the bedside
ne
- Ascertain conscious level and neurological status
- Check for medications which can cause hyponatremia i
- Take history with regards to fluid intake and loss
ic
- Assess the patients extracellular fluid volume status
ed
M
- Plasma glucose
rn
- Plasma osmolality
- Urine osmolality
te
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
56
Typical volumes used: Single infusion of 100 to 200 mls of
3% Saline over 1 to 2 hrs.
Frequent monitoring of sodium eg at 2hrs then 4 to 6 hrly.
Chronic Symptomatic Hyponatremia (>48hrs)
Increased risk of irreversible osmotic demyelination.
Rule out true volume depletion/dehydration.
Consider the use of hypertonic saline in severe symptoms.
y c
(Must discuss with senior)
en
A calculation of the appropriate infusion rate and amount
should be made.
id
Frequent monitoring of sodium eg 4 to 6 hrly.
es
Chronic Asymptomatic Hyponatremia
Most patients with a serum sodium concentration greater than
R
125 mmol/l or with
ne
chronic hyponatremia do not have neurologic symptoms.
Use of hypertonic saline is not warranted. i
ic
Treatment is directed at the underlying cause after
appropriate investigations.
ed
Rates of correction:
In
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
57
*SIADH is a diagnosis of exclusion. The diagnosis is made
in a patient with true plasma hypo-osmolality (< 275 mOsm/kg
H2O) with inappropriate urinary response to hypo-osmolality
(urine osmolality > 100 mOsm/kg H2O). In addition, the
patient has to be euvolemia and have no other causes of
euvolemic hyponatremia such as hypothyroidism and
hypocortisolism.
y c
en
The causes of SIADH include medications (eg TCA, SSRIs,
antipsychotics), disorders of the central nervous system (eg
id
bleeding and masses such as subdural hematoma,
es
haemorrhage and brain tumours), pulmonary disorders (eg
pneumonia, tuberculosis, lung carcinoma) and transient
R
causes such as nausea, pain, stress, endurance exercise and
ne
general anaesthesia.
i
ic
ed
M
al
rn
te
In
G
H
N
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
58
H. HYPERCALCEMIA
Symptoms: stones, groans, bones and psychic moans,
nephrogenic DI and dehydration
Calculate corrected Ca = [(40-Alb) x 0.02] + Ca
Causes
iPTH/PTHrp dependent (PO4 is usually low):
y c
hyperparathyroidism (primary or tertiary), FHH, malignancy
en
associated PTHrp secretion
iPTH independent (PO4 is usually high/normal):
id
dehydration, immobilization, multiple myeloma, lymphoma,
es
sarcoidosis, vitamin D excess, thyrotoxicosis, Pagets,
malignancy induced osteolytic bone activity
R
ne
Orders:
Assess ABCs, fluid and neurological status i
Paired Ca panel and serum iPTH, ALP, UECr, Mg, FBC,
ic
plasma glucose, CXR, ECG (look for shortened QT)
ed
y c
even when pH and HCO3 is normal
en
2. Identify any secondary abnormality by checking the
id
adequacy of compensation
es
3. Identify the possible underlying cause
R
Metabolic Acidosis
ne
CTSP: hyperglycemia, hypotension, AMS, renal failure, drug
OD i
ic
Identify HAGMA vs NAGMA
ed
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
60
Causes
HAGMA (CATMUDPILES) NAGMA (USEDCARP)
CCO, cyanide UUreterosigmoidostomy
AAlcoholic ketoacidosis (hypoK)
TToluene Ssmall bowel fistula (hypoK)
MMethanol, EExtra chloride (hyperK)
y
methemoglobin DDiarrhea (HCO3 > Cl loss)
c
UUremia (hypoK)
en
DDKA CCarbonic Anhydrase
PParaldehyde inhibitor (hypoK)
id
IINH/Iron AAdrenal insufficiency
es
LLactic acidosis (shock, (hyperK)
hypoxia, metformin) RRTA (I,II: hypoK, IV:
R
EEthylene Glycol hyperK)
SSalicylates, solvent
i ne
PPancreatic fistula (hypoK)
ic
Respiratory Acidosis
ed
concurrent MAcid
G
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
61
Thoracic cage abnormalities: Kyphoscoliosis, morbid
obesity, chest trauma
Neurological/neuromuscular: Myasthenia gravis, Guillian
Barre syndrome, cervical/high thoracic spine injury
y c
upper airway problem) or NIPPV
en
Supplemental oxygen for patients with known Type 2 RF
should be delivered by low flow nasal prongs or fixed
id
systems (venturi mask) to allow accurate titration and
es
prevent suppression of hypoxic drive
R
i ne
ic
ed
M
al
rn
te
In
G
H
N
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
62
Gastroenterology
A. GASTROENTERITIS
Common new GEM case or CTSP re: diarrhea/vomit
y
Assess for different causes of infective diarrhea and r/o
c
other non-infective causes as well
en
Infective: viral, bacterial or parasitic
o Viral GE most common, tend to be abrupt in nature
id
with vomiting
es
o Bacterial GE: Preformed toxins usually causes both
vomiting and diarrhea without fever within hours.
R
Toxins-forming usually causes watery diarrhea 1-2
ne
days later. Invasive organisms usually causes
diarrhea with +/- blood/mucus with fever and patients
i
ic
tend to be sicker and more febrile
o Parasitic GE - Suspect if positive contact/travel
ed
residents.
Non-infective causes of diarrhoea: e.g. thyrotoxicosis,
al
Hx
te
diarrhea/constipation, jaundice
N
Fever/chills/rigors, LoA/LoW
Travel and contact history
Drug h/x: Recent Abx use can lead to diarrhea, C. diff
colitis
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
63
PE
Postural hypotension, tachycardia can be an early sign of
dehydration
Assess hydration status
Abdominal Examination: To r/o acute abdomen
PR: Any blood, mucus, masses felt? Sprurious diarrhea?
y c
Mx
en
Hydration IV +/- oral 1.5-2L/day (Beware fluid status e.g.
IHD/CCF, ESRF)
id
Non-milk feeds as tolerated
es
Correct any electrolyte abnormalities
KIV Abx? Most GE are viral but if patient septic (Febrile,
R
Increased TW) or suspicion of bacterial GE (e.g. bloody,
ne
mucoid diarrhea) consider Abx e.g. PO cipro (after
blood/stool cultures) i
ic
KIV probiotics
KIV an anti-motility agent such as loperamide (usually not
ed
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
64
B. BGIT
CTSP re: Hb drop, malaena, coffee-grounds vomitus
y c
coffee ground vomitus or malaena for you to inspect
en
(they may not be able to differentiate Fe stools from
malaena etc.), exclude hemoptysis, PV bleeding etc.
id
Differentiate upper BGIT (malaena, haemetemesis) vs
es
LBGIT (PR bleed)
Assess if there is a need for urgent intervention (e.g.
R
transfusion, endoscopy)
ne
Assess for complications associated w/ BGIT (e.g. ACS)
i
ic
Causes (risk factors)
Peptic ulcer disease (NSAIDS, prev PUD, corticosteroids,
ed
alcohol, smoking)
M
y c
If dx of BGIT questionable or patient VERY stable KIV
en
refer GS/GE CM for elective endoscopy
If unstable call for senior ASAP, urgent bloods
id
If unstable UBGIT refer GS/GE for emergency endoscopy
es
If unstable LBGIT arrange for urgent CT mesenteric
angiogram (Duty radio: 8131, IR suite: 8157) KIV
R
angioembolisation (will need green plug)
ne
KIV prophylactic intubation for massive hematemesis
i
ic
ed
M
al
rn
te
In
G
H
N
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
66
C. ABDOMINAL PAIN
Over the phone - Ask for vitals and GCS - if unstable, see
patient IMMEDIATELY
By bedside
TRO acute abdomen (i.e. abdominal pain due to life
threatening condition) - making a specific diagnosis is of
y c
secondary importance
en
Hx
id
Characterizing the nature of pain: Visceral pain (dull, poorly
es
localized), parietal pain (sharper, better localized) Colicky
(hollow organs)
R
GI symptoms: Nausea, vomiting, constipation, abdominal
ne
distention (?I/O)
NSAIDs use: Perforated PUD i
Jaundice, Dark Urine, Acholic Stools: HBS pathology
ic
Drinking history, history of gallstones: Pancreatitis
ed
PE
Peritonitis?: board-like rigidity, tenderness/rebound
te
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
67
Causes based on location of pain
RHC Epigastric LHC
Cholecystitis Cholecystits Cholecystitis
Cholangitis Pancreatitis Pancreatitis
Pancreatitis PUD
Gastritis/GERD
ACS
c y
Right lumbar Umblical/Diffuse Left Lumbar.
en
Renal Colic AAA Renal Colic
Pyelonephritis Ischemic bowel Pyelonephritis
id
RIF Suprapubic LIF
es
Psoas abscess ARU Renal Colic
Appenidicits Gynae Diverticulitis
R
Renal colic Ectopic
ne
Diverticulitis pregnancy
Ectopic preg i
ic
Hip (referred)
ed
Ix (as indicated)
rn
Mx
Treat underlying cause
Treat symptoms analgesia ladder (avoid NSAIDS)
As required, NBM + IV drip, hrly para + SpO2
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
68
KIV PPI (e.g. IV nexium)
If I/O, insert NGT + intermittent suction
Last Notes
A common cause of abdo pain during night calls is
constipation colic. Confirm lack of BO and r/o acute
abdomen. KIV AXR TRO I/O. Rectal Dulcolax to clear
y c
bowel and IM/PO Buscopan for colicky pain relief
en
Have a high degree of clinical suspicion for ischaemic
bowel, especially if the patient has high
id
arteriosclerotic/embolic risk factor. Remember pain is out
es
of proportion of physical signs. If in doubt, do serum
lactate/ABG
R
ne
When to call a surgeon
Peritonitis i
ic
Severe/Unrelenting without relief
Complete/High grade Obstruction
ed
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
69
D. Endoscopic procedures
Preparation
OGD NBM 12mn + drip, list + consent
Sigmoidoscopy Fleet enema on morning of procedure,
list + consent
Colonoscopy Low residue diet ideally for 1-2 days, 2L
PEG + PO dulcolax 20mg ONCE 6pm + NBM 12mn + drip,
y c
list + consent
en
ERCP FBC, PT/PTT/INR, GXM +/- UECr, ECG, LFTs day
before procedure, NBM 12mn, list + consent
id
es
Risks for endoscopic procedures
OGD perforation (0.01%),
R
Colonoscopy perforation (0.1%)
ne
ERCP perforation(0.1%), bleeding(1-2%), infection,
pancreatitis (<5%), cholangitis i
ic
Post procedure review
ed
sensitivity
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
70
Endocrinology
A. HYPERGLYCEMIA
CTSP: High CBG (>20), new case poorly controlled DM,
DKA/HHS
y c
Usually just a case of poorly controlled DM
en
If pt well, avoid prescribing additional insulin or OHGAs
after dinner time may get nocturnal hypoglycemia
id
If CBG >20, can review CBG trend non-urgent KIV give
es
small dose soluble insulin (check CBG 4hrs later eg 2am)
R
If unstable, e.g. drowsy, signs of acidosis/ketosis diabetic
ne
emergency
DKA: Hyperglycemia >14, Ketosis e.g. BHOB > 2 mmol/L, i
ic
urine ketones, HAGMA pH <7.3, HCO3 <15
HHS: Hyperglycemia >30, High serum Osm >320, No
ed
Ix
In
c y
and serum electrolyte levels.
en
Aggressive IV K+ replacement once serum K+<5mmol/L
except renal failure / anuria
id
Eg IV K+ (in infusion) 10 mmol/hr if initial serum K+4,
es
20mmol/hr if serum K+3
Rpt U/E/K/HCO3 in 2 hrs then 4 to 6hrs
R
NS is used if Na+ >150 mmol/l
ne
D5 containing fluids when CBG <14mmol/l
i
ic
Insulin therapy
Do not administer insulin if U waves on ECG or initial
ed
(mmol/L) 6 8 - 14 - 18 - 22
In
10
IV 0 0.5 1.0 1.5 2.0 3.0 4.0 5.0
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actrapid
H
(U/hr)
N
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400ml of sterile H2O and infuse at 200ml/hr for 2 hours.
en
Treat underlying ppt factors
id
Guideline for conversion of IV to SC insulin.
es
Acidosis and ketosis has resolved - Bicarb >15, BHOB -ve,
pH normal
R
CBG readings stable and <14 mmol
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Alert and able to take orally
PPT event has resolved i
ic
Conversion is safest during dayshift
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B. HYPOGLYCEMIA
CTSP re: low CBG (will be called if CBG <4)
Ask over phone: pt GCS/mental status
If alert and able to take orally, can order oral glucose 15g
drink over phone, and repeat CBG in 15mins then CBG as
frequently as comfortable (e.g. CBG hrly x 4, then Q4H if
well). Give light meal or diet within one hour
y c
If symptomatic (e.g. drowsy, tremulous, diaphoretic,
en
seizure, coma) or persistent/recurrent, large bore IV plug,
IV D50 40ml stat, recheck CBG once patient responds or
id
within15mins. Set up IV D5% or 10% maintenance. Patient
es
should respond promptly, otherwise repeat IV D50 and
consider other causes for impaired consciousness.
R
ne
If no IV lines and desperate KIV NGT feeding with
glucose solution i
ic
Review all anti-hyperglycemics (i.e. insulin, OHGAs). Type
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complete omission
Ppt factors: poor oral intake, worsening of hepatic, renal
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74
Geriatric Medicine
A. CLERKING NEW GRM CASES
GRM cases may present undifferentiated, atypically or in
the form of Geriatric syndromes
Common geriatric syndromes:
o Functional decline
y
o Falls
c
o Delirium (see pg 16)
en
o Others: Incontinence, inanition/malnutrition etc
Assessment of the premorbid status is key as well as any
id
acute change in the function usually indicate acute
es
pathology (see pg 76 for premorbid assessment)
Effort should be made take a corroborative history from
R
caregiver EVEN on-call especially if the patient is unable to
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provide history
If the patient is from the nursing home and unable to give
i
ic
any history, call the nursing home staff to obtain the history
for the present admission.
ed
tube again.
In
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H
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By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
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B. FALLS
Medical emergency, see the patient ASAP
Assess vitals, ABCs and mental status (compare with
baseline if possible)
Assess for cause (perpetuating and precipitating factors)
and complications of fall
Hx: mechanism of fall, etiology, extend of injury, sinister
y c
symptoms after fall (BOV, nausea/vomiting, severe pain)
en
Causes
id
Intrinsic co-morbidities, deconditioning/muscle weakness,
es
poor vision, poor balance, postural hypotension, vestibular
dysfunction, peripheral neuropathy, dementia, poor safety
R
awareness
ne
Extrinsic drugs, environmental hazards, poor footwear
Precipitating acute medical illness (e.g. sepsis, ACS, i
ic
stroke), AMS (see pg 16), giddiness/syncope (see pg 14),
mechanical (e.g. trip/slip)
ed
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PE
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- Inform MO if needs escalation or needs scans
en
id
es
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C. FUNCTIONAL DECLINE
Functional decline is too vague need to specify which
component of function has deteriorated
Functional assessment
Mobility - ?-man assist, walking aids (e.g. WS, WF),
wheelchair bound, bed-bound
y c
ADLs (DEATH - dressing, eating, ambulating, feeding,
en
toileting, hygiene)
iADLs (SHAFT shopping, housework, accounting, food
id
preparation, transport, medication, telephone)
es
Swallowing
Cognition
R
DSM IV definition of dementia
ne
1. Amnesia (long/short term memory loss) AND
2. One of the following i
ic
Aphasia (communication, word finding difficulty)
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4. Exclude delirium
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Urine/bowel continence
Vision/hearing impairment
In
Sleep disturbances
G
Behavioral disturbances
Mood disturbances
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Determine etiology for decline (e.g. sepsis, CVA, ACS,
change of meds, progression of co-morbidities like dementia)
y c
exam, abdo exam (look for palpable bladder), digital rectal
en
exam (masses, fecal impaction), bedsores and wounds
Swallowing assessment
id
Risk factors for swallowing impairment: e.g. stroke,
es
pneumonia/recurrent chest infection, Parkinsons
dysphagia
R
Beside swallowing test (30mls of H20 in small plastic cup
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with patient seated upright)
o Look for drooling, coughing, spluttering, change in
i
ic
quality of voice, SOB, delayed or multiple swallows,
desaturations on Sp02 monitoring
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AMT
1. Recall of address given (e.g. 37 Bukit Timah Road)
2. Age
3. Date of Birth
4. Address
5. Where are you now?
y
6. What year is it?
c
7. What time is it?
en
8. Recognition of 2 persons
9. Who is the current Prime Minister?
id
10. Serial subtraction of 1 starting from 20
es
Gait if possible
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Orders (as indicated)
ne
FBC, U/E/Cr, Ca+ Alb/Mg/PO4, Folate, VB12, TFT, LFTs,
anaemia panel, blood c/s, ABG if indicated i
ic
ECG +/- CE
ed
Fall precautions
Behaviour chart
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In
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
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Palliative Medicine
A. CLERKING PALL MED CASES
y c
expectations and many other factors
en
E.g. Patients with newly diagnosed Ca may sometimes be
id
admitted under palliative medicine simply because they are
es
on follow-up with palliative medicine for e.g. symptom control.
If the premorbid and prognosis is good, more aggressive
R
management may be indicated
symptom meds)
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B. COMMON SITUATIONS ON-CALL
y c
the nurses can be instructed to serve the breakthrough
en
medication first, but patient must be reviewed if symptom is
severe, of a different nature or is still not relieved in spite of
id
breakthrough medication
es
When possible and appropriate, try to reverse the cause of
the symptom
R
Opioids are HIGH-ALERT medications which should not
ne
be prescribed unless one is familiar. The senior should
always be informed and approval sought before initiating or
i
escalating the dose of opioid.
ic
Some general principles regarding the use of opioids:
ed
1. Verify indication
M
respiratory failure
4. Review the patients comorbidities to decide on the
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Suggested starting dose of morphine (the most commonly-
used opioid)
o Pain - PO morphine 2.5mg PRN up to Q4-6H
o Dyspnoea - PO morphine 2.5mg PRN up to Q4-6H
y c
doctor-on-call should always be consulted.
en
Patient is imminently dying
id
Besides symptoms such as pain and dyspnoea, the patient
es
may have noisy breathing from secretions and may be
agitated.
R
ne
Principles of management:
1. Communicate with the carer/family i
2. Empathize and be sensitive to their needs remember
ic
that this is a difficult moment (DO NOT DISREGARD THE
ed
Q4H
rn
improvement
5. Discuss with the senior to cease non-essential
G
medications
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83
Rheumatology, Allergy and Immunology (RAI)
A. CLERKING NEW RAI CASES
Prerequisites
In general, 3 types of cases to expect. 1) Connective tissue
diseases 2) Arthritides 3) Allergy-related
Fill up all fields, especially the pain section and Drug
y
Allergy/ADR (including reaction if pt remembers)
c
Obtain a complete medication list (pts may obtain their
en
meds from different sources), careful of step doses
Use the homunculus for joint involvement. Shade =
id
Swelling, Cross = Tenderness, Box = Limitation in movt
es
Print the last discharge summary if available
Print the lab results (in small font format) and file under
R
relevant section
ne
Order UFEME + dipstick instead of UFEME alone
Justify all investigations ordered. Serologies and special
i
ic
investigations do not need to be ordered at night as they
will not change management
ed
nephritis)
N
Some tips:
1. Patients with SLE: Do not panic. Think about the disease
manifestations as little modules (skin, blood, kidneys etc)
and ask about symptoms from each one. This will also
help you in ordering the appropriate blood tests
y c
2. Patients with lupus/vasculitis and have diarrhoea may be
en
having gut vasculitis if bowel sounds are sluggish or
there is significant tenderness, keep them NBM
id
3. Patients who are immunosuppressed may not mount high
es
fevers, err on the side of caution and culture and cover if
there may be an infection
R
ne
Arthritides
General approach involves determining i
1. Onset and duration of joint pain
ic
2. Number (mono-, oligo-, polyarthritis) and pattern of joints
ed
asymmetrical)
3. Inflammatory symptoms (early morning stiffness,
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constitutional symptoms)
rn
sources of infection
N
Some tips:
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
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1. as a general rule, not more than prednisolone 10mg/day
is given for inflammatory arthritis
2. higher doses will be needed in gout if colchicine/NSAIDS
are contraindicated
3. use colchicine in gout only if the patient presents within
48h of onset of attack, remember that it requires renal
dose adjustment
y c
4. do not discontinue allopurinol during a flare if the pt is
en
already on a stable dose, it may worsen the flare
id
Allergy related reactions
es
May be related to food / medications / insect bites or
unknown / idiopathic
R
Common complaints include: Angioedema, Urticaria,
ne
Maculopapular rash
Ask for other signs & symptoms of anaphylaxis: SOB, i
syncope or low BP, abdominal cramps, etc
ic
ed
investigated
Detailed food / medication history is required in
al
If rash is present,
- describe it correctly to differentiate mechanism (eg
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By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
86
morning team (in case the rash resolves overnight)
Monitor pt closely for deterioration overnight
- Be wary of delayed reactions
If there is significant MP or purpuric rash, do FBC, U/E/Cr,
LFT, UFEME and dipstix (dont forget SJS/TEN and DIHS
have multi-organ involvement
Do not give steroids until allergy consult made
y c
en
Initial Mx of anaphylaxis
Assess ABCs
id
Epinephrine (IM) is the first line drug for anaphylaxis e.g.
es
IM epinephrine 0.3ml of 1:1000 (i.e. NEAT from vial)
Inform senior
R
Check for response to epinephrine may need to intubate,
ne
continue IV fluids resus, O2 supp
i
ic
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Haematology/Oncology
A. NEUTROPENIC FEVER
38.3, or sustained temp >38 for >1hr with ANC <500 (or
expected drop <500 in 48h)
y c
*Fever may be only indicator of serious infection (other
en
markers may be absent)
id
High risk:
es
Anticipated prolonged (>7 days duration) neutropenia
Profound neutropenia (ANC <100 cells)
R
Hypotension, pneumonia, hypoxia, chronic lung disease,
ne
oral/GI mucositis, new abdominal pain, N/V/D, new
neurologic changes, hepatic (>5x normal) or renal i
ic
insufficiency (CrCl<30)
ed
Ix:
rn
y c
(severe disease)
en
- Add IV vancomycin 15mg/kg q12h if CVC(+), mucositis(+),
skin/soft tissue with high MRSA risk, clinical /
id
hemodynamic instability (KIV stop vancomycin in 48 hours
es
if Gram(+) unlikely and not identified)
- Continue abx for >7 days (even if culture negative) until
R
fever resolves and ANC >500 x 2 days
ne
(serial addition of antifungal, antiviral as needed)
G-CSF (filgrastim) expensive, check w/ senior; not i
ic
routine treatment of established febrile neutropenia
ed
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B. ACUTE TRANSFUSION REACTION
Febrile non-hemolytic transfusion reaction
Frequency For red cells not leukocyte depleted 0.5-6%,
for platelets not leukocyte depleted 1-38%. For leukocyte
depleted red cells and platelets 0.1-1%, more frequently
associated with platelets.
Symptoms fever (>1 deg C above baseline) usually
y c
during transfusion but may occur 1-2 hours after the end of
en
transfusion.
Mx
id
o Stop transfusion, ABCs
es
o Exclude hemolytic reaction (re-check transfusion slip
and re-ascertain patient identity and that correct blood
R
is given to the correct patient, perform transfusion
ne
reaction workup), sepsis and TRALI (ensure that
patients SpO2 is still normal). i
o Paracetamol should be given if no allergies
ic
o Another unit of packed red cells can be transfused
ed
filter.
In
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
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Acute hemolytic transfusion reaction
Frequency ABO and Rh mismatch occurs in about
1:10000-20000 transfusions
Symptoms and signs Most common is fever with/ without
chills and rigors. Patients can also have abdo pain, flank
pain, chest and back pain, pain at infusion site. More
severe patients can develop hypotension, dyspnoea and
y c
dark or red urine.
en
Mx
o Stop transfusion, ABCs
id
o Normal saline infusion (avoid lactated ringer or
es
dextrose-containing solutions) to keep urine output
>100-200ml/hr KIV inotropes (e.g. dopamine) for BP
R
support
ne
o Recheck transfusion slip and re-ascertain patient
identity and that correct blood is given to the correct
i
patient, perform transfusion reaction workup.
ic
o Monitor electrolytes (e.g. K) and PT/PTT/INR
ed
M
Mx
o Stop transfusion, ABCs
G
hydrocortisone 100mg
o If urticaria wanes and no SoB, hypotension or
anaphylaxis occurs resume transfusion at a slower
rate. For future transfusions, consider pre-medicating
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
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with anti-histamines. If recurrent even with pre-
medications, consider using washed red cells (please
consult haematologist-on-call)
Transfusion-associated sepsis
Frequency 1:5000 units for platelets and 1:50000 units
for red blood cells
y c
Symptoms and signs High spiking fever, chills and
en
hypotension shortly after transfusion.
Mx
id
Stop transfusion, ABCs, exclude hemolytic reaction (re-
es
check transfusion slip and re-ascertain patient identity and
that correct blood is given to the correct patient, perform
R
transfusion reaction workup)
ne
If this is suspected, perform blood cultures and start broad
spectrum antibiotics as per ARUS-C guidance for empiric i
ic
therapy for Severe Sepsis Or Septic Shock Without Clear
Source.
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Miscellaneous
Blue letter - which to call?
CALL all URGENT blue letters
CALL for following non-urgent blue letters - ALL
surgical disciplines, Anaesthesia, RAI, Respiratory
Medicine (Secretary: 7861), Haematology, Endocrinology,
y
Neurology, Oncology, Radiation Oncology
c
FAX/LIST for following non-urgent blue letters -
en
General Medicine, Cardiology, Gastroenterology, Infectious
diseases, Renal Medicine, Palliative, Psychiatry,
id
Dermatology, Dental
es
Check with nurses or ward clerk if in doubt
R
Controlled drug prescription sample intranet -> e-bulletin
ne
-> pharmacy notice board-> CDs -> prescription sample
Antibiotics renal adjustment dose intranet -> e-bulletin ->
i
ic
pharmacy notice board -> Antimicrobial Stewardship
Programme-> ASP guidelines -> renal dose OR eIMR >
ed
(automatic)
IVIg guidelines intranet -> e-bulletin -> pharmacy notice
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IVIg
Warfarin/heparin guidelines intranet -> e-bulletin ->
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AURORA
G
y c
en
eIMR
Help nurses obtain prn meds for patients when the patient
id
asks for it- order e.g. paracetamol prn (instead of qds prn)
es
and put Up to Q6H special instructions. Otherwise they
can only serve those meds during specific times
R
Drug serving times - OM - 8am, BD - 8am/8pm, tds
ne
8am/2pm/8pm (vs Q8H 12pm/8pm/12mn), qds -
8am/12pm/4pm/8pm (vs Q6H 8am/2pm/8pm/2am). i
st
ic
Administer 1 dose > eIMR > parenteral medicine (one of
the tabs near the top) > administer order (near the bottom)
ed
if the nurses help you, it is a bonus. Dont get nasty over it.
Learn how to actually do it rule of thumb dissolve Abx
al
they can go home after a long shift, usually means DND and
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By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
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KTPH
Important locations
Tower A
Level 1 A&E department
Level 2 Endoscopy centre and board room (for IM modular
teaching sessions)
Level 4 staff lounge (there is pool table, fuss ball, carrom,
y c
library and comfy seats)
en
Tower B
id
Level 1 (learning centre) Lecture rooms (for modular
es
specialty teaching sessions)
Level 2 Diagnostic Radiology (note: MRI operates after
R
office hours at the diagnostic radiology, CT scan/XR operate
ne
both here and at the A&E)
i
ic
Wards
Tower A (A1/A2/B1 class)
ed
Level 8 Wards 82
rn
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
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*note: in case of max bed occupancy rate --> new cases will
be lodged in Virtual Ward (Ward 71 in A&E dept) --> check
with your MOs if you are covering this ward!
Calls
Collect call key from security office at level 1 on day of call
Return key the next day ($50 penalty if return >1day later)
y c
Request for either Tower A or B on-call room for general
en
medicine (depending on your call coverage areas) there
will always be spare rooms on level 10.
id
2 HOs on call each night - 1 follows MO2 (covering wards
es
56,75,76,95,96) and 1 follows MO4 (covering Tower A,
wards 66,86,105)
R
MO3 will tag on MO1 (covering wards 55, 65, 85)
ne
2 registrars on call each night (1 covers ICU and A&E, 1
covers general ward and blue letters) i
ic
Most of the time, the medical registrar buys dinner.. but ask
around.. a couple don't!
ed
Food options
rn
fried rice
H
IT system
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
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- KTPH uses sunrise clinical manager
- Vitals: located in the flowsheet tab or in the patient
summary tab if u want to see graphical view
- Discharging patients: need to ensure the primary diagnosis
is filled up right at the bottom option of summary
completed or not. If these 2 fields are not completed,
patients summary copy of the discharge will not be printed
y c
out. (it will come out as a blank page)
en
- Investigations ordered on arrival will be printed out together
with the patients copy of discharge summary.
id
- To assess the ward occupancy rate and the details of a
es
booking from ED, you can use BMS-live mozifire webpage.
Password and ID is common to the wards.
R
For eg: ward b66 ID would be wardb66 and password would
ne
be wardb66.
- You are required to annotate all results by pressing down
i
on the middle scrolling button.
ic
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the ward phones. The booking will then appear on BMS-
live webpage.
- All patients coming up from the ED must be reviewed, even
if it has been clerked by the virtual ward team in ED
already. Transfers from other wards (esp A tower lodgers)
should be reviewed as appropriately.
There is fixed blue letter referral workflow. There is a copy
y
-
c
of the workflow in each work, find out where it is! Some
en
services need calling, some faxing only, some call and fax.
- PSYCH referrals have to be made before 11am sharp and
id
must call the on-call. or else it you will get a scolding and
es
patient will not be seen on that day.
- Certain services like RAI, derm, neurology have fixed blue
R
letter days (not every day), so replies may not be as
ne
prompt (because its reviewed by visiting consultants).
Services like hematology will need to call TTSH. i
All scans with contrast and MRI (with or without contrast)
ic
-
need consent.
ed
- Scans done during office hrs till abt 9-10pm will be charged
at normal rates. Scans outside these hours will be more
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patient. PSAs here do not do discharges.
y c
Must be punctual!
en
- Thursday lunch time teachng at 1pm is at Kaizen room 1 at
the learning centre.
id
- Tuesdays IM modular teaching at 730am will be
es
videoconferencing with TTSH. Venue either at boardroom
(tower A level 2 office) or at tower B level 1 main office.
R
- Monday and Tuesday 7.30am emergency and core acute
st
ne
tutorials will be for the 1 3 months
- Departmental meeting on Friday mornings 7.30am: i
Mortality rounds alternate with combined teaching
ic
ed
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99
List of Impt Numbers in KTPH
c y
Hemato 2338 Counter (appt) 2700/01/2698
en
Blood bank 2321 CT rm 2699
Angio rm 2706
id
MSW 2588/2599 US rm 2693/94/95
es
MRI rm 2709
MOT 2760/2770 Snr SN (Carol) Angio - 2669
R
MRO 2466/2464
ne
ITD helpdesk 1800 587 4478 Inpt Pharm 2632/33/34
i On call Pharm 98550620
Ms Xin Yee (BMU) 91142116 Drug Info 2629
ic
Impt! For transfers of
ed
Tower B
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From Kenny Tan, Joel Lee, Quek Zhi Han w/ special thanks
rn
to Eugene Chua
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Drugs doses
Antibiotics/Antimicrobials
Amoxicillin 250mg1g 8h PO
Ampicillin 0.250.5g 6h PO; 150-200 mg/kg/day IV
Amikacin 7.5mg/kg 12h/15mg/kg 24h (CrCl >90)
Augmentin 625mg 8h/12h PO, 1.2g 8h/12h IV bolus/slow inf.
Bactrim (Co-trimox) 2 tab (960mg) bd PO [CI: CRF]
y c
Cefazolin 1-2g 8-12h IV (2g on call to OT) bolus
en
Cefepime 1-2g 12h IV
Ceftazidime (Fortum) 1-2g 8-12h IV infusion [pseudomonas]
id
Ceftriaxone 1-2g om IV bolus (1g)/infuse (2g), 2g bd
es
[meningitis]
nd
Cefuroxime (Zinnat) 500mg 12h PO [2 gen cephalosporin,
R
PO]
ne
Cephalexin 250-500mg 6h PO
Ciprofloxacin 500mg 12h PO; 400mg 12h IV infusion (8h if i
ic
Pseudomonas)
Clarithromycin (Klacid) 500mg bd PO
ed
infusion
Piperacillin-Tazo (Tazocin) 4.5g 6-8h IV [pseudomonas]
G
750mg 8h IV
Chloroquine 600mg base (4 tab) x1 then 300mg [chk G6PD]
om PO
Quinine: Load (wt x20) in 1 pint D5% IV over 4h then (wt x
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101
10) in pint D5 over 4-8h bd-tds [Falciparum malaria]
TB: Mantoux (10U (0.1ml) ID) (occ. 1U). 10mm wheal = +ve
Rifampicin 450mg (600mg if > 50kg) om PO x 6/12 [liver]
Isoniazide 300mg om PO x 6/12[liver] + Pyridoxine 10mg om
Pyrazinamide 1.5g om x 2/12 [liver]
th
Ethambutol 600mg (15mg/kg) (1=100mg) om x 2/12 [if 4
required]
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TripleRx: Clarithromycin 500mg bd PO + Amoxycillin 1g bd
en
PO x 2/52 + Omeprazole 20mg bd PO x 6/52
id
Allergy/Anti-inflamm/Anti-histamines/Steroids
es
Dexamethasone 4-8mg 6-8h i/v, 0.5-10mg/day PO
Chlorpheniramine (Piriton) 4mg 6-8h PO
R
Hydroxyzine (Atarax) 10-25mg tds [itch]
ne
Loratidine (Clarityne) 10mg om PO
Fludrocortisone (Mineralocorticoid) 50-200mcg OM PO
i
ic
Hydrocortisone 100mg 6-8h IV, 5-20mg OM/5-10mg ON PO
Prednisolone 10-30mg om PO then 2.5-15mg/day maint
ed
Asthma
rn
y
High: Calcium: [(40-Alb) x 0.02] + Ca
c
(1) Stop thiazides. (2) IV N/S 1L/hour or 4L/24h
en
(3) Pamidronate (bisphosphonate) 30-90mg in 500ml N/S
over 4 hour
id
es
Cardio-Vascular
Aspirin 100mg om PO + famotidine 40mg bd
R
Clopidogrel 75mg om PO
ne
Clexane 1mg/kg SC om (prophy) /bd (tx) [LMW Hep]
Digoxin 62.5-250mcg om po [lvls] i
ic
Dopamine 3-20mcg/kg/min IV [200mg in 0.1L NS at 2-
7.5ml/h]
ed
Cholesterol/Lipids
N
Constipation
Fybogel 1/1 om [bulk]
y c
Lactulose 10mls tds, 30mls in hep encephalopathy [osmotic]
en
Senna 11/11 ON [stimulant]
Dulcolax (Bisacodyl) PO 5-15 mg (up to 30 mg) PR 10 mg
id
Bowel prep: PEG 2L, PO dulcolax 2 tab BD or 4 tab once,
es
KIV fleet enema
R
Cough
ne
Bromhexine (Bisolvon) 8mg or 1/1 tds (expectorant)
Dequalium or Difflam lozenges 1/1 tds/prn (sore throat) i
Dextromethorphan 10mls tds (black) (suppressant)
ic
Diphenhydramine 10mls tds (black) (expectorant)
ed
Diarrhoea
rn
Lacteolforte 1 sachet BD
In
Diabetes/Hypoglycemia
H
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
104
fat pt)
Metformin (Glucophage) Retard 850mg bd
st
Tolbutamide 0.25-1g om/ bd [short act 1 gen SU]
Insulin: R=SI, Actrapid [yellow bottle, clear][short]
N=Insulatard [green,cloudy][intermediate]. Mixtard usu 30/70
(R:N)
y c
Epilepsy/Fits: h/c, U/E/Ca,Mg,P, ABG, drug levels
en
Carbamazepine 200mg OM/ BD PO
Diazepam (Valium) 5-10mg IV / rectal over 2 min [acute fit]
id
es
Gastritis/Bleeding GIT/PUD
Antacid 2 tab bd-tds PO
R
Famotidine 20-40mg bd PO [with NSAIDs]
ne
Mist carminative 10mls tds/prn PO [wind]
Magnesium Trisilicate (MMT) 10mls tds/qds/prn PO i
Omeprazole (Losec)/Pantoprazole 20-40mg om/bd
ic
Esomeprazole IV 40mg om-bd
ed
50mls/h)
Somatostatin 0.25mg IV stat then 0.25mg/h infusion
al
(Varices).
rn
Gout
G
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
105
Hypertension
Comorb: Angina/AMI: Ace/Beta/Ca. CCF: Ace+Diur. DM: Ace
C/I: Ace: Cr>300, B: Asthma, heart-blk, dyslipid, C: dyslipid
2+
Amlodipine (Norvasc) 2.5-10mg om PO [Ca ]
Atenolol 25-100mg om PO [B]
Captopril 6.25mg-50mg tds PO [ACE]
Enalapril 2.5-10mg om-bd PO [ACE]
y c
Frusemide (Lasix) 20-80mg om-bd PO/IV bolus [loop D][+ K+]
en
Hydrochlorthiazide 12.5-50mg om PO [Thiaz D](elderly)[+ K+]
Metolazone: 2.5-20 mg OD (edema) or 2.5-5 mg OD (BP)
id
2+
Nifedipine LA 30-60mg om-bd PO [Ca ]
es
Propanolol 10-40 mg bd-tds PO, 1mg over 1 min max 5mg IV
[B]
R
+
Spironolactone 12.5-50mg om-bd PO [K sparing D]
ne
Hypt Emergency/Urgency (>230/130). Aim 160/100 slowly
Amlodipine 5-10mg om PO +/- enalapril 2.5-10mg om-bd i
ic
Nifedipine 10mg PO Q8H +/- Atenolol
ed
Neuro-psych meds
In
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
106
Paracetamol: N-acetylcysteine (200mg/ml): 150mg/kg in
200mls D5 over 30min (usu from A&E) then 50mg/kg in 1 pint
D5 over 4h then 50mg/kg 1 pint D5 over 8h.
Pain
Paracetamol 0.5-1g tds-qds/prn po, 325mg supp (kid 125mg)
Anarex (Paracetamol+Orphendarine) 2 tab tds/prn
y c
NSAIDS: With famotidine 20mg bd / omeprazole 20mg bd
en
Diclofenac (Voltaren) 25-50mg tds, 75mg IM max bd; supp
25mg
id
Indomethacin 25-50mg tds PO + PPI [gout]
es
Mefenamic acid (Ponstan) 250-500mg tds/prn PO + PPI
Naproxen (Synflex) 550mg bd/prn po (EC 375mg BD)
R
Opioids: With Laxative (Senna/Lactulose) + Maxolon 10mg
ne
Opioid: Naloxone 0.4mg in 10ml (give 1ml/ time up to 2 mg)
Codeine phosphate 15-30mg TDS PO+ laxative (max 60mg i
Q4H)
ic
Durogesic (Fentanyl) patch 6-50 mcg/h over 72h [CD]
ed
(1ml) IM
In
Piles
H
Daflon 2 tab (900mg) tds x 4/7 then 2 tab bd x 4/7 then 1 tab
N
bd
Fybogel 1/1 bd + Lactulose 10ml tds
Lignocaine gel prn for pain
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
107
Potassium
Low: Inverted T, U wave, PR elevation, ST depression
Stop diuretics, glucose.
<2.5: K 7.45% 10mls in 100ml N/S IV over 1hr
max 20mmol/h, max 20mmol/pint, do not flush
Mist KCL 10-15mls tds PO
Span K 0.6-1.2g om/bd PO (also give with diuretics)
y c
High: >6 ECG: Tall T,wide QRS, small P
en
Resonium 15-30g 8h PO/ 30g fleet
Glucose 50% 40mls (dilute w/ N/S) + insulin 10IV (check h/c
id
stat + hrly h/c)
es
Calcium gluconate 10% 10mls over 10min IV (cardioprotect)
with continuous ECG monitoring
R
ne
Renal
Calcium acetate 625mg tds w/ meals PO i
Ferrous fumarate 200-400mg om-bd PO
ic
Renalmin 1/1 om PO
ed
+
<120/Fitting: Na 3% + Lasix [3%=514/L instead of 154]
In
Vitamins/Food
H
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
108
Fe: Ferrous fumarate 100-400mg om/bd PO +/- laxative;
Sangobion/ Neogobion 1-2 tab om/bd PO; IV Venofer 100-
200mg in 200ml N/S over 1 hour (check Fe after 48h) 2-
3x/week
Folate 5-10mg om PO (check for B12 def before
replacement)
Neurobion 1-2 tab om
y c
Vit B Co 1-2 tab OM
en
Vit C: 100-500mg om PO, 100-500mg/ml IM/IV
Vit K: 10mg OM IV x 3/7 for raised PT
id
Thiamine (Vit B1) 10-30mg PO, 100mg OM PO/IV (alcoholic)
es
IM Vit B12 1mg OM x 3/7 then PO Princi-B forte 1 tab om
R
Common calculations
ne
Cr Clear (ml/min) = (140-Age) x Wt x 1.23 Cr(mol/ml) (x 0.85
for female) Online at nephron.com. For renal failure, use i
ic
MDRD.
Glucose: mmol/L = mg/dl x 0.055
ed
Edited from:
HO Drug list ver 4.70716 updated 16/7/2007
te
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
109
Important phone numbers
Lab Miscellaneous
Biochem 8938/9 BTS MO 9186 4133
Haemato 8955 Drug Info 2016
MicroB 8968/9 TTSH prefix 6357 xxxx
y
Histo 8976 Operator 0
c
Immuno 8464 ITD Help 1800 4834
en
desk 357
id
Imaging Surgical
Duty Radio 8131 Main OT 1492
es
Interven. Radio 8157/3 EOT 1485
R
CT Room 8142/3 OT Fax 1478
US Room 8145 Endo centre 8484/5
MRI
NNI (MRI)
8163/4
7053
i ne
ic
NNI (CT brain) 7056
ed
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
110
Acknowledgements
Special thanks to:
y c
Dr Charles Vu, Dr Stephen Tsao, Dr Quan Wai Leong, Dr
en
Daniel Chew, Dr Lieu Ping Kong, Dr Wu Huei Yaw, Dr Faith
Chia, Dr Ong Kiat Hoe, Dr Goh Kian Peng
id
es
Our chief residents Dr Endean Tan, Dr Chen Shiling, Dr
Seow Cherng Jye
R
ne
Our Program coordinators (i.e. baby-sitters) - Ms Selvia
Kosim, Ms Melody Kuan, Mr Winson Low i
ic
And many others who have come together to make this book
ed
possible
M
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
111