Call To See Patient PDF

y c
en
id
es
R
i ne
ic
ed
M
al
rn
te
In
G
H
CALLED.TO.SEE.PATIENT v1.1
N
By NHG IM Residents 2010 batch

With contribution from TTSH, KTPH and NNI
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
1
Table of contents Page
Prologue 3
General Advice 5
General Medicine 11
c y
Cardiology 20
en
Respiratory Medicine 35
id
Neurology 41
es
Renal/Electrolytes 45
R
ne
Gastroenterology 63
Endocrinology
i 71
ic
ed
Geriatric Medicine 75
M
Palliative Medicine 81
al
Rheumatology, Allergy, Immunology 84

rn
Haematology/Oncology 88
te
Miscellaneous 93
In
KTPH 95
G
H
Drug list 101

N
Important contact numbers 110
2
This book is dedicated to:
Our Patients & their caregivers

Our mentors and faculty members, seniors and colleagues
Our underappreciated nurses, pharmacists, PT/OT/ST/MSWs
and other allied health workers
y c
Foreword
en
It gives me great pleasure as the program director of the
id
NHG-AHPL Internal Medicine Residency Program, to write
es
the foreword for this booklet entitled Called To See Patient
(CTSP), which embodies the work and tremendous effort of
R
the pioneer batch of our Internal Medicine residents.
I am sure that we remember our first day of work as a doctor,

i
just fresh out of medical school, and of course, our first call -
ne
ic
the sense of helplessness, insecurity and anxiety. I had
ed
wished then, that there was a manual that will provide tips to
M
survive the call and the day, and also guidance for the
management of acute conditions.
al
rn
In response to these needs, the residents have come

together to write this booklet that aims to provide a practical
te
guide to many common acute conditions, including survival

In
tips developed from their collective experience in the past one

year. Through this booklet, they hope to help the new
G
residents manage the challenges they face on the ground

H
better and ultimately, provide better patient care. These are

N
the features which make this booklet unique and useful.
This is our very first edition of CTSP and there will be

refinements and changes as our understanding of medicine
3
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.
y c
Dr. Koh Nien Yue
en
Program Director
NHG-AHPL Internal Medicine Residency Program
id
es
Disclaimer
R
This booklet serves as a brief general guide to the
ne
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.
ic
Every patient and situation may differ; hence the information
ed
presented here should be used in context. When in doubt,

M
always consult the immediate supervisor or the senior staff.

al
rn
te
In
G
H
N
4
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
y
sleep youll get post-call (if you get to go post-call)
c
- Confirm which level youre covering, get the numbers of
en
your MOs and contact them early to ask them how they
want to work (e.g. SMS or call? Contact them for new
id
cases or clerk first?)
es
- Get your call room early and changed
- HAVE AN EARLY DINNER. Best time to eat is around 5 to
R
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
ic
down: DIL patients, bloods/ECGs/blue letters etc to trace
ed
(and WHAT to do/expect with the results e.g. keep Hb>

what level?), investigations to be performed (eg serial
M
cardiac enzymes, ABGs). May be asked to review sick pts

but this is usu done by MOs
al
- Scout the wards for empty beds. Can also look at BMU bed
rn
bookings on Intranet. This can be terribly deceiving though;

te
seemingly full wards have poor predicative value for the

eventual quality of your call
In
- Develop a system of keeping track of the things you have

G
done or not done and prioritizing changes also useful for

you to recall pts because the primary team may call you
H
the next day if they have any doubts about your

N
management and also for you to follow-up on the patients

after your night call
5
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:
y c
1. Patient COLLAPSE
en
2. Urgent passives/patient complaints
3. New cases (generally try to see before your MO)
id
4. Tracing labs/investigations and acting on them
es
5. Time sensitive bloods (e.g. cardiac enzymes)
6. Procedures (IDCs, plugs). More urgent if: ARU x long
R
time with high RU/PVRU, plugs for dopamine etc
ne
7. Non-urgent passives (cough syrup, sleeping pills,
change med order in eIMR, etc.) i
ic
8. Updating/speaking with relatives
ed
- KNOW YOUR LIMITS! both in terms of experience and

M
the capacity to bear responsibility if something goes wrong.

Call seniors early if in any doubt!
al
- Check with a senior first before ordering certain

rn
investigations (e.g. generally all scans, expensive bld ix)

and interventions (e.g. blue letters, high risk meds, listing
te
for scopes)
In
- PLEASE be polite to the nurses! A bad call with

G
incessant calls from the nurses and never-ending

H
admissions/passives will fray the nerves and crush the

N
souls of the hardiest of HOs. No matter what though,

nurses are your allies and friends: they can make or break
your call in more ways than one.
6
- 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
y
system
c
- Dont dismiss complaints like headache and giddiness.
en
Always check BP and neurology (dont miss ICH!!)
- Simple investigations like CBG, SpO2, ECGs can be
id
performed quickly and potentially yield impt information wrt
es
patient complaints.
- Try to trace all labs/ECGs youre asked to review
R
document in case notes as appropriate
- Common types of cases encountered: i ne

ic
o HO1 (Lvl 5, 12) GM, PSY (W5D); Can be flooded by
ed
the sheer volume as all the wards are C class wards

(Up to 42 patients per ward)
M
o HO2 (Lvl 7, 11) GRM, RAI, PMD, ID generally gets

admitted to these levels if beds are available
al
o HO3 (Lvl 8, 10) RM and cardio cases Expect to

rn
trace on many ECGs/cardiac enzymes, calls for

te
abnormal rhythms on telemetry, SoB/chest pain

o HO4 (Lvl 9, 13) Renal (W9B), private/A class patients
In
on lvl 13 generally expect to be attended to quickly

- Neuro patients both active and passive are taken care of
G
by neuro MOs. Gently remind the nurses if they do call you

H
for NNI patients

N
- 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.
7
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
y c
it makes future work easier because you do not have to
en
call 0 (for operator) and wait
id
Accompanying DIL patients down for scans/procedures
es
know at least what the resus status is and ensure
appropriate equipment is available (e.g. drugs, fluids,
R
working IV plug available) if for active and unstable may
ne
want to carry defibrillator for continuous ECG monitoring,
ensure O2 tank has enough O2 to last the journey. Help to
i
ic
push the heavy beds (the Ah-Mahs and nurses will
appreciate it)
ed
M
Clerking new cases

Clerk PMHx from CPRS (rmb to click CMRx at bottom right
al
hand corner to get Singhealth notes) & HIDS

rn
There may be mistakes in discharge summaries if in

doubt, check earlier summaries or check with patient
te
CDMR is a useful place to trace the latest HbA1c, lipid

In
panel from polyclinics etc.

ePACE can also provide a useful summary for patients
G
who have undergone major surgery recently

H
Look through both prescribed and dispensed medications

N
(e.g. IMH or SingHealth meds may only be reflected in

dispensed meds). Patient may also be seeing several Drs
look through at least the first few prescriptions
Can try to ask nurses to prepare items you may need while
8
clerking the patient while you write to save time (e.g.
otoscope/ophthalmoscope, tendon tapper, bag of ice for
ABG, lactate)
Have a system when writing orders

1. Monitoring paras+SpO2 ?frequent, CLC, CBG
?frequent, postural BP, fit/behavior/stool/vomit chart
y c
2. Diet
en
Fluids N/S, D/S, premix etc etc.
NBM, feeds, soft diet, full diet
id
Type/therapeutic (Dieticians realm): e.g. low salt, low fat,
es
DM, non-milk, low purine, renal, high protein
Consistency (STs realm)
R
o Solids: easy chew, soft moist, blended
ne
o Fluids: thin, nectar, honey, pudding, NGT
o NGT feeding usually over 6-8 shares (e.g. 200ml x 6 i
ic
+ 50ml H2O flushes)
Types: Ensure, glucerna, nephro etc.
ed
Supplements: myotein etc.

M
3. Disposition CRIB, fall precaution etc.

4. Investigations blds, imaging, urine, stool,
al
5. Management drugs, nursing interventions (e.g

rn
dressings), referrals to PT/OT etc, +/- blue letters

te
Review the patient through the night if the patient is ill

In
(most of the time the MO will do it)

G
H
N
9
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
y c
- Post-call (ie leave by 1pm or so) privilege has now become
en
more common for HOs unlike in the good (bad) old days.
Responsibility must however be borne when exercising this
id
privilege. Be sure to finish up ALL your morning round
es
changes and handover appropriately before you saunter off
home.
R
- 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
ic
may develop, cases will evolve. You may even end up
ed
seeing some of these same cases on your next night call.

- Read up and reflect on your performance that call. Aim to
M
do better next call!

- Savour the post-call euphoria while you can. Its back to
al
work the next day

rn
te
In
G
H
N
10
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
y
37.5 (R) may be significant); Non-infectious fever: drugs,
c
RAI dz, tumour, DVT/PE, CNS insult etc
en
Approach: Differentiate isolated fever (have time) from sepsis
id
(urgent) and severe sepsis/shock (emergency)
es
SIRS: At least 2 of : T>38.5C or <35.0C; HR >90; RR
R
>20 or PaCO2 of <32; WBC >12K or <4K or >10% bands
ne
Sepsis = SIRS + proven OR suspected infection (Non-
septic sirs = burn, pancreatitis, large PE etc) i
ic
Severe Sepsis = Sepsis + organ dysfxn (mottled skin, low
ed
u/o, low platelet, high lactate, heart/lung/kidney dyxfxn,

DIVC, altered mentation etc
M
Septic Shock: Sepsis + large volume IVF/pressor need

Note: if Sepsis + Hypotension, correct antibiotics need to be
al
in vein in <1 hr of low bp (golden hour)

rn
Find Source:
te
Skin (cellulitis, sacral sore), soft tissue (abscess, myositis,

In
nec fasc, forniers), respi (sinus, lung CAP, HAP, HCAP),

CNS (mening / enceph), GU (pyelo, prostate, cystitis), GI
G
(Cdiff, GE), Joint (Septic jt), Abd (peritonitis / perf gut), HBS
H
(cholangitis, absess), bloodstream, plug, endocarditis,

N
device
Travel/contact/exposure hx
Recent antibiotics & treatment by e.g. GP
11
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
y c
team to decide CM
en
o If patient has new/worsening sepsis, repeat w/u (unless
done within 24-48 hours), escalate abx
id
es
Rule of thumb: can never be too many blood cultures done if
source / diagnosis not confirmed.
R
ne
PE
Vitals, GCS, SpO2; Ensure pt not in shock (check tissue i
and organ perfusion)
ic
Look for source: front, back, cavity (oral / PR), plug
ed
Ix
M
- FBC, CRP, Blood c/s x2 from different sites (1 set never

enough in adults) procal (esp if uncertain re: bacterial
al
infection); others eg CK, creat, LFT, LP depending on s/s

rn
- CXR +/- AXR

- UFEME, urine c/s
te
- If new pneumonia: Urine strep / Legionella Ag, Influenza

In
PCR (remember deep nasopharyngeal swab or sputum,

NOT nasal swab for flu PCR)
G
- Sputum AFB, c/s if suspect TB e.g. chronic cough

H
symptoms, LoW/LoA, night sweats, prev pTB

N
- Sputum smear and c/s

- If diarrhea, Stool culture only if <72 hours since admission.
(NO stool cx if diarrhea occurs after 72 hrs of adm). Fresh
12
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
y
st
c
differential time to positivity >120 min (line 1 , then periph)
en
highly suspect line source. If unstable remove line send
tip for c/s, do periph c/s x2.
id
es
Mx
- KIV Isolate: Airborne (TB, measles, chickenpox, unknown
R
severe resp. illness), droplet (influenza, mumps, rubella,
ne
meningococcal meningitis until 24 hrs abx), contact
- REFER ARUS-C for empirical antibiotic guidelines i
- Remember to adjust Abx for renal function
ic
ed
Common empirical Abx

M
CAP: IV Augmentin+ PO Klacid (! Prolonged QTc use

Doxycyline)
al
Severe CAP: KIV ICU, use IV Penicillin 4 MU 6h, IV ceftaz

rn
2g 8h, IV Azithro 500mg 24h

HAP/HCAP: IV piptazo + vancomycin
te
Aspiration: IV / PO Augmentin
In
Meningitis: Ceftraixone 2g q12h + Vanco

Meningitis if listeria suspect: add IV ampicillin
G
Meningoencephalitis: add IV acyclovir

H
Severe HBS: IV cefazolin+PO flagyl+IV Gentax1

N
Non-catheterized Cystitis, Foley UTI, neurogenic bladder: If

pt stable, Wait for urine culture (no hurry); culture-guided
PO bactrim ideal
13
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
y c
en
id
es
R
i ne
ic
ed
M
al
rn
te
In
G
H
N
14
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)
y c
o preictal (aura/palpitations/pallor), ictal (GTC, loss of
en
continence, biting of tongue, veering of eyes) and post-
ictal (drowsiness, Todds paralysis)
id
- True syncope - transient LOC of few seconds with
es
spontaneous recovery
- Ensure no HI, contusion, # (if fragility # over typical sites
R
eg. radius, hip, VB, ?coexistence of osteoporosis); then
ne
consider the following causes:
o CVS: Arrhythmias or LVOTO eg. AS/HOCM i
ic
o Neuro: CVA/TIA
o Postural hypotension: dehydration, blood loss, BP
ed
meds, autonomic failure (DM, MSA, amyloidosis),

M
adrenal insufficiency/ panhypopit, peripheral

vasodilation 2* sepsis, baroreceptor insensitivity
al
(e.g. old age)

rn
o Vasovagal
o Situational e.g. cough, pain, micturition (e.g.
te
straining from LUTS 2* BPH)

In
Giddiness:
G
Differentiate into the following categories

H
o Vertigo - central (eg. vetebrobasilar insufficiency

N
(VBI) or posterior circulation CVA) or peripheral

(BPPV, menieres, vestibular neuronitis from
URTI/otitis media)
15
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)
Examine for mumurs, carotid bruits
y c
Dix-Hallpike maeuveur and otoscopy for vertigo
en
Orders
id
Fall precaution
es
Postural BP monitoring
FBC, UECr (depending on Na/K KIV 8am cortisol), cardiac
R
enzymes, CBG monitoring
ne
ECG
X-rays of areas suspected #s +/- BMD i
ic
KIV CT head, MRI/MRA
Treatment depends on cause - KIV ENT referral for
ed
peripheral vertigo for audiometry; KIV 24-hr Holter

M
monitoring in patients w/ suspected arrhythmias

Symptomatic treatment e.g. sturgeron for vertigo; avoid
al
stemetil in patients with parkinsonism

rn
te
In
G
H
N
16
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
c y
en
Causes
Medications (e.g Antidepressants, pain meds,
id
anticholinergics. Anti-parkinsonism)Exercise caution when
es
prescribing COUGH MIXTURES, PAIN MEDICATIONS,
SLEEPING PILLS
R
Metabolic ( hypo/hyperglycemia, thyroid conditions,
ne
electrolytes
Infx (sepsis, pneumonia, meningitis)
i
ic
CVA/ICH
Acute coronary syndromes
ed
ARU/Constipation
M
Pain (Be cautious with pain meds, if need for opoids, KIV
low dose e.g. PO tramadol 25mg BD PRN and titrate)
al
rn
- Ix as appropriate for causative factors

- Treat causative and reversible factors
te
In
- If agitated, encourage family members to stay with patient,

nurse close to nursing counter
G
- If patient very disruptive or in danger of self-harm - low

H
dose antipsychotics e.g.

N
o PO syrup haloperidol, starting with 1-2 drops (0.1 0.2

mg); review 2 hrs later if patient still very agitated, can
give more haloperidol (up to 0.5 1 mg in total).
o Consider atypical antipsychotics (eg PO quetiapine
17
12.5 -25 mg) for patients already having Parkinsonian
features.] Watch for hypotension, QTc prolongation in
ECG. Ask for behaviour chart so that team looking after
patient can better decide on how to continue with
antipsychotics.
Physical restraints as a LAST resort and should be
deployed if the patient could potentially get hurt when
y c
confused (e.g. climbing and falling out of bed
en
Note: May get calls for the elderly being unable to sleep,
id
requesting for sleeping pills or coughing elderly requesting for
es
cough mixture
Advise on S/E e.g. AMS, ARU (piriton)
R
Encourage sleep hygiene
ne
KIV substitutes (e.g. fluimucil instead of cough syrup)
i
ic
ed
M
al
rn
te
In
G
H
N
18
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
y c
arrives. Listen to the senior nurses they have more
en
experience than you. After which, be vigilant, listen to
instructions and help out wherever appropriate (i.e. dont
id
switch off)
es
Start BCLS Start CPR, get E-trolley
R
Attach ECG leads (not 12-lead) watch for cardiac rhythm
ne
on defibrillator and shock PRN i.e. ACLS
Start bag-valve-mask with 100% O2 i
ic
Ask for stat CBG
Set 2 large bore IV lines +/- draw all 4 tubes/ABG
ed
Prepare intubation set intubate if appropriate

M
Start running IV fluids FAST i.e. 1L over 30 mins

Ask nurses to prepare and start appropriate meds e.g.
al
adrenaline, dopamine (may have to specify exact dilution

rn
and dose esp if no experienced nurses are around)

Help to arrange for transfer to HD/ICU
te
Help to document events and record important events and

In
medications given
+/- help to update family
G
H
N
19
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
y c
Cardiac: ACS AMI/NSTEMI/UA, aortic dissection
en
Respi: PE, tension pneumothorax
GI: perf viscus (e.g. perf peptic ulcer, esophagus)
id
es
Eyeball the patient
Read through the case-notes quickly (e.g. look for risk factors
R
for IHD) and look at the ECG
Call senior for help if vitals unstable, looks ill i ne

ic
Hx typical cardiac pain retrosternal, ppt by exertion and
ed
relieved by GTN (2 out of 3); crushing, radiation to jaw or left

M
shoulder, a/w nausea, diaphoresis, SoB, syncope, duration

>15mins
al
rn
PE quick head to toe including GCS, BP on both arms, R-

R/R-F delay, heart sounds (?new murmur), JVP, creps, acute
te
abdomen, calves/LL
In
ECG (compare w/ prev ECGs) ST, T wave changes, new

G
arrhythmias (e.g. LBBB)

H
N
Cardiac enzymes (CEs) TropI (detectable 4-6hrs, peak 12-

36hrs, normalize after 1-2 wks), CKMB (detectable 4-6hrs,
peak 18-24hrs, normalize after 36-48hrs), not everyone
needs 3 sets of CEs (the third set is indicated when pt has
20
st
strong suspicion of an ACS but 1 2 sets of CEs are negative)
**Trace the investigations you ordered!
Consider FBC (?bleed, anaemia ppt MI), UECr, Ca/Mg/PO4

(if new arrhythmias), PT/PTT/INR (will need if pt going for
procedure), D-dimer (TRO PE in low risk patients, see pg 28),
y c
ABG (if unstable, desat or respiratory distress)
en
id
es
R
i ne
ic
ed
M
al
rn
te
In
G
H
N
21
B. ACUTE CORONARY SYNDROMES
CTSP re: chest pain/SoB, trace ECG, trace CEs
Inform senior immediately

If dx in doubt but suspicion is high repeat 12 lead ECG
up to Q10mins
y c
Assess and stablise ABCs
en
Supplemental O2 if pt hypoxic, keep SpO2 >95%
Focussed hx and PE: Assess for left heart failure,
id
hemodynamic compromise, baseline neurologic function
es
(to watch signs of ICH later)
R
FBC, UECr, PT/PTT/INR, cardiac enzymes, GXM
ne
S/L GTN 0.5mg up to x 3
PO aspirin 300mg STAT + 100mg OM (if no i
ic
contraindications e.g. recent major GI bleed, ICH)
Beta-blockers e.g. bisoprolol 1.25-2.5mg, atenolol 25mg
ed
if no heart failure, hypotension, bradycardia, severe

M
reactive airway dz
IV morphine 2-4mg slow Q5-15mins
al
Cover with PPI

rn
If STEMI - Inform senior KIV arrange for urgent PCI (within

te
90mins)
In
If NSTEMI/Unstable angina Inform senior KIV urgent PCI if

G
hemodynamically unstable or cardiogenic shock, heart failure,

H
add plavix 300mg STAT + 75mg OM, S/C clexane

N
22
C. ACUTE DECOMPENSATED HEART FAILURE
CTSP re: SoB, new case: fluid overload
Hx/PE frequently signs/symptoms of pulmonary edema

(e.g. SoB, creps, rhonchi or cardiac asthma), S3/S4,
elevated JVP
Consider non-cardiogenic pulmonary edema and other
y c
causes of symptoms ARDS (e.g. pneumonia),
en
neurogenic (e.g. CVA)
id
Identify ppt factors
es
Cardiac: ACS, arrhythmias (e.g. AF), progression of CCF
Non-cardiac: severe hypertension, renal impairment,
R
anaemia, hypo/hyperthyroidism, fluid/diet indiscretion, non-
ne
compliance, iatrogenic (e.g. fluid resus, bld transfusion)
Ix
i
ic
ECG e.g. T wave inversions, LVH, Q waves
ed
CXR
M
FBC, UECr, cardiac enzymes, ABG

al
Rx
rn
ABCs
Supplemental O2 as required if hypoxic keep SpO2 >92-
te
95% KIV NPPV/intubation

In
Diuretics IV frusemide 20-80mg STAT + BD (watch BP,

UECr) watch for response and titrate
G
Close monitoring - hrly para + SpO2

H
KIV vasodilators, inotropes

N
Strict I/O insert IDC if required

Fluid restrict 0.8-1L/day, Low salt diet
Daily weight
23
D. HYPERTENSION
CTSP re: BP >180/120
Differentiate HTN urgency (w/o end organ damage) vs
HTN emergency (w/ end organ damage)
Evidence of end organ damage

Neuro: infarct/bleed/encephalopathy/papilloedema
y c
CVS: AMI/APO/Aortic dissection
en
Renal: AKI
id
Quick assessment
es
Symptoms e.g. chest pain, blurring of vision, headache,
nausea/vomiting, confusion
R
Signs - Assess ABCs, vitals and recheck manual BP (on
ne
both limbs), review BP trend, GCS, neuro exam, JVP,
lungs for creps, pedal edema, peripheral pulses, i
ic
fundoscopy for papilloedema
ECG, blds (e.g. UECr, cardiac enzymes) +/- CT brain, CT
ed
aortogram
M
Mx for HTN Urgency

al
Serve anti-HTN meds early if near meds time

rn
Amlodipine 2.5-5mg or captopril 12.5-25mg

Aim to reduce BP over hrs to days
te
In
Mx for HTN Emergency:

Inform a senior
G
Monitor hrly para, GCS + initiate supportive Mx for

H
complications
N
Help to arrange for HD/ICU transfer

Possible meds (will need at least HD usu)
o IV GTN 5mcg/min up to 100mcg/min
o Labetalol 20mcg bolus then 20 to 80mg Q10mins or
24
0.5 to 2 mcg/min
o IV hydralazine 10mg bolus (up to 20mg)
st
o Aim for 10% BP reduction in 1 hr then additional 15%
in next 2-3hrs
y c
en
id
es
R
i ne
ic
ed
M
al
rn
te
In
G
H
N
25
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
y c
Order a fast drip i.e. 500ml over 15-30mins over the
en
phone and see the pt ASAP/early
Look through case notes looking particular for hx of CCF,
id
ESRF (i.e. risk factors for fluid overload)
es
If pt unstable or doesnt respond to fluid challenge, inform
senior
R
ne
Evaluation Hx (chest pain, SoB), PE (include assess fluid
status, DRE) i
ic
Ix (as indicated)
ed
FBC, UECr, PT/PTT +/- GXM, septic w/u

M
ECG + CEs
al
Mx
rn
Hrly para+SpO2
Strict I/O (insert IDC or at least urosheath)
te
Large bore IV plug (x2 if pt unstable)

In
Contd fluid resuscitation

Look through eIMR off anti-hypertensives
G
If pt already beginning to show signs of pulmonary

H
edema/fluid overload or pt high risk (elderly, CCF/poor EF,

N
ESRF) and already given large volumes of fluid (>1-1.5)

but still hypotensive, consider inotropes (i.e. dopamine up
to 20mcg/kg/min)
26
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
y c
Assess for underlying cause, common causes:
en
Fever, pain
Hypovolemia/shock from various causes (e.g. sepsis),
id
anaemia
es
Cardiac e.g. Fast AF, atrial flutter, SVT, VT/VF may be
ppt by cardiac or non-cardiac causes
R
Pulmonary embolism
ne
Hyperthyroidism, hypoglycemia, electrolyte abnormalities
Drugs (e.g. caffeine, salbutamol nebs, smoking) i
ic
Anxiety/Panic attack
ed
If ECG not sinus tachycardia, inform senior ASAP

M
See ACLS (pg 30)

al
Mx of fast AF
rn
Determine if it is new onset unlikely but if new onset AF

KIV pharmacological or electrical cardioversion
te
If hemodynamically unstable sedate & electrical

In
cardioversion (50J, 100J, 150J) until sinus rhythm

If stable for rate control consider:
G
Beta blockers e.g. bisoprolol 1.25mg, atenolol 25mg

H
if no cardiac failure, severe reactive airway dz

N
Digoxin (AF w/ cardiac failure) e.g. IV 250mcg,

review 4-6hrs later, KIV add 125mcg, review 4-6hrs
later KIV add 125mcg (!caution if WPW, acute MI, AV
block, thyroid dz, monitor with defibrillator)
27
Ca channel blockers e.g. verapamil, diltiazem
(!caution cardiac failure, heart block)
APPROACH TO CTSPS FOR TELEMETRY

If you cover wards with telemetry (e.g. level 8, 13) may
be called to review pt who had abnormal rhythms detected
on telemetry
y c
Can be either too fast (e.g. multiple PVCs, fast AF) or too
en
slow (e.g. sinus pause, sinus bradycardia, heart blocks)
Check pts vitals, GCS and for any symptoms, ask for a 12
id
lead ECG
es
If unstable or symptomatic inform senior
If stable
R
o Read through case notes to find out WHY pt is on
ne
telemetry (e.g. recent NSTEMI, severe hypokalemia)
o Look for ischemia on 12-lead ECG (may be missed on i
ic
telemetry)
o Continue Mx - e.g. correct electrolytes
ed
M
al
rn
te
In
G
H
N
28
G. DVT/PE
Hx Unilateral LL swelling, pain, tenderness, erythema
Wells Score for DVT

Findings Points
Paralysis, paresis, recent ortho casting of LL 1
y
Bedridden for >3 days or major surgery within past 1
c
4 weeks
en
Localized tenderness in deep vein system 1
Swelling of entire leg 1
id
Calf swelling >3cm other LL measured 10cm below 1
es
tibial tuberosity
R
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,
i ne 1
-2
ic
Bakers cyst)
ed
*Probability 3pts high, 1-2pts mod, 0pts low

M
Ix
FBC, PT/PTT/INR, D-dimer (to rule out if pt is low risk on
al
Wells score)
rn
+/- Thrombophilia screen (i.e. anti-cardiolipin, Protein C,

te
Protein S, APC resistance, lupus anticoagulant for

unprovoked or recurrent venous thromboembolism or in
In
young pts need to be done before pt started on anti-

G
coagulation, (may not change Mx)

US LL venous system
H
N
Mx
S/C clexane 1mg/kg BD (! Bleeding, low Hb)
Prevention! TED stockings etc.
29
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
y c
Wells Score for PE
en
Findings Points
Symptoms of DVT 3
id
No alternative dx that better explains dz 3
es
Tachycardia >100 1.5
Immobilization 3 days or surgery in prev 4 weeks 1.5
R
Prev hx of DVT/PE 1.5
Presence of hemoptysis
Presence of Ca i ne 1
1
ic
*Probability: 7pts high; 2-6 mod; 1 low
ed
Ix
M
FBC, ABG, UECr, D-dimer (to rule out if pt is low risk on

Wells score)
al
ECG + CE
rn
CXR (to exclude other resp causes)

te
CT pulmonary angiogram (will need green plug)

KIV 2DEcho
In
G
Mx
If unstable Inform senior, ABCs, transfer pt to HD/ICU,
H
KIV thrombolysis or embolectomy

N
hrly paras, fluids, inotropes as indicated

If stable - S/C clexane 1mg/kg BD (! Renal adjust)
30
H. ACLS protocols
y c
en
id
es
R
i ne
ic
ed
M
al
rn
te
In
G
H
N
31
y c
en
id
es
R
i ne
ic
ed
M
al
rn
te
In
G
H
N
32
y c
en
id
es
R
i ne
ic
ed
M
al
rn
te
In
G
H
N
33
y c
en
id
es
R
i ne
ic
ed
M
al
rn
te
In
G
H
N
34
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
c y
Important (life-threatening) causes:
en
Cardiac: AMI, APO, ADHF/CCF, arrhythmias, tamponade
Pulmonary: Pneumothorax, PE, Pneumonia (maybe
id
aspiration??), COPD/asthma attack, pleural effusion
es
GI: BGIT, ascites
Symptomatic anemia, shock (e.g. hypovolemic)
R
Metabolic: Acidosis (e.g. DKA), Poisons (e.g. salicylates),
ne
thyrotoxicosis
Others: anaphylaxis w/ bronchospasm, GBS, myasthenia
i
ic
More benign causes (but still must be addressed):
ed
Anxiety, hyperventilation fever, pain

M
ARU, constipation??
al
Hx
rn
Onset, associated symptoms (e.g. chest pain, cough,

hemoptysis)
te
Quickly review case notes/CPSS, I/O charts, DIL status,

In
main diagnoses, latest bloods/CXR

G
PE
H
!ALERT AMS, inability to sustain respiratory effort,

N
cyanosis, upright/tripod position, use of accessory muscles

and retractions, diaphoretic, short words, stridor/wheezing
/silent chest
Inform senior early if any doubt!!
35
Orders (as indicated)
Hrly paras, CRIB, review patient frequently prn
FBC, UECr, ABG (if indicated e.g. clear desaturation on
SpO2, doubt re: SpO2 reading, history of Type 2 RF/ recent
deranged ABGs), +/- BNP, D-dimer GXM
ECG + cardiac enzymes
y c
CXR
en
Supplemental O2 (95%, 90-92% in COPD pts)
id
Supplemental O2 devices and est. FiO2
es
INO2 up to ~40% - max 4-6L
VM - 24-50%
R
Non-rebreather mask (NRM) 60% (2 valve leaflets are
ne
taken off), 80%, 100%
i
ic
Treat underlying cause (i.e. SpO2 100% on 100% NRM
means nothing if the underlying cause is not addressed) -
ed
e.g. fluid resus, lasix for APO (Note: Giving nebs to pt with
M
cardiac wheeze without diuresis may worsen CCF,

predispose to arrhythmias)
al
Always interpret ABG with knowledge of the FiO2 (key amt

rn
of O2 supp pt is on into special instructions of AURORA so

other people will know)
te
To assess the severity of hypoxia, calculate the PaO2/FiO2

In
ratio.
o PaO2/FiO2 < 300: acute lung injury
G
o PaO2/FiO2 <200: ARDS

H
Type 1 RF: pO2<60mmHg, normal/low pCO2

N
Type 2 RF: pO2 <60 mmHg, pCO2 >50 mmHg
36
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
y c
to meds, unknown
en
Consider other causes of SoB e.g. PE, pneumonia,
pulmonary edema/CCF, asthma, bronchiectasis, PTX
id
Other points LTOT at home? Prev intubations/ICU adm,
es
social Hx
R
Staging on lung function test: FEV1/FVC<0.7 AND
ne
Stage 1 FEV1 >80% predicted
Stage 2 FEV1 50-80% predicted i
ic
Stage 3 FEV1 30-50% predicted
ed
Stage 4 FEV1 <30% predicted or <50% w/ chronic resp

failure
M
Ix
al
FBC, UECr +/- bld c/s

rn
ABG (e.g. background Stage 3-4 COPD)

CXR
te

*Sputum c/s not indicated unless there are CXR features
In
suggestive of pneumonia and patient is able to produce

good sputum for specimen collection
G
(Sputum gram stain and C/S is not ordered for infective

H
exacerbation of COPD if CXR does not show presence of

N
consolidation. Urinary Strep/Legionella Ag only ordered for

CAP and not COPD exacerbation)
ECG +/- CEs
37
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
not respond to initial Mx)

M
al
rn
te
In
G
H
N
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
>=4x/wk 2-3x/wk 1x/wk 1-2x /mth None

4. How often use rescue inhaler or nebs
M
>=3x/day 1-2x/day 2-3x/wk >=1x /wk None

5. Self-rating of asthma
al
Not Poorly Some- Well Complet

rn
controlled what e
te
If ACT<20 = not controlled

In
Other points prev intubations/adm to hosp/EDs (may not

G
be recorded in prev d/c summaries), atopy

H
Ix
N
FBC, UECr +/- ABG

CXR
ECG +/- CEs
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
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
FBC (before starting antiplatelets), UECr, LFT, Cardiac

M
enzymes (3-4% have intercurrent MI)

Lipid panel/HbA1c CM if not up to date; fasting glucose if
al
not evaluated before

rn
PT/INR (should pt need warfarin/thrombolysis and in

hemorrhagic CVA)
te
KIV ESR, ACA, LA, fasting homocysteine, Syphilis IgG LIA,

In
thrombophilia evaluation if patient is young

KIV Doppler carotid US + TCD with bubble contrast +
G
2DEcho CM
H
Check CBG; avoid hyperglycemia which can worsen stroke

N
penumbra; keep CBG between 4-8mmmol (use SC insulin

if CBG > 10 mmol/L)
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
SAH necessitates urgent NS referral; pt would need to be

started on PO nimodipine and require a 4-vessel
al
angiogram KIV clipping/coiling

rn
te
In
G
H
N
42
B. SEIZURES
CTSP pt having seizures - ?active or aborted
Orders over the phone: stat hypocount, check vitals, SpO2 ;

turn to left lateral, prepare IV/IM 5mg diazepam (ward does
not stock up rectal diazepam or lorazepam); give INO2
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
Non-epileptic: infection, electrolyte abnormalities,

M
hypoxemia, acidosis, uraemia, hyperammonemia, drugs,

CVA, intracranial mets, alcohol withdrawal, HI
al
rn
Orders
Insert IV cannula (may need for further meds)
te
Review hypocount results (correct if needed)

In
ECG after seizure aborted: arrhythmias/heart block

(Stokes-Adams attack)
G
FBC, UECr, Ca/Mg/Po4, Cl- (anion gap), ABG +/- AED

H
levels, toxicology screen,

N
KIV CT head plain (to check with MO)

Hrly para, CLC charting, fit chart, (call dr if GCS drops >2),
keep NBM + drip
IV thiamine 100mg in cirrhotics/alcoholics
43
Usually early EEG done only during office hours
If second seizure, give IV 5mg diazepam again
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
dose of BZD given (consult MO)

M
al
rn
te
In
G
H
N
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
o Previous peritonitis or problems with PD?

M
- If transplant:
al
o What kind of transplant deceased, living related from

rn
who, overseas from where? Follow-up where/who?

o How long ago was the transplant?
te
o What immunosuppression usually on three types?

In
o Transplant functioning, failed on dialysis or being

planned for dialysis, or allograft dysfunction previous
G
renal function?
H
o Previous infectious complications?

N
o Previous rejections? Or Allograft biopsies?

o Complications from immunosuppression?
Last Ca/PO4/Fe/TIBC/ferritin (if not done for 1 month KIV
repeat), iPTH (if not done for 3 months KIV repeat),
45
+/- summary of previous failed vascular access, previous
line sepsis and organisms
Common reasons for admission

o Mechanical issues: Blocked perm cath, AVF/AVG
thrombosis, blocked TK catheter
o Infection: Fever/chills during dialysis, PD peritonitis
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
hypotension, poor blood flow (QB)

M
Dialysis centres may change patients meds or give meds

not reflected in discharge meds (e.g. IV calcijex 1x/month)
al
Non-urgent bloods can be deferred to be taken pre-HD in

rn
next HD except PT/PTT/INR

te
Indications for urgent dialysis

In
Refractory fluid overload

Refractory hyperkalemia or rapidly rising potassium levels
G
Signs of uremia, such as pericarditis, neuropathy, or an

H
otherwise unexplained decline in mental status (uraemic

N
encephalopathy)
+/- Metabolic acidosis (pH less than 7.1)
+/- Certain alcohol and drug intoxications
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
Strict I/O charting ++/- insert IDC

KIV Ix - FBC, UECr, Ca/PO4, PT/PTT, ABG, ECGs +/-
M
cardiac enzymes, CXR, UFEME, urine PCR, urgent U/S

kidneys
al
May need urgent dialysis (see above)

rn
te
In
G
H
N
47
C. LOW URINE OUTPUT/URINE CATHETERS
If NPU > 12hrs do random RU
Assess patients fluid status
If NPU +/- palpable bladder + if RU

>300ml insert IDC
150-300ml gray area, IDC indicated for: symptomatic
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
If NPU and IDC in-situ

rn
Assess for blocked IDC

te
Palpate for bladder, bladder scan

In
Look for kinks, blockage etc. along length of tube to urine

bag
G
Flush IDC (using aseptic technique, flush 20-30ml of sterile

H
normal saline with large tipped 50ml syringe, repeat until

both in and outflow is smooth)
N
If unable to get smooth flow, can try to deflate balloon and

manipulate IDC (!aseptic technique and not to re-inflate
balloon in urethra) KIV change IDC
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
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
K>6.5 or ECG changes, or high risk pts (e.g. IHD):

i
ic
o to do above and
ed
o IV Ca gluconate 10% 10ml over 2-3 min (** check if

M
patient is on digoxin
o Close monitoring with telemetry bed
al
o Repeat ECG in 10 mins to check for resolution, if

rn
not, repeat IV Calcium Gluconate dose

o Otherwise repeat ECG in 1hr and K in 2 hours
te
In
If persistent, repeat above +/- IV lasix, ventolin nebulizer or

dialysis (urgent referral to renal), refer dietician if repeated
G
H
N
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
If hypokalaemia with metabolic acidosis

Think of conditions with both K and bicarbonate loss/H+
al
retention e.g. RTA, Acute diarrhoea

rn
If hypokalaemia with metabolic alkalosis

te
Think of hypoMg, intracellular shift and renal loss without

In
significant bicarbonate loss e.g. diuretic use. KIV additional Ix

such as urine K, renin-aldosterone levels and ratio, etc.
G
H
Other Considerations
N
Keep K >/= 4 in patient with digoxin

Usual to have hypokalemia after haemodialysis, especially
if the blood is drawn immediately after dialysis
Patients on Peritoneal Dialysis usu need regular K supp
51
Potassium Replacement
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
Patients with critical hypokalaemia (< 2 mmol/l), those with

ECG changes or those who need rapid replacement (> 10
M
mmol/hour) consider cardiac monitoring (either telemetry

or in high dependency)
al
Review medication list

rn
Correct hypomagnesaemia
te
If asymptomatic/K>2.5:
In
PO Span-K 1-2 tab OM to BD (large tablet, cannot be

G
pounded) or mist KCl 5-10ml tds (bitter) for a fixed duration

(e.g. 2/7)
H
Correct hypomagnesaemia
N
Recheck after replacement
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
Diuretics, osmotic diuresis,

diabetes insipidus (central,
M
nephrogenic)
al
rn
Symptoms: Increased thirst, AMS, coma, seizures

te
In
Management:
1. Correct underlying cause
G
2. Correct hyperosmolar and hypernatremic state

H
N
Rate of Correction: Unless we know for sure that the

hypernatremia is acute i.e. developed over a few hours, it
is best to correct the sodium slowly to prevent cerebral
oedema and convulsion.
53
Maximum rate: 0.5 mmol/l/hour or 10 mmol/l/day
Goal: reduce sodium to 145 mmol/l
Calculation of Infusate (for those with net water loss)

Preferred route of administering fluids is oral or NG
IV fluids are used if the above are not feasible.
Only hypotonic fluids are appropriate. Normal saline is
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
Step 1: Decide on the infusate and estimate the effect of 1

i ne
ic
litre of the infusate on the serum sodium
ed
Change in serum Na = (Infusate Na - Serum Na) (#Total

M
Body Water + 1)
al
OR if using infusate with potassium,

rn
Change in serum Na = ((Infusate Na+ Infusate K) Serum

Na) (#Total Body Water + 1)
te
(#Total body water = F x Body Weight -- where F=0.6 in non-

In
elderly men, 0.5 in non-elderly women and F=0.5 in elderly

men and 0.45 in elderly women)
G
H
Step 2: Determine rate of infusion usual target is to reduce

N
serum sodium by no more than 10 mmol/l over 24 hours
Volume of Infusate required = 10/Change in serum Na

(Change of Na was determined at step 1)
54
Step 3: Determine total volume of infusate to be given over 24
hours
Total volume to be administered over 24 hours = Volume of

infusate required (determined at step 2) + 1.5 Litres (to
compensate for ongoing obligatory fluid and electrolyte loss)
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
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
Pertinent Laboratory Investigations

- U/E/Creatinine
al
- Plasma glucose
rn
- Plasma osmolality
- Urine osmolality
te
- Urine sodium concentration

In
- Thyroid function test and evaluation for hypocortisolism

G
Acute Symptomatic Hyponatremia (<48hrs)

H
This is an indication for the use of hypertonic saline. (Must

N
discuss with senior)

Goal to increase serum sodium to abort symptoms eg
seizures or to increase serum sodium to >120mmol/l to avoid
cerebral edema.
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
On a night call, do not presume the cause is SIADH*. In

M
hemodynamically stable patient, a maintenance IV 0.9%

Saline at 60mls/hr may be appropriate.
al
Limits of therapy are to raise the serum sodium

rn
concentration by less than 12 mmol/l in the first 24 hours and

less than 18 mmol/l in the first 48 hours.
te
Rates of correction:
In
Acute symptoms (eg seizures) 2-4 mEq/L per hr

Symptoms 1-2 mEq/L per hr
G
Mild symptoms 0.5 mEq/L per hr

H
1 liter of 3% Saline contains 513 mmol of sodium

N
1 liter of 0.9% Saline contains 154 mmol of sodium
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
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
IV fluid hydration is the cornerstone of treatment

M
In tolerant patients, aim for total fluid intake >= 3 liters/day

In symptomatic or severe hyperCa >= 3.5mmol/l, Consider:
al
o IM/SC/intranasal calcitonin 200 -400 units/day in 2

rn
divided doses (Tachyphylaxis develops in 48 to 72 hrs)

o IV Bisphosphonates (Do not initiate in dehydrated
te
patients with renal impairment. Effect peaks in 5 to 6

In
days) IV Zoledronate 4mg over minimum 15mins OR IV

Pamidronate 60mg in 500mls NS as a slow infusion
G
over 4 hrs (Renal impairment is a contraindication)

H
o If well hydrated, consider IV Lasix 20-40 mg to induce

N
diuresis and decrease calcium reabsorption. (May

contribute to electrolyte disturbances)
Steroids for hypervitaminosis D, bone mets & sarcoidosis
Treat underlying etiology
59
I. ACIDS-BASES
1. Identify primary abnormality
pH <7.35 and HCO3<20mmol/L: MAcid
pH <7.35 and pCO2>45mmHg: RAcid
pH >7.35 and HCO3>24mmol/L: MAalk
pH >7.35 and pCO2<35 mmHg: RAlk
*Elevated AG is marker of high anion gap metabolic acidosis
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
AG = Na HCO3 Cl (HAGMA = AG>12)

M
Identify concurrent respiratory acid-base abnormality

al
Expected pCO2 = (1.5 X HCO3) + 8 2

rn
If pCO2<expected, concurrent RAlk, If pCO2 >expected,

concurrent RAcid
te
In
Concurrent metabolic acid-base abnormality

Corrected HCO3 = (AG-12) + measured HCO3
G
If >28, concurrent MAlk, <22, concurrent NAGMA

H
N
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
CTSP: respiratory distress, respiratory failure, AMS

M
Identify the secondary abnormality

Acute - Expected HCO3: increase 1-2 mmol/l for every
al
10mmHg increase in PCO2

rn
Chronic: Expected HCO3: increase 4-5mmol/l for every

te
10mmHg increase in PCO2

If HCO3>expected, concurrent MAlk, HCO3<exp,
In
concurrent MAcid
G
Causes - mainly CO2 retention from hypoventilation

H
Central causes: Drugs (sedatives, opiates), Head injury,

N
CNS lesions, Metabolic alkalosis, Loss of hypoxic drive in

chronic type 2 RF treated with O2
Airway obstruction: COPD/ asthma
61
Thoracic cage abnormalities: Kyphoscoliosis, morbid
obesity, chest trauma
Neurological/neuromuscular: Myasthenia gravis, Guillian
Barre syndrome, cervical/high thoracic spine injury
Treat the underlying cause

Ventilatory support: KIV intubate (if pt is drowsy or has
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
62
Gastroenterology
A. GASTROENTERITIS
Common new GEM case or CTSP re: diarrhea/vomit
Vitals, ABCs, GCS

Assessment of the degree of dehydration
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
history and immunocompromised, nursing home

M
residents.
Non-infective causes of diarrhoea: e.g. thyrotoxicosis,
al
tumour/villious adenoma, IBD

rn
Hx
te
Diarrhea: duration, difference from normal habits, quality of

In
stools, any blood/mucus,

Other GI symptoms: Nausea, Vomiting
G
(Blood/watery/bilious), abdominal pain, alternating

H
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
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
required unless multiple episodes of diarrhea, may

M
increase risk of HUS in EHEC)

al
rn
te
In
G
H
N
64
B. BGIT
CTSP re: Hb drop, malaena, coffee-grounds vomitus
Vitals, ABCs, GCS see pt ASAP if unstable

Assess if the patient is stable
Assess if it is truly BGIT e.g. DRE (determine if it is fresh
or stale malaena); aspirate NGT; ask the nurse to keep the
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
Varices (liver cirrhosis chronic hepatitis, alcohol)

Diverticular disease (known diverticular dz, painless fresh
al
PR bleed, chronic constipation)

rn
Hemorrhoids proctoscopy to avoid embarrassment

Cancer gastric, colon
te
AVMs gastric, colon

In
G

H
Hrly para + SpO2

N
Large bore IV cannulas + IV fluids, NBM

FBC, UECr, PT/PTT/INR, GXM +/- LFTs
ECG +/- cardiac enzymes
Stool/vomit chart
65
Consider insert NGT if pt stable (unless high suspicion of
varices) diagnostic if aspirate bloody
Check eIMR take off anti-platelets, anti-coagulants, anti-
hypertensives
IV nexium 40mg BD
For varices, IV somatostatin 250mcg STAT + 250mcg/hr
infusion
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
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
Prev surgeries, hernias: I/O

M
Fever/chills/rigours: Intra-abdominal abscess, peritonitis

Sexual History, LMP: Ectopic Pregnancy
al
rn
PE
Peritonitis?: board-like rigidity, tenderness/rebound
te
Masses? E.g. palpable bladder

In
PR: Any BGIT, impacted Stools

G
H
N
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
Remember extra-abdominal causes of abdominal pain -

M
e.g. AMI, pneumonia, DKA

al
Ix (as indicated)
rn
FBC, UECr, LFT, amylase cardiac enzymes bld c/s,

PT/PTT, GXM, ABG/lactate (R/O ischemic bowel)
te
Erect CXR (80% perf viscus have air under diaphragm),

In
AXR (supine), CTAP

ECG
G
UPT, UFEME, urine c/s

H
N
Mx
Treat underlying cause
Treat symptoms analgesia ladder (avoid NSAIDS)
As required, NBM + IV drip, hrly para + SpO2
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
Patient is Unstable: Tachycardic, Hypotensive

M
al
rn
te
In
G
H
N
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
Assess the patient for possible complications of the

M
procedure e.g. nausea, vomiting, drowsiness from

sedation, perforation from procedure
al
Follow the POT in the endoscopic report

rn
Generally, for OGD, sigmoidoscopy, colonoscopy hrly

para x 4 then 4hrly if well, feeds to DoC as tolerated when
te
round (BEWARE of contraindications to start feeding e.g.

In
Forrest 1a ulcer found and clipped, should keep the pt

NBM in case rebleed)
G
If suspecting perforation, may consider escalating and

H
send pt directly for CTAP (instead of erect CXR) higher

N
sensitivity
70
Endocrinology
A. HYPERGLYCEMIA
CTSP: High CBG (>20), new case poorly controlled DM,
DKA/HHS
Ask over phone: mental status, vitals
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
acidosis (or mild lactic acidosis), HCO3 >15, normal AG

M
*calculated Serum Osm=2(Na+K) + glucose + urea

al
Ppt factors: infection/sepsis, inappropriate OHGAs/insulin,

rn
non-compliance, ACS, CVA, pancreatitis, drugs e.g.

corticosteroids
te
Ix
In
FBC, UECr, HCO3,Cl, ABG, serum Osm, plasma glucose,

BHOB (green tube)
G
ECG + CEs (MI, T and U waves)

H
CXR KIV septic w/u (bld c/s, UFEME, urine c/s)

N
Initial Mx Principles for DKA/HHS

D/w senior transfer to HD/ICU for unstable
Fluid and K+ replacement
71
HHS fluid deficit may be 5 to 10% BW
Aggressive fluids required if hypotensive + inotropes (e.g.
dopamine) if in shock
Administer IV isotonic saline (0.9% NaCl) at a rate of 15
20ml/kg/hr or 1 1.5L during the first hour in the absence
of cardiac compromise
Subsequent fluid replacement depends on hydration status
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
serum K+ is < 3.3mmol/L

M
Start Actrapid infusion at 0.1U/kg/hr, and titrate dose hrly

according to CBG
al
Example of sliding scale for 55kg patient

rn
CBG <4 4.1 6.1 8.1 10.1 14.1 18.1 >22

te
(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
G
actrapid
H
(U/hr)
N
Appropriate rate of glucose decline 3 to 4 mmol/hr

Intensify insulin scale if necessary
72
Target CBG maintenance level 8 to 12 mmol/l
Hrly CLC, para + SpO2, Strict I/O chart KIV urinary catheter
for oliguric/unstable
Hrly CBG
*in DKA, consider bicarbonate therapy only if pH is <6.9
despite adequate hydration or if hemodynamically unstable.
Dilute 100mmol sodium bicarbonate with 20mmol/L KCl in
y c
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
ne
Alert and able to take orally
PPT event has resolved i
ic
Conversion is safest during dayshift
ed
M
al
rn
te
In
G
H
N
73
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
ed
1 DM will require retitration of basal insulin but not

M
complete omission
Ppt factors: poor oral intake, worsening of hepatic, renal
al
function, infection, drugs, alcohol, adrenal insufficiency

rn
**When ordering sliding scale SI in eIMR for e.g.

te
TDS+10pm pls indicate BSL frequency tds+10pm but

In
dosing frequency to be only tds (pre-meal)

G
H
N
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
ne
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
Always ask the care-givers about any recent drug allergies.

M
If the patient has NG tube feeding and a chest X ray had

been done at the A&E department, review the position of
al
the tip of NG tube before commencing feeding. If the tip of

rn
the NG tube is not below the diaphragm and in the

stomach, inform the nurses to remove it and re-insert the
te
tube again.
In
G
H
N
75
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
M
Complications e.g. fractures/dislocation, intracranial bleed

al
PE
rn
Inspection - bruising, cuts, joint deformities

Neuro: pupils, reflexes, power, Babinski, gait
te
Abdo: tenderness, digital rectal exam

In
Musculoskeletal: Spine, hips, wrist and other joints

Cardio: murmurs, carotid bruit
G
H

N
Hrly para, CLC monitoring, postural BP, CRIB

FBC, UECr, Ca+Alb/Mg/PO4, capillary blood glucose +/-
PT/PTT, GXM
ECGs +/- cardiac enzymes
76
CXR, XR affected parts (e.g. hip, wrist)
KIV urgent CT brain, MRI/MRA brain
Raise incident report (eHor) report police
Review meds (e.g. sedatives, anti-coagulants,
antihypertensives) KIV withhold
- Update relative (main spokesperson)
y c
- Inform MO if needs escalation or needs scans
en
id
es
R
i ne
ic
ed
M
al
rn
te
In
G
H
N
77
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)
ed
Agnoisa (recognition of familiar items/faces)

Apraxia (dressing, buttoning)
M
Loss of executive function (planning, goal-directed

activity)
al
3. Interferes with work, social activities

rn
4. Exclude delirium
te
Urine/bowel continence
Vision/hearing impairment
In
Sleep disturbances
G
Behavioral disturbances
Mood disturbances
H
Hx from patient (but can be challenging)

N
Hx from caregiver (preferably staying with patient)
78
Determine etiology for decline (e.g. sepsis, CVA, ACS,
change of meds, progression of co-morbidities like dementia)
Complications (falls/near falls, low mood)
Vitals, postural BP, hydration status

Comprehensive physical examination, including neuro
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
ne
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
ed
If unsafe to feed: NBM + IV drip

M
Can modify diet (see pg 8) and pound medicines (note:

some medicines cannot be pound)
al
KIV NGT, ST referral

rn
te
In
G
H
N
79
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
R
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
Capillary glucose monitoring

CXR/AXR
M
CT brain / MRI brain

I/O charting
al
PT/OT gentle as tolerated, ST if needed

rn
Fall precautions
Behaviour chart
te
In
Mx - Identify and treat reversible cause (e.g sepsis,

electrolyte abnormalities, stop offending meds)
G
H
N
80
Palliative Medicine
A. CLERKING PALL MED CASES
Palliative medicine Do nothing!
How aggressive the treatment should be determined by the

patients premorbid, patients prognosis, patient and familys
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
Important information to include when clerking i ne

ic
Premorbid/functional assessment
Underlying condition (only patients with Ca are supposed
ed
to be admitted under palliative, but things do fall through

M
sometime) and investigations (diagnosis, latest scans,

histo) and management so far (surgery, chemo, radio,
al
symptom meds)
rn
Thorough history and examination (including oral cavity

and PR where indicated)
te
Reverse reversible factors contributing to symptoms (e.g.

In
constipation for abdo colic)

G
H
N
81
B. COMMON SITUATIONS ON-CALL
Pain and Dyspnoea

Patients admitted under PMD or being reviewed by PMD
usually have meds for breakthrough (BT) symptoms (i.e.
increased symptoms on a background of otherwise well-
controlled symptoms)
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
2. Communicate with patient and/or relatives before

initiating opioids to explain indication, benefits and
al
potential side effects

rn
3. Choose the lowest effective dose, particularly for those

who are opioid-nave, elderly and frail or at high risk of
te
respiratory depression e.g. COPD with chronic type 2

In
respiratory failure
4. Review the patients comorbidities to decide on the
G
appropriate type and dose of opioids e.g. fentanyl

H
instead of morphine should be used in patients with

N
significant renal impairment

5. Review symptom again after medication is
administered to assess if there is improvement
82
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
If other preparations of opioid or non-enteral route is required

and if in doubt, the senior and/or the Palliative Medicine
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
PATIENTS SYMPTOMS OR THE FAMILYS DISTRESS)

M
3. Manage the symptoms:

o Terminal secretions S/C buscopan 20mg PRN up to
al
Q4H
rn
o Terminal agitation S/C haloperidol 1-2mg PRN up to

Q4H
te
4. Review symptoms in the next hour to assess if there is

In
improvement
5. Discuss with the senior to cease non-essential
G
medications
H
If family requests for terminal discharge, inform senior &

N
nurses, prepare a good discharge summary to allow the

GP to sign the death certificate in the event of patients
demise at home, and consider referring to the home
hospice team (if appropriate)
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
Some medications are taken on specific days of the week.

M
Check that you have ordered them correctly.

Stop immunosuppressants (except hydroxychloroqine) if
al
the patient is being admitted for a severe infection

rn
Do not be intimidated by the complexities of some cases.

Follow up on the interesting ones & learn from them
te
In
Connective tissue diseasess

Pts are usually admitted for
G
1. Flare / activity of the underlying condition (e.g. lupus

H
nephritis)
N
2. Complication of condition / treatment (e.g. DVT in APS,

infxn from immunosuppression)
3. Treatment related (e.g. IVIg infusion, Dental works for pt
on warfarin these will be elective admissions and have
84
plans laid out)
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
involved (Axial vs peripheral, symmetrical vs

M
asymmetrical)
3. Inflammatory symptoms (early morning stiffness,
al
constitutional symptoms)
rn
4. Presence of extra-articular manifestations

5. History of inflammatory arthritis and treatment
te
In
If there is a suspicion of septic arthritis, diagnostic tap

should be performed with blood cultures
G
Remember to take sexual history and look for possible

H
sources of infection
N
Empiric abx can be considered if suspicion of underlying

infection is high (preferably after joint aspirate)
Some tips:
85
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
Ask if this has occurred before and if pt has been

M
investigated
Detailed food / medication history is required in
al
chronological order (get exact timing)

rn
Ask if there is relation with physical activity

History of atopy in patient and family
te
In
If rash is present,
- describe it correctly to differentiate mechanism (eg
G
maculopapular rash vs urticarial)

H
- if there are blisters/bullae look for Nikolskys sign or

N
denudation (danger signs)

- Ask and examine for mucosal involvement (eyes, mouth,
genitals)
- Suggest to pt to take photo of their rash to show the
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
ed
M
al
rn
te
In
G
H
N
87
Haematology/Oncology
A. NEUTROPENIC FEVER
38.3, or sustained temp >38 for >1hr with ANC <500 (or
expected drop <500 in 48h)
ANC = Tw x (Neutophils% + Bands%)

* If neutrophils dysfunctional, dont count towards ANC
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
Hx/PE - THOROUGH: lines, catheters, sinuses, fundus,

M
perirectal, skin, mucosa (AVOID PR)

al
Ix:
rn
>2 sets blood cultures

If no CVC: 2 sets (separate sites);
te
If CVC: each lumen + peripheral culture simultaneously.

In
o Differential Time to Positivity >120 min suggests CVC

source
G
FBC, UECr, LFTs, plus tests based on findings: CXR,

H
sputum GS & cx, stool cx & CDiff toxin (if diarrhea)

N
abscess GS and cx, Biopsy of skin findings (very useful);

CT, LP etc as needed. Discouraged: stool c/s / CDiff if no
diarrhea, urine cx if no symptoms / no catheter / no pyuria,
superficial wound swab
88
Review old micro data for MRSA, ESBL, VRE etc to guide
empiric abx
New onset abdominal pain: suspect typhlitis
Rx: (renal adjust!)

- IV PipTazo 4.5g Q8h plus IV amikacin 15mg/kg stat, OR
- IV imipenem 500mg 6h plus IV amikacin 15mg/kg stat
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
M
al
rn
te
In
G
H
N
89
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
once the symptoms have subsided. Do not re-use the

M
same unit of blood unless there is difficulty obtaining

blood for the patient, in which case the transfusion
al
should be discussed with the haematologist-on-call.

rn
Incidence of febrile non-hemolytic transfusion reaction

can be reduced by leukodepletion using a leukocyte
te
filter.
In
Transfusion reaction workup includes:

G
Filling up transfusion reaction form

H
2 pink tubes, 1 yellow tube (this is for LDH and bilirubin,

N
which is to be ordered separately if hemolysis is

suspected)
5 mls urine
Blood bag with remaining blood product
90
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
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
Anaphylactic transfusion reaction refer to treatment of

anaphylaxis (pg 85.)
al
rn
Urticarial transfusion reaction

Frequency 1-3%, more frequently with blood products
te
containing significant quantities of plasma

In
Mx
G
o IV diphenhydramine 25-50mg or PO piriton 4mg. For

H
severe urticarial reactions, may require IV

N
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
91
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.
ed
M
al
rn
te
In
G
H
N
92
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
parenteral > ARUS-C guidance > renal dose adjustment

M
(automatic)
IVIg guidelines intranet -> e-bulletin -> pharmacy notice
al
board -> Drug administration Guidelines -> RAI protocol

rn
IVIg
Warfarin/heparin guidelines intranet -> e-bulletin ->
te
pharmacy notice board -> anticoagulation guidelines

In
AURORA
G
Renal panel has no urea, chloride, bicarbonate; LFT has

H
no AST, GGT (need to key in separately)

N
Remember to fill in the box on the top right hand corner

briefly explain the pts situation - esp when ordering scans
or risk getting a phone call from an angry radiologist
AXR is keyed in as XR, abdomen
93
All intervention radiology orders start with IR,
Many options are not in use dont get confused e.g.
skin scrape [IDS], (EMOS) diet DM 1500k, Treatment PCN
Can order multiple relevant tests fast by clicking on Order
template (drop down just above area for ordering, to the
right), but dont order EVERYTHING on the panel blindly
Can customize results trending by creating your own list
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
> check appropriate buttons (it is still the Drs responsibility,

M
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
with water for injection as some may ppt w/ N/S)

rn
Passing report times sacred timings for the nurses before

te
they can go home after a long shift, usually means DND and
In
the nurses will need the case notes - 7-8am (night AM

shift), 2-3pm (AM PM shift), 9-10pm (PM night shift)
G
H
UpToDate can access from home! Login to

N
intouch.nhg.com.sg click lotus notes client access

http://intranet - bottom right hand corner UpToDate Online
94
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 5 Wards 51,52

M
Level 6 Wards 61,62

Level 7 Wards 71,72
al
Level 8 Wards 82
rn
Tower B (ICU/B2/C class)

te
Level 2 Wards 26 (MICU)

In
Level 3 Wards 36 (SICU)

Level 4 Ward 45 (renal centre), Ward 46 (isolation ward)
G
Level 5 Wards 55,56 (Geriatric and medical overflow wards)

H
Level 6 Wards 65, 66 (medical wards)

N
Level 7 Wards 75,76 (medical wards)

Level 8 Wards 85,86 (Surgical and medical overflow wards)
Level 9 Wards 95,96 (Orthopaedic and medical overflow)
Level 10 Ward 105 (medical ward)
95
*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
Always keep your MOs informed of any sick passive case

M
i.e. desaturation or typical chest pain

al
Food options
rn
Tower B B1 level: kopi kaki. Sells drinks, toast and mee

rubus, mee siam.
te
Level 1: subway, Mr Bean, edo sushi

In
Food fare food court (Tower C, level 1): recommended

food- ayam penyet, wanton mee, fish and co, kampong
G
fried rice
H
Outside: northpoint, coffeeshop opp safra yishun (nice

N
chicken rice and zi char!), coffee shop near to northpoint.

Higher end: Eatzi (Jack's place) at Safra Yishun
IT system
96
- 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
ed
Daily Work flow:

M
Morning after rounds

- Phlebotomist service comes 3 times a day, of which the
al
timing depends on which ward you are in. they do not do

rn
blood cultures or ABG or GXM. Latest blood taking timing

range from 7 to 8 plus.
te
- GXM/antibodies screening cannot be ordered in the

In
system. You need a manual form. Need to sign on the

tube, 2 stickers on the top and the ordering dr blank,
G
altogether 4 signatures. Another staff needs to counter sign

H
on the form before u can despatch.

N
- Albumin does not require GXM. Traditional PCT/ platelets

and FFP require GXM.
- Everytime there is a new booking from ED, a classical ring
that you will soon learn to hate, will sound throughout all
97
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
- HOs can sign consent (unlike in TTSH)

M
- Scans done during office hrs till abt 9-10pm will be charged
at normal rates. Scans outside these hours will be more
al
expensive, so decide if they are warranted or urgent.

rn
- CT brain/MRI brain when ordered, will usually be done on

the same day. No need to call radiologists. If urgent, can
te
try calling the CT/MRI dept staff first.

In
- When discharging patients, the IMR can be ticked during

the rounds, so that the nurses can send off the IMR to the
G
pharmacy in the morning. Give your signature to sign off.

H
Remember to look at the top left hand corner where

N
medications that has been stopped during admission are

written, and consider if these need to be restarted.
- After doing all the necessary documents for discharge,
pass the file and all to the staff nurse incharge of the
98
patient. PSAs here do not do discharges.
Afternoon after changes

Teachings
- Fridays Prof rajas teaching will be at 1pm in ward 65s
Location may change so keep a look out for weekly
schedule sent out by secretary every week) tutorial room.
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
M
al
rn
te
In
G
H
N
99
List of Impt Numbers in KTPH
KTPH prefix = 6602 + ____ (see below)
Lab main 2322 Radiology

MicroB 2335 On call radiographer
Biochem 2322/2325 91371751
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
lodgers from Tower A back to

M
Tower B
al
From Kenny Tan, Joel Lee, Quek Zhi Han w/ special thanks
rn
to Eugene Chua
te
In
G
H
N
100
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
Cloxacillin 0.5-2g 4-6h IV bolus/infusion; 250-500mg 6h PO

M
Crystalline Penicillin 4mU 4h IV infusion, [5mU per vial]

Doxycycline 100mg bd PO
al
Erythromycin 500mg-1g 6h PO/IV, EES 800mg 12h PO

rn
Gentamicin 80mg 8h or120-240mg om IV infus [chk lvls]

Imipenem 500mg 6h IV
te
Metronidazole (Flagyl) 400mg 8-12h PO, 500mg 6-8h IV

In
infusion
Piperacillin-Tazo (Tazocin) 4.5g 6-8h IV [pseudomonas]
G
Vancomycin 0.5-1g om-12h IV [chk lvls]

H
Others:Acyclovir 800mg 5x/day x 7-10/7 PO (zoster);250-

N
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
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]
c y
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
Promethazine (Phenergan) 25-50mg PO/ IM/ IV

M
Synacthen test IV 250 g at 0 min (check 0, 30, 60 min)

al
Asthma
rn
Aminophylline: Load IV 6mg/kg/20min (not on Theopylline)

then 25mg/h. (25mg/ml in D5%, Theophy lvl 10-20mg/L)
te
IV Hydrocortisone 100mg 6-8h

In
Neb Ventolin: Atrovent: N/S 1:(0):3 (asthma), 1:2:1 Q4-6h

(COPD)
G
PO Prednisolone 30mg OM x 5/7

H
Theophylline (Nuelin SR) PO 125mg ON/bd, 250mg ON

N
Relievers: Atrovent (20g) (Ipatropium MDI) 2/2 bd

Ventolin (Salbutamol) 4/4 qds/prn MDI, PO 4mg tds/prn
Preventers: Becotide (50g) (Beclomethasone MDI) 2/2 bd-
tds
102
Flixotide (250g) (Fluticasone MDI) 1/1-2/2 bd
Pulmicort (200g) (Budesonide turbohlaer) 2/2 bd
+
Calcium: Calcium: [(40-Alb) x 0.02] + Ca
Low: Ca gluconate 10% 10ml over 10min then 40mls/24h.
Ca et vit D 1/1 OM/bd PO, Calcichew 625-1250mg OM/bd
+
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
GTN (0.3g) 1/1 S/L max x3. Patch (Nitrodisc) 5-10mg/24h

M
Heparin (refer to heparin infusion protocol on pharmacy

bulletin)
al
ISDN 5-20mg bd-tds po [angina, LVF]

rn
ISMN (Imdex 30-60mg om) (Ismo 20mg bd-tds) PO [angina,

CCF]
te
Ticlopidine (Ticlid) 250mg bd PO

In
Warfarin: Load 5,5,3 mg OM then check PT, INR.

[counselling]
G
H
Cholesterol/Lipids
N
Gemfibrozil 0.3-0.6g bd (Triglycerides)

Fenofibrate 100-300mg on
Lovastatin 10-60mg ON (LDL, total) (CI: liver dz)
Simvastatin (Zocor) 10-80mg ON (LDL, total)
103
Pravastatin 10-40mg ON
Atorvastatin 10-80mg ON
Rosuvastatin 5-40mg ON
Ezetimibe 10mg ON
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
Guaifenesin 200-400 mg Q4H (max 2.4 g/day) (expectorant)

M
Procordin 10mls tds (red) (suppressant, hemoptysis)

al
Diarrhoea
rn
Lomotil 1/1 tds-qds [Antimotility]

Loperamide (Imodium) 2-4mg tds-qds [Antimotility]
te
Lacteolforte 1 sachet BD
In
Activated charcoal 2 tab TDS

G
Diabetes/Hypoglycemia
H
Acarbose (Glucobay) 25-100mg tds

N
Glibencamide (Daonil) 2.5-15mg om [long act SU][CI >60yrs]

nd
Gliclazide (Diamicron) 40-80mg om/bd [short act SU, 2 gen]
nd
Glipizide (Minidiab) 2.5mg-10mg om/bd [2 gen SU]
st
Metformin 250mg-1g om-tds [CI: ESRF, acidosis] (1 line in
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
Esomeprazole infusion 8mg/h (80mg in 1 pint N/S @

M
50mls/h)
Somatostatin 0.25mg IV stat then 0.25mg/h infusion
al
(Varices).
rn
Mebeverine 135 mg tds (IBS)

Fluimucil (Acetylcysteine) 60mg BD x 2/7 (b4 CT scan); PO
te
140 mg/kg; IV 150 mg/kg over 60 minutes

In
Gout
G
Allopurinol 100-300mg om [CI: acute attack]

H
Diclofenac sodium SR 75mg BD

N
Colchicine 0.5mg tds

Prednisolone 30mg om x 5/7
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
Nausea, Vomitting, Giddiness

M
Metoclopramide (Maxolon) 10mg tds/prn PO/ IM/ IV

Ondansetron (Zofran) 4mg IV/ 8mg bd PO
al
Prochlorperazine (Stemetil) 5-10mg bd/tds PO, 12.5mg IM

rn
Cinnarizine (Stugeron) 25mg tds/prn PO

te
Neuro-psych meds
In
Diazepam (Valium) 2-10mg PO, 5-10mg IV/IM

Fluoxetine (Prozac) 10-40mg om-bd PO
G
Haloperidol 0.5-5mg bd-tds or on PO, 5mg stat-tds IM/IV

H
Midazolam (Dormicum) 7.5-15mg PO, 1-5mg IV

N
BDZ antag: Flumazenil IV 0.4-0.5mg
Overdose [drug tox = LiH (green tube), levels=plain] Lavage

[<2h,send tox], Act. charcoal 50g 4-6h [<4h]
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
IV 1-3 mcg/kg to 10 mcg/ml; give 10mcg/ 2 min

M
Mist Morphine 5-15mg 4-6h PO + laxative & Maxolon

Morphine 0.5-2mg/h IV or 2-5mg/h SC (AMI: 2-4mg/5min)
al
Pethidine 25-75mg tds/prn IM or 0.5-1mg/kg IV + Maxolon

rn
Tramadol 25-100mg tds prn PO + Lactulose

Hyoscine butylbromide (Buscopan) 10-20mg tds po, 20mg
te
(1ml) IM
In
Topical: Fastum/Voltaren gel

G
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
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
Recormon (Erythropoeitin) 2000-4000u 1-3x/wk SC/IV

M
Sodium True Na+ = Na+ + gluc/4

al
Low: max by 10mM/24h

rn
Not dry, renal fxn good or SIADH: Fluid restrict, Frusemide

+
Dry: 0.9% N/S 0.6 x wt x [125-Na ]/154 litres /24h
te
+
<120/Fitting: Na 3% + Lasix [3%=514/L instead of 154]
In
NaCl 600mg (10mmol @) PO

G
Vitamins/Food
H
IV albumin 20% 100ml over 2hr

N
Calcitonin 100u om-bd IM (test dose 0.1ml S/C) x 5/7, nasal

spray (200U) 1/1 each nostril OM [sitting up, 1 hour before
breakfast]
++
Ca : Ca et vit D 1-2 tab om PO. See also Calcium.
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
Length: 1 cm = 0.394 in = 0.0328 ft

M
Temperature: Celsius=5 x (Farenheit-32) / 9

Weight: 1 kg = 2.2 lb
al
rn
Edited from:
HO Drug list ver 4.70716 updated 16/7/2007
te
Edit history: Gerald Tan, Lim Baoying, Grace Chang

In
This is an informal list only. Always check if in doubt.

Updates/corrections: http://www.geraldtan.com/school
G
H
N
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
EMG / EEG 7070

M
Ward numbers = 2(XX)(Y) where XX is ward level and Y is

al
ward letter (A=1 or 5, B=2 or 6 etc) - e.g. Ward 5A = 2051/5,

rn
Ward 12C = 2123/7

te
When in doubt, press 0 or 63571000 if using workphone

In
G
H
N
110
Acknowledgements
Special thanks to:
Our mentors - for helping to edit this book (in order of

appearance) Prof Koh Nien Yue, Dr Changa, Prof Suresh,
Dr Ranjana, Dr Chia Yew Woon, Dr Phoa Lee Lan, Dr Nigel
Tan, Dr Lee Sze Haur, Dr Adrian Liew, Prof Chia Chung King,
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
With contributions by:

al
rn
R1s 2010/11 Jacqueline Foo, Goh Wen Yang, Ho Quan

Yao, Violet Hoon, Raphael Lee, Joel Lee, Andrew Leong,
te
Raymond Liang, Joel Lim, Brenda Lim, Lin Huiyu, Mahaboob

In
Shariff, Mogilan, Mok Kwang How, Ivy Ng, Quek Zhihan,

Emily Tan, Tan Seng Kiong, Kenny Tan, Valliammai, Daniel
G
Yap, Yeo Chong Ming, Zeng Shanyong

H
N
111

Call To See Patient PDF

Hochgeladen von

Dokumentinformationen

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Call To See Patient PDF

Hochgeladen von

Copyright:

Verfügbare Formate

y c

By NHG IM Residents 2010 batch

Rheumatology, Allergy, Immunology 84

Drug list 101

Important contact numbers 110

Our Patients & their caregivers

I am sure that we remember our first day of work as a doctor,

In response to these needs, the residents have come

guide to many common acute conditions, including survival

tips developed from their collective experience in the past one

residents manage the challenges they face on the ground

better and ultimately, provide better patient care. These are

the features which make this booklet unique and useful.

This is our very first edition of CTSP and there will be

presented here should be used in context. When in doubt,

always consult the immediate supervisor or the senior staff.

(and WHAT to do/expect with the results e.g. keep Hb>

cardiac enzymes, ABGs). May be asked to review sick pts

bookings on Intranet. This can be terribly deceiving though;

seemingly full wards have poor predicative value for the

- Develop a system of keeping track of the things you have

done or not done and prioritizing changes also useful for

the next day if they have any doubts about your

management and also for you to follow-up on the patients

- KNOW YOUR LIMITS! both in terms of experience and

the capacity to bear responsibility if something goes wrong.

- Check with a senior first before ordering certain

investigations (e.g. generally all scans, expensive bld ix)

- PLEASE be polite to the nurses! A bad call with

incessant calls from the nurses and never-ending

admissions/passives will fray the nerves and crush the

souls of the hardiest of HOs. No matter what though,

- Common types of cases encountered: i ne

the sheer volume as all the wards are C class wards

o HO2 (Lvl 7, 11) GRM, RAI, PMD, ID generally gets

o HO3 (Lvl 8, 10) RM and cardio cases Expect to

trace on many ECGs/cardiac enzymes, calls for

abnormal rhythms on telemetry, SoB/chest pain

on lvl 13 generally expect to be attended to quickly

by neuro MOs. Gently remind the nurses if they do call you

for NNI patients

Clerking new cases

hand corner to get Singhealth notes) & HIDS

There may be mistakes in discharge summaries if in

CDMR is a useful place to trace the latest HbA1c, lipid

panel from polyclinics etc.

who have undergone major surgery recently

Look through both prescribed and dispensed medications

(e.g. IMH or SingHealth meds may only be reflected in

Have a system when writing orders

Supplements: myotein etc.

3. Disposition CRIB, fall precaution etc.

5. Management drugs, nursing interventions (e.g

dressings), referrals to PT/OT etc, +/- blue letters

Review the patient through the night if the patient is ill

(most of the time the MO will do it)

seeing some of these same cases on your next night call.

do better next call!

work the next day

u/o, low platelet, high lactate, heart/lung/kidney dyxfxn,

Septic Shock: Sepsis + large volume IVF/pressor need

in vein in <1 hr of low bp (golden hour)

Skin (cellulitis, sacral sore), soft tissue (abscess, myositis,