Residency: Called - To.See - Patient V1.1

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CALLED.TO.SEE.PATIENT v1.1
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
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Table of contents Prologue General Advice General Medicine Cardiology Respiratory Medicine Neurology Renal/Electrolytes Gastroenterology Endocrinology Geriatric Medicine Palliative Medicine
Page 3 5 11 20 35
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Miscellaneous Drug list
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Haematology/Oncology
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Rheumatology, Allergy, Immunology
Important contact numbers
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41 45 63 71 75 81 84 88 93 95 101 110
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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 Foreword
In response to these needs, the residents have come together to write this booklet that aims to provide a practical guide to many common acute conditions, including survival tips developed from their collective experience in the past one year. Through this booklet, they hope to help the new 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 refinements and changes as our understanding of medicine
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I am sure that we remember our first day of work as a doctor, just fresh out of medical school, and of course, our first call the sense of helplessness, insecurity and anxiety. I had wished then, that there was a manual that will provide tips to survive the call and the day, and also guidance for the management of acute conditions.
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It gives me great pleasure as the program director of the NHG-AHPL Internal Medicine Residency Program, to write the foreword for this booklet entitled Called To See Patient (CTSP), which embodies the work and tremendous effort of the pioneer batch of our Internal Medicine residents.
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progresses in future years. I would like to commend the residents on the great effort and thoughts which went into the writing of this booklet. I would also like to thank the Internal Medicine faculty from Tan Tock Seng Hospital, Khoo Teck Puat Hospital and National Neuroscience Institute for their unfailing guidance and support. Dr. Koh Nien Yue Program Director NHG-AHPL Internal Medicine Residency Program Disclaimer
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This booklet serves as a brief general guide to the management of acute conditions commonly encountered in the ward. It is not meant to be exhaustive and the reader should use the standard reference text for further reading. Every patient and situation may differ; hence the information presented here should be used in context. When in doubt, always consult the immediate supervisor or the senior staff.
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General Advice On Call PRE-CALL: - Get enough SLEEP the night before. Extremely impt - Psych up! Easier said than done though; pre-call depression has been known to afflict hapless HOs up to 1 WEEK before the call itself. Think about the wonderful sleep youll get post-call (if you get to go post-call) - Confirm which level youre covering, get the numbers of your MOs and contact them early to ask them how they want to work (e.g. SMS or call? Contact them for new cases or clerk first?) - Get your call room early and changed - HAVE AN EARLY DINNER. Best time to eat is around 5 to 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 down: DIL patients, bloods/ECGs/blue letters etc to trace (and WHAT to do/expect with the results e.g. keep Hb> what level?), investigations to be performed (eg serial cardiac enzymes, ABGs). May be asked to review sick pts but this is usu done by MOs - Scout the wards for empty beds. Can also look at BMU bed bookings on Intranet. This can be terribly deceiving though; seemingly full wards have poor predicative value for the eventual quality of your call - Develop a system of keeping track of the things you have done or not done and prioritizing changes also useful for you to recall pts because the primary team may call you the next day if they have any doubts about your management and also for you to follow-up on the patients after your night call
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- 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, nurses are your allies and friends: they can make or break your call in more ways than one. 6
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- KNOW YOUR LIMITS! both in terms of experience and the capacity to bear responsibility if something goes wrong. Call seniors early if in any doubt! - Check with a senior first before ordering certain investigations (e.g. generally all scans, expensive bld ix) and interventions (e.g. blue letters, high risk meds, listing for scopes)
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ON-CALL: - Got time sleep, got food eat, got water drink. - Learn to PRIORITISE. You may be overwhelmed by the sheer amount of work esp during the first few calls, but if you sieve out whats impt and deal with those first, things become much more manageable. - In rough order of priority: 1. Patient COLLAPSE 2. Urgent passives/patient complaints 3. New cases (generally try to see before your MO) 4. Tracing labs/investigations and acting on them 5. Time sensitive bloods (e.g. cardiac enzymes) 6. Procedures (IDCs, plugs). More urgent if: ARU x long time with high RU/PVRU, plugs for dopamine etc 7. Non-urgent passives (cough syrup, sleeping pills, change med order in eIMR, etc.) 8. Updating/speaking with relatives
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- Common types of cases encountered: o HO1 (Lvl 5, 12) GM, PSY (W5D); Can be flooded by the sheer volume as all the wards are C class wards (Up to 42 patients per ward) o HO2 (Lvl 7, 11) GRM, RAI, PMD, ID generally gets admitted to these levels if beds are available 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 o HO4 (Lvl 9, 13) Renal (W9B), private/A class patients on lvl 13 generally expect to be attended to quickly - Neuro patients both active and passive are taken care of by neuro MOs. Gently remind the nurses if they do call you for NNI patients - 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.
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- When giving meds/ordering investigations/taking blood: Check its the correct patient!! Always check sticky label + order form - Taking GXMs: Sign BOTH the sticky label and order form. Indicate on sticky label date and time the blood was taken - Learn how to dispatch your own bloods using the tube system - Dont dismiss complaints like headache and giddiness. Always check BP and neurology (dont miss ICH!!) - Simple investigations like CBG, SpO2, ECGs can be performed quickly and potentially yield impt information wrt patient complaints. - Try to trace all labs/ECGs youre asked to review document in case notes as appropriate
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Clerking new cases Clerk PMHx from CPRS (rmb to click CMRx at bottom right hand corner to get Singhealth notes) & HIDS There may be mistakes in discharge summaries if in doubt, check earlier summaries or check with patient CDMR is a useful place to trace the latest HbA1c, lipid panel from polyclinics etc. ePACE can also provide a useful summary for patients who have undergone major surgery recently Look through both prescribed and dispensed medications (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
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Accompanying DIL patients down for scans/procedures know at least what the resus status is and ensure appropriate equipment is available (e.g. drugs, fluids, working IV plug available) if for active and unstable may want to carry defibrillator for continuous ECG monitoring, ensure O2 tank has enough O2 to last the journey. Help to push the heavy beds (the Ah-Mahs and nurses will appreciate it)
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Always carry a few add-test form and KY gel with you Useful to carry green (heparin) for BOHB, toxicology, and grey (floride) tubes for lactate with you not all wards stock and may need for acute emergencies Carry coins with you for a quick coffee/coke break at the vending machines Save phone numbers into your work phone as you work it makes future work easier because you do not have to call 0 (for operator) and wait
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 2. Diet Fluids N/S, D/S, premix etc etc. NBM, feeds, soft diet, full diet Type/therapeutic (Dieticians realm): e.g. low salt, low fat, DM, non-milk, low purine, renal, high protein Consistency (STs realm) o Solids: easy chew, soft moist, blended o Fluids: thin, nectar, honey, pudding, NGT o NGT feeding usually over 6-8 shares (e.g. 200ml x 6 + 50ml H2O flushes) Types: Ensure, glucerna, nephro etc. Supplements: myotein etc. 3. Disposition CRIB, fall precaution etc. 4. Investigations blds, imaging, urine, stool, 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)
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POST-CALL: - HAND-BACK sick patients you encountered overnight esp those that should be seen by the primary team early in the AM round - Also be sure to HAND-BACK any significantly abnormal lab/imaging results, esp if asked to trace them overnight - Try to grab a quick breakfast before AM rounds start - Post-call (ie leave by 1pm or so) privilege has now become more common for HOs unlike in the good (bad) old days. Responsibility must however be borne when exercising this privilege. Be sure to finish up ALL your morning round changes and handover appropriately before you saunter off home. - 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, signs may develop, cases will evolve. You may even end up seeing some of these same cases on your next night call. - Read up and reflect on your performance that call. Aim to do better next call! - Savour the post-call euphoria while you can. Its back to work the next day
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Approach: Differentiate isolated fever (have time) from sepsis (urgent) and severe sepsis/shock (emergency) SIRS: At least 2 of : T>38.5C or <35.0C; HR >90; RR >20 or PaCO2 of <32; WBC >12K or <4K or >10% bands Sepsis = SIRS + proven OR suspected infection (Nonseptic sirs = burn, pancreatitis, large PE etc) Severe Sepsis = Sepsis + organ dysfxn (mottled skin, low u/o, low platelet, high lactate, heart/lung/kidney dyxfxn, DIVC, altered mentation etc Septic Shock: Sepsis + large volume IVF/pressor need Note: if Sepsis + Hypotension, correct antibiotics need to be in vein in <1 hr of low bp (golden hour)
Find Source: Skin (cellulitis, sacral sore), soft tissue (abscess, myositis, nec fasc, forniers), respi (sinus, lung CAP, HAP, HCAP), CNS (mening / enceph), GU (pyelo, prostate, cystitis), GI (Cdiff, GE), Joint (Septic jt), Abd (peritonitis / perf gut), HBS (cholangitis, absess), bloodstream, plug, endocarditis, device Travel/contact/exposure hx Recent antibiotics & treatment by e.g. GP
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General Medicine A. SEPSIS/SPIKE FEVER CTSP: new case sepsis, or inpt spike fever Definition: True fever is > 38 C Low Grade fever: query significance (exception: elderly, immunosuppressed, dialysis pts, persistent >37.2 (E) or 37.5 (R) may be significant); Non-infectious fever: drugs, RAI dz, tumour, DVT/PE, CNS insult etc
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Rule of thumb: can never be too many blood cultures done if source / diagnosis not confirmed.
PE Vitals, GCS, SpO2; Ensure pt not in shock (check tissue and organ perfusion) Look for source: front, back, cavity (oral / PR), plug Ix - FBC, CRP, Blood c/s x2 from different sites (1 set never enough in adults) procal (esp if uncertain re: bacterial infection); others eg CK, creat, LFT, LP depending on s/s - CXR +/- AXR - UFEME, urine c/s - If new pneumonia: Urine strep / Legionella Ag, Influenza PCR (remember deep nasopharyngeal swab or sputum, NOT nasal swab for flu PCR) - Sputum AFB, c/s if suspect TB e.g. chronic cough symptoms, LoW/LoA, night sweats, prev pTB - 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
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If existing inpt case reason for adm, last septic w/u, current Abx regime, old culture data, standing orders from primary team, r/o fever vs sepsis (see above) o If pt well (fever but not septic) and w/u done within 4 days, usu no need to repeat septic w/u. May repeat blood cx x2 if T>38 and still no diagnosis. Also no need to escalate Abx on night call can wait for primary team to decide CM o If patient has new/worsening sepsis, repeat w/u (unless done within 24-48 hours), escalate abx
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Common empirical Abx CAP: IV Augmentin+ PO Klacid (! Prolonged QTc use Doxycyline) Severe CAP: KIV ICU, use IV Penicillin 4 MU 6h, IV ceftaz 2g 8h, IV Azithro 500mg 24h HAP/HCAP: IV piptazo + vancomycin Aspiration: IV / PO Augmentin Meningitis: Ceftraixone 2g q12h + Vanco Meningitis if listeria suspect: add IV ampicillin Meningoencephalitis: add IV acyclovir Severe HBS: IV cefazolin+PO flagyl+IV Gentax1 Non-catheterized Cystitis, Foley UTI, neurogenic bladder: If pt stable, Wait for urine culture (no hurry); culture-guided PO bactrim ideal
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Mx - KIV Isolate: Airborne (TB, measles, chickenpox, unknown severe resp. illness), droplet (influenza, mumps, rubella, meningococcal meningitis until 24 hrs abx), contact - REFER ARUS-C for empirical antibiotic guidelines - Remember to adjust Abx for renal function
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stool for ova/cyst/parasite if(+)travel hx. KIV CDiff in all (prior abx or not). - Wound swabs never helpful (actually harmful b/c confusing). Should ONLY swab if pus seen from draining sinus. All others: do not swab (await deep biopsy by GS / IR). - Line sepsis draw bld from line AND periphery. If st differential time to positivity >120 min (line 1 , then periph) highly suspect line source. If unstable remove line send tip for c/s, do periph c/s x2.
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IF UTI pt unstable, suspect pyelonephritis, perinephric/prostate abscess etc; start IV cefazolin plus gentax1, do imaging (US, CT) Line sepsis (e.g permanent catheter), prosthetic septic joint: IV vancomycin Cellulitis, native septic joint: IV cefazolin
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B. GIDDINESS/SYNCOPE Rule out hypoglycaemia and uncontrolled hypertension Determine if there was syncope/LOC or not Syncope: - Rule out seizures (need not be GTC; can be atonic seizure) o preictal (aura/palpitations/pallor), ictal (GTC, loss of continence, biting of tongue, veering of eyes) and postictal (drowsiness, Todds paralysis) - True syncope - transient LOC of few seconds with spontaneous recovery - Ensure no HI, contusion, # (if fragility # over typical sites eg. radius, hip, VB, ?coexistence of osteoporosis); then consider the following causes: o CVS: Arrhythmias or LVOTO eg. AS/HOCM o Neuro: CVA/TIA o Postural hypotension: dehydration, blood loss, BP meds, autonomic failure (DM, MSA, amyloidosis), adrenal insufficiency/ panhypopit, peripheral vasodilation 2* sepsis, baroreceptor insensitivity (e.g. old age) o Vasovagal o Situational e.g. cough, pain, micturition (e.g. straining from LUTS 2* BPH) Giddiness: Differentiate into the following categories o Vertigo - central (eg. vetebrobasilar insufficiency (VBI) or posterior circulation CVA) or peripheral (BPPV, menieres, vestibular neuronitis from URTI/otitis media) 15
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Dysequilibrium: Parkinsons disease, cervical myelopathy, peripheral neuropathy Presyncope (approach as per syncope) Non-specific giddiness eg. from hyponatremia/ psychiatric causes (e.g. anxiety)
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Orders Fall precaution Postural BP monitoring FBC, UECr (depending on Na/K KIV 8am cortisol), cardiac enzymes, CBG monitoring ECG X-rays of areas suspected #s +/- BMD KIV CT head, MRI/MRA Treatment depends on cause - KIV ENT referral for peripheral vertigo for audiometry; KIV 24-hr Holter monitoring in patients w/ suspected arrhythmias Symptomatic treatment e.g. sturgeron for vertigo; avoid stemetil in patients with parkinsonism
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Examine for mumurs, carotid bruits Dix-Hallpike maeuveur and otoscopy for vertigo
- If agitated, encourage family members to stay with patient, nurse close to nursing counter - If patient very disruptive or in danger of self-harm - low dose antipsychotics e.g. 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 By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
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- Ix as appropriate for causative factors - Treat causative and reversible factors
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Causes Medications (e.g Antidepressants, pain meds, anticholinergics. Anti-parkinsonism)Exercise caution when prescribing COUGH MIXTURES, PAIN MEDICATIONS, SLEEPING PILLS Metabolic ( hypo/hyperglycemia, thyroid conditions, electrolytes Infx (sepsis, pneumonia, meningitis) CVA/ICH Acute coronary syndromes ARU/Constipation Pain (Be cautious with pain meds, if need for opoids, KIV low dose e.g. PO tramadol 25mg BD PRN and titrate)
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C. DELIRIUM Aka AMS, CTSP re: pt confused, behaviourial change Confusion Assessment Method (CAM) Acute onset and fluctuating course AND Inattention AND Disorganised thinking OR Altered level of consciousness
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Note: May get calls for the elderly being unable to sleep, requesting for sleeping pills or coughing elderly requesting for cough mixture Advise on S/E e.g. AMS, ARU (piriton) Encourage sleep hygiene KIV substitutes (e.g. fluimucil instead of cough syrup)
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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 confused (e.g. climbing and falling out of bed
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Start BCLS Start CPR, get E-trolley Attach ECG leads (not 12-lead) watch for cardiac rhythm on defibrillator and shock PRN i.e. ACLS Start bag-valve-mask with 100% O2 Ask for stat CBG Set 2 large bore IV lines +/- draw all 4 tubes/ABG Prepare intubation set intubate if appropriate Start running IV fluids FAST i.e. 1L over 30 mins Ask nurses to prepare and start appropriate meds e.g. adrenaline, dopamine (may have to specify exact dilution and dose esp if no experienced nurses are around) Help to arrange for transfer to HD/ICU Help to document events and record important events and medications given +/- help to update family
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D. COLLAPSE/MEGACODE RESUS i.e. patient found unresponsive, pulseless, no BP See patient IMMEDIATELY, contact MO/Reg ASAP Find out if patient has any resus status if none = DILactive until proven otherwise Usually there will be chaos (Try to) stay calm and assume the leadership position until someone more senior arrives. Listen to the senior nurses they have more experience than you. After which, be vigilant, listen to instructions and help out wherever appropriate (i.e. dont switch off)
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
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ECG (compare w/ prev ECGs) ST, T wave changes, new arrhythmias (e.g. LBBB) Cardiac enzymes (CEs) TropI (detectable 4-6hrs, peak 1236hrs, 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
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PE quick head to toe including GCS, BP on both arms, RR/R-F delay, heart sounds (?new murmur), JVP, creps, acute abdomen, calves/LL
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Hx typical cardiac pain retrosternal, ppt by exertion and relieved by GTN (2 out of 3); crushing, radiation to jaw or left shoulder, a/w nausea, diaphoresis, SoB, syncope, duration >15mins
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Call senior for help if vitals unstable, looks ill
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Eyeball the patient Read through the case-notes quickly (e.g. look for risk factors for IHD) and look at the ECG
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Life-threatening causes Cardiac: ACS AMI/NSTEMI/UA, aortic dissection Respi: PE, tension pneumothorax GI: perf viscus (e.g. perf peptic ulcer, esophagus)
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), ABG (if unstable, desat or respiratory distress)
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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 Assess and stablise ABCs Supplemental O2 if pt hypoxic, keep SpO2 >95% Focussed hx and PE: Assess for left heart failure, hemodynamic compromise, baseline neurologic function (to watch signs of ICH later)
If NSTEMI/Unstable angina Inform senior KIV urgent PCI if hemodynamically unstable or cardiogenic shock, heart failure, add plavix 300mg STAT + 75mg OM, S/C clexane
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If STEMI - Inform senior KIV arrange for urgent PCI (within 90mins)
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FBC, UECr, PT/PTT/INR, cardiac enzymes, GXM S/L GTN 0.5mg up to x 3 PO aspirin 300mg STAT + 100mg OM (if no contraindications e.g. recent major GI bleed, ICH) Beta-blockers e.g. bisoprolol 1.25-2.5mg, atenolol 25mg if no heart failure, hypotension, bradycardia, severe reactive airway dz IV morphine 2-4mg slow Q5-15mins Cover with PPI
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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 causes of symptoms ARDS (e.g. pneumonia), neurogenic (e.g. CVA)
Rx ABCs Supplemental O2 as required if hypoxic keep SpO2 >9295% KIV NPPV/intubation Diuretics IV frusemide 20-80mg STAT + BD (watch BP, UECr) watch for response and titrate Close monitoring - hrly para + SpO2 KIV vasodilators, inotropes Strict I/O insert IDC if required Fluid restrict 0.8-1L/day, Low salt diet Daily weight
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Ix ECG e.g. T wave inversions, LVH, Q waves CXR FBC, UECr, cardiac enzymes, ABG
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Identify ppt factors Cardiac: ACS, arrhythmias (e.g. AF), progression of CCF Non-cardiac: severe hypertension, renal impairment, anaemia, hypo/hyperthyroidism, fluid/diet indiscretion, noncompliance, iatrogenic (e.g. fluid resus, bld transfusion)
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D. HYPERTENSION CTSP re: BP >180/120 Differentiate HTN urgency (w/o end organ damage) vs HTN emergency (w/ end organ damage) Evidence of end organ damage Neuro: infarct/bleed/encephalopathy/papilloedema CVS: AMI/APO/Aortic dissection Renal: AKI
Mx for HTN Emergency: Inform a senior Monitor hrly para, GCS + initiate supportive Mx for complications 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
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Mx for HTN Urgency Serve anti-HTN meds early if near meds time Amlodipine 2.5-5mg or captopril 12.5-25mg Aim to reduce BP over hrs to days
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Quick assessment Symptoms e.g. chest pain, blurring of vision, headache, nausea/vomiting, confusion Signs - Assess ABCs, vitals and recheck manual BP (on both limbs), review BP trend, GCS, neuro exam, JVP, lungs for creps, pedal edema, peripheral pulses, fundoscopy for papilloedema ECG, blds (e.g. UECr, cardiac enzymes) +/- CT brain, CT aortogram
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0.5 to 2 mcg/min IV hydralazine 10mg bolus (up to 20mg) st Aim for 10% BP reduction in 1 hr then additional 15% in next 2-3hrs
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Mx Hrly para+SpO2 Strict I/O (insert IDC or at least urosheath) Large bore IV plug (x2 if pt unstable) Contd fluid resuscitation Look through eIMR off anti-hypertensives If pt already beginning to show signs of pulmonary edema/fluid overload or pt high risk (elderly, CCF/poor EF, ESRF) and already given large volumes of fluid (>1-1.5) but still hypotensive, consider inotropes (i.e. dopamine up to 20mcg/kg/min)
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Ix (as indicated) FBC, UECr, PT/PTT +/- GXM, septic w/u ECG + CEs
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Evaluation Hx (chest pain, SoB), PE (include assess fluid status, DRE)
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E. HYPOTENSION CTSP re: BP low Exclude SHOCK i.e. end organ damage from any cause (commonly hypovolemic, septic, cardiogenic; also obstructive, anaphylactic, neurogenic) Ask other vital signs, GCS, usual BP trend, resus status over the phone Order a fast drip i.e. 500ml over 15-30mins over the phone and see the pt ASAP/early Look through case notes looking particular for hx of CCF, ESRF (i.e. risk factors for fluid overload) If pt unstable or doesnt respond to fluid challenge, inform senior
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 Assess for underlying cause, common causes: Fever, pain Hypovolemia/shock from various causes (e.g. sepsis), anaemia Cardiac e.g. Fast AF, atrial flutter, SVT, VT/VF may be ppt by cardiac or non-cardiac causes Pulmonary embolism Hyperthyroidism, hypoglycemia, electrolyte abnormalities Drugs (e.g. caffeine, salbutamol nebs, smoking) Anxiety/Panic attack
Mx of fast AF Determine if it is new onset unlikely but if new onset AF KIV pharmacological or electrical cardioversion If hemodynamically unstable sedate & electrical cardioversion (50J, 100J, 150J) until sinus rhythm If stable for rate control consider: Beta blockers e.g. bisoprolol 1.25mg, atenolol 25mg if no cardiac failure, severe reactive airway dz 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)
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If ECG not sinus tachycardia, inform senior ASAP See ACLS (pg 30)
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Ca channel blockers e.g. verapamil, diltiazem (!caution cardiac failure, heart block)
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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 Can be either too fast (e.g. multiple PVCs, fast AF) or too slow (e.g. sinus pause, sinus bradycardia, heart blocks) Check pts vitals, GCS and for any symptoms, ask for a 12 lead ECG If unstable or symptomatic inform senior If stable o Read through case notes to find out WHY pt is on telemetry (e.g. recent NSTEMI, severe hypokalemia) o Look for ischemia on 12-lead ECG (may be missed on telemetry) o Continue Mx - e.g. correct electrolytes
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G. DVT/PE Hx Unilateral LL swelling, pain, tenderness, erythema Wells Score for DVT Findings Paralysis, paresis, recent ortho casting of LL Bedridden for >3 days or major surgery within past 4 weeks Localized tenderness in deep vein system Swelling of entire leg Calf swelling >3cm other LL measured 10cm below tibial tuberosity Pitting edema greater in symptomatic leg Collateral non-varicose superficial veins Active Ca or Ca treated within 6 months Alternative diagnosis more likely (e.g. cellulitis, Bakers cyst) *Probability 3pts high, 1-2pts mod, 0pts low Points 1 1
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Ix FBC, PT/PTT/INR, D-dimer (to rule out if pt is low risk on Wells score) +/- Thrombophilia screen (i.e. anti-cardiolipin, Protein C, Protein S, APC resistance, lupus anticoagulant for unprovoked or recurrent venous thromboembolism or in young pts need to be done before pt started on anticoagulation, (may not change Mx) US LL venous system Mx S/C clexane 1mg/kg BD (! Bleeding, low Hb) Prevention! TED stockings etc. 29
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1 1 1 1 1 1 -2
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 Wells Score for PE Findings Symptoms of DVT No alternative dx that better explains dz Tachycardia >100 Immobilization 3 days or surgery in prev 4 weeks Prev hx of DVT/PE Presence of hemoptysis Presence of Ca *Probability: 7pts high; 2-6 mod; 1 low
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Mx If unstable Inform senior, ABCs, transfer pt to HD/ICU, KIV thrombolysis or embolectomy hrly paras, fluids, inotropes as indicated If stable - S/C clexane 1mg/kg BD (! Renal adjust) 30
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Ix FBC, ABG, UECr, D-dimer (to rule out if pt is low risk on Wells score) ECG + CE CXR (to exclude other resp causes) CT pulmonary angiogram (will need green plug) KIV 2DEcho
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Points 3 3 1.5 1.5 1.5 1 1
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ACLS protocols
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Respiratory Medicine A. SHORTNESS OF BREATH/DESATURATION CTSP pt c/o SoB, pt desaturated on VM50% Generally should see ASAP Over the phone - vitals (SpO2 especially!!), patients general condition, any other concurrent symptoms Important (life-threatening) causes: Cardiac: AMI, APO, ADHF/CCF, arrhythmias, tamponade Pulmonary: Pneumothorax, PE, Pneumonia (maybe aspiration??), COPD/asthma attack, pleural effusion GI: BGIT, ascites Symptomatic anemia, shock (e.g. hypovolemic) Metabolic: Acidosis (e.g. DKA), Poisons (e.g. salicylates), thyrotoxicosis Others: anaphylaxis w/ bronchospasm, GBS, myasthenia More benign causes (but still must be addressed): Anxiety, hyperventilation fever, pain ARU, constipation?? Hx Onset, associated symptoms (e.g. chest pain, cough, hemoptysis) Quickly review case notes/CPSS, I/O charts, DIL status, main diagnoses, latest bloods/CXR PE !ALERT AMS, inability to sustain respiratory effort, cyanosis, upright/tripod position, use of accessory muscles and retractions, diaphoretic, short words, stridor/wheezing /silent chest Inform senior early if any doubt!! 35 By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
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Treat underlying cause (i.e. SpO2 100% on 100% NRM means nothing if the underlying cause is not addressed) e.g. fluid resus, lasix for APO (Note: Giving nebs to pt with cardiac wheeze without diuresis may worsen CCF, predispose to arrhythmias) Always interpret ABG with knowledge of the FiO2 (key amt of O2 supp pt is on into special instructions of AURORA so other people will know) To assess the severity of hypoxia, calculate the PaO2/FiO2 ratio. o PaO2/FiO2 < 300: acute lung injury o PaO2/FiO2 <200: ARDS Type 1 RF: pO2<60mmHg, normal/low pCO2 Type 2 RF: pO2 <60 mmHg, pCO2 >50 mmHg
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Supplemental O2 devices and est. FiO2 INO2 up to ~40% - max 4-6L VM - 24-50% Non-rebreather mask (NRM) 60% (2 valve leaflets are taken off), 80%, 100%
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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 CXR Supplemental O2 (95%, 90-92% in COPD pts)
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FBC, UECr +/- bld c/s ABG (e.g. background Stage 3-4 COPD) CXR *Sputum c/s not indicated unless there are CXR features suggestive of pneumonia and patient is able to produce good sputum for specimen collection (Sputum gram stain and C/S is not ordered for infective exacerbation of COPD if CXR does not show presence of consolidation. Urinary Strep/Legionella Ag only ordered for CAP and not COPD exacerbation) ECG +/- CEs
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Staging on lung function test: FEV1/FVC<0.7 AND Stage 1 FEV1 >80% predicted Stage 2 FEV1 50-80% predicted Stage 3 FEV1 30-50% predicted Stage 4 FEV1 <30% predicted or <50% w/ chronic resp failure
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B. ACUTE EXACERBATION OF COPD CTSP new case, SoB in existing cases Acute exacerbation = acute increase in symptoms beyond normal day-to-day variation (cough frequency and severity, sputum volume and character/purulence, SoB) Ppt factors: infection viral (1/3 to 2/3 of cases), bacterial (1/3 to of cases), environmental factors, non-compliance to meds, unknown Consider other causes of SoB e.g. PE, pneumonia, pulmonary edema/CCF, asthma, bronchiectasis, PTX Other points LTOT at home? Prev intubations/ICU adm, social Hx
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Rx O2 aim SpO2 >92% (For pts with chronic T2RF with or without LTOT SpO2 >88% may suffice), PAO2 >60mmhg w/ Venturi mask (more precise control of FiO2) or INO2 (more comfortable) FiO2 by INO2 = 21 + Ax4 (where A=No. of L of O2) (Very rough estimate - dependent on RR of patient) Nebs salbutamol:ipratropium:N/S (1:2:1) stat and Q4-6H. Up to 2 stat nebs can be given to break bronchospasm. PO prednisolone 30mg 1/52 or IV hydrocortisone 100mg 6hrly (if unable to tolerate orally) Mucolytics (e.g. fluimicil) no evidence but can be given for symptom control Antibiotics (e.g. augmentin/klacid) if increase sputum purulence + SOB or increase sputum volume KIV NPPV (e.g. pH <7.33, pCO2 >50 and patients clinically worsen eg increasing drowsiness despite Mx) or intubation if severe (inform senior if patient unwell or does not respond to initial Mx)
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Other points prev intubations/adm to hosp/EDs (may not be recorded in prev d/c summaries), atopy Ix FBC, UECr +/- ABG CXR ECG +/- CEs 39
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Asthma control test: In past 4 weeks Points 1 2 3 4 5 1. How often asthma limited activity at work or home All the Most of Some of A little of None of time the time the time the time the time 2. How often SoB >1x/day 1x/day 3-6x/wk 1-2x/wk None 3. Wake up at night or earlier than usual >=4x/wk 2-3x/wk 1x/wk 1-2x /mth None 4. How often use rescue inhaler or nebs >=3x/day 1-2x/day 2-3x/wk >=1x /wk None 5. Self-rating of asthma Not Poorly SomeWell Complet controlled what e If ACT<20 = not controlled
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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
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 depending on severity. Up to 3 stat nebs can be given to break bronchospasm if no contraindications. Beware of higher freq of nebs in the elderly). +/- add ipratropium nebs (i.e. 1:2:1) PO prednisolone 30mg OM or IV hydrocortisone 100mg 6Hly (if unable to tolerate orally) Reassess pt frequently PRN to monitor response KIV IV MgSO4 2g over 20mins KIV intubation if severe (inform senior if patient unwell or does not respond to initial Mx)
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Orders Hrly paras, CLC monitoring, call Dr if GCS drop >2 (see below), NBM + IV NS 2L/day unless CCF/renal impairment (risk of asp), IN O2 if SaO2<90% FBC (before starting antiplatelets), UECr, LFT, Cardiac enzymes (3-4% have intercurrent MI) Lipid panel/HbA1c CM if not up to date; fasting glucose if not evaluated before PT/INR (should pt need warfarin/thrombolysis and in hemorrhagic CVA) KIV ESR, ACA, LA, fasting homocysteine, Syphilis IgG LIA, thrombophilia evaluation if patient is young KIV Doppler carotid US + TCD with bubble contrast + 2DEcho CM Check CBG; avoid hyperglycemia which can worsen stroke penumbra; keep CBG between 4-8mmmol (use SC insulin if CBG > 10 mmol/L)
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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 IA thrombolysis, <8hours consider MERCI/TREVO) barring contraindications Determine handedness Examine patient for focal neurology congruent to site of CVA, AFib /mitral stenosis /prosthetic heart valves /CCF stigmata of IE (all of which may suggest cardioembolic source), carotid bruit
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SAH necessitates urgent NS referral; pt would need to be started on PO nimodipine and require a 4-vessel angiogram KIV clipping/coiling
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Fall in GCS or deterioration in neurological status consider: hypoglycemia, electrolyte imbalance, infection (UTI, aspiration pneumonitis), hypotension, arrhythmia, AMI, hyperviscosity syndrome and complications of CVA (cerebral edema, hemorrhagic conversion, new CVA, progression of thrombosis, postictal state, obstructive hydrocephalus). Consider decompression craniectomy if <48 hours from onset for malignant MCA infarction.
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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 >220mmHg/DBP >120mmHg or hypertensive encephalopathy/crisis
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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 (give IM/IV 2.5mg diazepam for GRM pts due to low volume of distribution and lower hepatic metabolism)
Document seizure type (generalized/partial; complex/simple), duration and number of seizures, aborted spontaneously or by BZDs/AEDs Causes Known epileptic: non-compliance, intercurrent illness, sleep deprivation, recent change in meds, drug interactions reducing [AED] AND also causes listed below Non-epileptic: infection, electrolyte abnormalities, hypoxemia, acidosis, uraemia, hyperammonemia, drugs, CVA, intracranial mets, alcohol withdrawal, HI Orders Insert IV cannula (may need for further meds) Review hypocount results (correct if needed) ECG after seizure aborted: arrhythmias/heart block (Stokes-Adams attack) FBC, UECr, Ca/Mg/Po4, Cl- (anion gap), ABG +/- AED levels, toxicology screen, 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
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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 of consciousness in between (status epilepticus) escalate to MO to consider NL referral and to start loading with IV 1820mg/kg phenytoin infusion (must monitor HR, RR, BP. Max rate is 50mg/min)
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*Pt should become more alert post-ictally in a few hours; if not consider neuroimaging or flumazenil if more than one dose of BZD given (consult MO)
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- If transplant: o What kind of transplant deceased, living related from who, overseas from where? Follow-up where/who? o How long ago was the transplant? o What immunosuppression usually on three types? o Transplant functioning, failed on dialysis or being planned for dialysis, or allograft dysfunction previous renal function? o Previous infectious complications? 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),
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- If PD: o For how long? o CAPD or APD? What regime? o Care-giver? o PD book available usual UF? Missed exchanges? o Previous peritonitis or problems with PD?
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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? If HD: o HD where, which days? - e.g. NKF AMK Ave 1 1,3,5 o HD which vascular access e.g. AVF, Perm cath, AVG if perm cath date when it was inserted o Last dialysis when completed? (usually 4 hrs) o Latest dry weight
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+/- 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 o Hypotension/giddiness during dialysis whether high intradialytic weight gain, shortened dialysis times, problems with dialysis o Always assume cardiac event if patient presents with SOB or low BP if on regular dialysis. o Other medical conditions e.g. pneumonia DO NOT TAKE BLOOD FROM PERM CATH! (OR THE RENAL TEAM WILL KILL YOU) **esp when writing blue letters may need to call dialysis centre for more details re: any issues during dialysis e.g. hypotension, poor blood flow (QB) Dialysis centres may change patients meds or give meds not reflected in discharge meds (e.g. IV calcijex 1x/month) Non-urgent bloods can be deferred to be taken pre-HD in next HD except PT/PTT/INR Indications for urgent dialysis Refractory fluid overload Refractory hyperkalemia or rapidly rising potassium levels Signs of uremia, such as pericarditis, neuropathy, or an otherwise unexplained decline in mental status (uraemic encephalopathy) +/- Metabolic acidosis (pH less than 7.1) +/- Certain alcohol and drug intoxications
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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
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Orders Reverse reversible causes (e.g. IV hydration for dehydration, Insert IDC for obstruction) Review medications take off nephrotoxic medications (e.g. ACE-Is/ARBs) Strict I/O charting ++/- insert IDC KIV Ix - FBC, UECr, Ca/PO4, PT/PTT, ABG, ECGs +/cardiac enzymes, CXR, UFEME, urine PCR, urgent U/S kidneys May need urgent dialysis (see above)
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Assess for causes Pre-renal (decreased renal perfusion) - Shock (Sepsis, Dehydration), Uncontrolled HTN etc. Renal - ATN, GN, AIN, drugs Post-renal obstruction
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 patients, otherwise can try potting patient, CIC if recurrent RU <150ml watch or pot patient If difficult catheterization, try different sizes, nelaton catheter but careful not to create false track Sometimes a larger IDC may be easier to insert as the tip is firmer
If NPU and IDC in-situ Assess for blocked IDC Palpate for bladder, bladder scan Look for kinks, blockage etc. along length of tube to urine bag Flush IDC (using aseptic technique, flush 20-30ml of sterile normal saline with large tipped 50ml syringe, repeat until both in and outflow is smooth) 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
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Assess for common causes of ARU constipation, UTI, BPH +/- order Ix (e.g. UFEME, urine c/s) and Mx (e.g. clear bowels)
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Document IDC insertion indicate if there were difficulties with catheterization
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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 If NPU + no bladder + dehydrated = hypovolemia Look through I/Os Fluid challenge (e.g. 500ml N/S over 1-4hrs) Watch for urine output
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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 o D50 can be omitted if CBG>18, KIV dextrose drip if CBG<6 or patient at risk of hypogly o PO/PR resonium STAT and tds x 1/7 o Stop all medications tt can increase K (e.g. ACE/ARB, K drip) o CBG q1 hr x 6H (12H if renal failure) o Keep hrly para till resolution o Repeat K and ECG in 4 hours
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If persistent, repeat above +/- IV lasix, ventolin nebulizer or dialysis (urgent referral to renal), refer dietician if repeated
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Other Considerations 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 By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
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If hypokalaemia with metabolic acidosis Think of conditions with both K and bicarbonate loss/H+ retention e.g. RTA, Acute diarrhoea
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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) Look for possible source of loss: GI (e.g. diarrhea), renal (e.g. diuretics) Look for possible causes of intracellular shift: insulin therapy, hyperthyroidism, beta 2 agonist therapy Check BP - if high, may need to consider: Hypertension with diuretic use, Conns, RAS, Hypercortisolic states Check blood for magnesium, bicarbonate and creatinine kinase (if muscle aches, weakness) Check ECG for U waves (V4-6), ST depression, T inversion, large/wide P wave, increased QT interval, ectopics, arrhythmia
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Potassium Replacement PREPARATION Span K 0.6 gram Mist KCL 10 ml Potassium Citrate 10 ml Potassium Citrate 1 tablet IV 7.45% KCL 10 ml IV KH2PO4 10 ml K (mmol) 8 13.4 28 10 10 10
If asymptomatic/K>2.5: PO Span-K 1-2 tab OM to BD (large tablet, cannot be pounded) or mist KCl 5-10ml tds (bitter) for a fixed duration (e.g. 2/7) Correct hypomagnesaemia Recheck after replacement
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If symptomatic/K<2.5/ECG changes: 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 mmol/hour Patients with critical hypokalaemia (< 2 mmol/l), those with ECG changes or those who need rapid replacement (> 10 mmol/hour) consider cardiac monitoring (either telemetry or in high dependency) Review medication list Correct hypomagnesaemia
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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 Hypervolemic Hypertonic saline, Cushings, Hyperralodsteronism
Extra-renal GI, skin loss
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 By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
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Management: 1. Correct underlying cause 2. Correct hyperosmolar and hypernatremic state
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Renal loss Diuretics, osmotic diuresis, diabetes insipidus (central, nephrogenic)
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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 used only if there is significant hypotension from dehydration. INFUSATE Dextrose 5% 0.45% NaCl 0.33% NaCl/Dextrose 5%/10mmol KCl
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OR if using infusate with potassium, Change in serum Na = ((Infusate Na+ Infusate K) Serum Na) (#Total Body Water + 1) (#Total body water = F x Body Weight -- where F=0.6 in nonelderly men, 0.5 in non-elderly women and F=0.5 in elderly men and 0.45 in elderly women)
Step 2: Determine rate of infusion usual target is to reduce 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)
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Change in serum Na = (Infusate Na - Serum Na) (#Total Body Water + 1)
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Step 1: Decide on the infusate and estimate the effect of 1 litre of the infusate on the serum sodium
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Na (mmol/l) 0 77 56 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) Caution if pt has CCF or CKD (!fluid overload)
Monitor the serum sodium closely and adjust the volume and rate of infusate accordingly.
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Acute Symptomatic Hyponatremia (<48hrs) This is an indication for the use of hypertonic saline. (Must 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
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Pertinent Laboratory Investigations - U/E/Creatinine - Plasma glucose - Plasma osmolality - Urine osmolality - Urine sodium concentration - Thyroid function test and evaluation for hypocortisolism
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At the bedside - Ascertain conscious level and neurological status - Check for medications which can cause hyponatremia - Take history with regards to fluid intake and loss - Assess the patients extracellular fluid volume status
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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 severe hyponatremia - Determine the acuity or chronicity of the hyponatremia as this determines the severity of symptoms and the appropriate rapidity to which the hyponatremia should be corrected
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. (Must discuss with senior) A calculation of the appropriate infusion rate and amount should be made. Frequent monitoring of sodium eg 4 to 6 hrly. Chronic Asymptomatic Hyponatremia Most patients with a serum sodium concentration greater than 125 mmol/l or with chronic hyponatremia do not have neurologic symptoms. Use of hypertonic saline is not warranted. Treatment is directed at the underlying cause after appropriate investigations. On a night call, do not presume the cause is SIADH*. In hemodynamically stable patient, a maintenance IV 0.9% Saline at 60mls/hr may be appropriate. Limits of therapy are to raise the serum sodium concentration by less than 12 mmol/l in the first 24 hours and less than 18 mmol/l in the first 48 hours. Rates of correction: Acute symptoms (eg seizures) 2-4 mEq/L per hr Symptoms 1-2 mEq/L per hr Mild symptoms 0.5 mEq/L per hr 1 liter of 3% Saline contains 513 mmol of sodium 1 liter of 0.9% Saline contains 154 mmol of sodium
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The causes of SIADH include medications (eg TCA, SSRIs, antipsychotics), disorders of the central nervous system (eg bleeding and masses such as subdural hematoma, haemorrhage and brain tumours), pulmonary disorders (eg pneumonia, tuberculosis, lung carcinoma) and transient causes such as nausea, pain, stress, endurance exercise and general anaesthesia.
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*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.
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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): hyperparathyroidism (primary or tertiary), FHH, malignancy associated PTHrp secretion iPTH independent (PO4 is usually high/normal): dehydration, immobilization, multiple myeloma, lymphoma, sarcoidosis, vitamin D excess, thyrotoxicosis, Pagets, malignancy induced osteolytic bone activity
Orders: Assess ABCs, fluid and neurological status Paired Ca panel and serum iPTH, ALP, UECr, Mg, FBC, plasma glucose, CXR, ECG (look for shortened QT) IV fluid hydration is the cornerstone of treatment In tolerant patients, aim for total fluid intake >= 3 liters/day In symptomatic or severe hyperCa >= 3.5mmol/l, Consider: o IM/SC/intranasal calcitonin 200 -400 units/day in 2 divided doses (Tachyphylaxis develops in 48 to 72 hrs) o IV Bisphosphonates (Do not initiate in dehydrated patients with renal impairment. Effect peaks in 5 to 6 days) IV Zoledronate 4mg over minimum 15mins OR IV Pamidronate 60mg in 500mls NS as a slow infusion over 4 hrs (Renal impairment is a contraindication) o If well hydrated, consider IV Lasix 20-40 mg to induce diuresis and decrease calcium reabsorption. (May contribute to electrolyte disturbances) Steroids for hypervitaminosis D, bone mets & sarcoidosis Treat underlying etiology
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2. Identify any secondary abnormality by checking the adequacy of compensation 3. Identify the possible underlying cause
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Concurrent metabolic acid-base abnormality Corrected HCO3 = (AG-12) + measured HCO3 If >28, concurrent MAlk, <22, concurrent NAGMA
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Metabolic Acidosis CTSP: hyperglycemia, hypotension, AMS, renal failure, drug OD
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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 even when pH and HCO3 is normal
Causes HAGMA (CATMUDPILES) CCO, cyanide AAlcoholic ketoacidosis TToluene MMethanol, methemoglobin UUremia DDKA PParaldehyde IINH/Iron LLactic acidosis (shock, hypoxia, metformin) EEthylene Glycol SSalicylates, solvent NAGMA (USEDCARP) UUreterosigmoidostomy (hypoK) Ssmall bowel fistula (hypoK) EExtra chloride (hyperK) DDiarrhea (HCO3 > Cl loss) (hypoK) CCarbonic Anhydrase inhibitor (hypoK) AAdrenal insufficiency (hyperK) RRTA (I,II: hypoK, IV: hyperK) PPancreatic fistula (hypoK)
Respiratory Acidosis CTSP: respiratory distress, respiratory failure, AMS Identify the secondary abnormality Acute - Expected HCO3: increase 1-2 mmol/l for every 10mmHg increase in PCO2 Chronic: Expected HCO3: increase 4-5mmol/l for every 10mmHg increase in PCO2 If HCO3>expected, concurrent MAlk, HCO3<exp, concurrent MAcid Causes - mainly CO2 retention from hypoventilation Central causes: Drugs (sedatives, opiates), Head injury, CNS lesions, Metabolic alkalosis, Loss of hypoxic drive in chronic type 2 RF treated with O2 Airway obstruction: COPD/ asthma 61
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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 upper airway problem) or NIPPV Supplemental oxygen for patients with known Type 2 RF should be delivered by low flow nasal prongs or fixed systems (venturi mask) to allow accurate titration and prevent suppression of hypoxic drive
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Gastroenterology A. GASTROENTERITIS Common new GEM case or CTSP re: diarrhea/vomit Vitals, ABCs, GCS Assessment of the degree of dehydration Assess for different causes of infective diarrhea and r/o other non-infective causes as well Infective: viral, bacterial or parasitic o Viral GE most common, tend to be abrupt in nature with vomiting o Bacterial GE: Preformed toxins usually causes both vomiting and diarrhea without fever within hours. Toxins-forming usually causes watery diarrhea 1-2 days later. Invasive organisms usually causes diarrhea with +/- blood/mucus with fever and patients tend to be sicker and more febrile o Parasitic GE - Suspect if positive contact/travel history and immunocompromised, nursing home residents. Non-infective causes of diarrhoea: e.g. thyrotoxicosis, tumour/villious adenoma, IBD
Hx Diarrhea: duration, difference from normal habits, quality of stools, any blood/mucus, Other GI symptoms: Nausea, Vomiting (Blood/watery/bilious), abdominal pain, alternating diarrhea/constipation, jaundice Fever/chills/rigors, LoA/LoW Travel and contact history Drug h/x: Recent Abx use can lead to diarrhea, C. diff colitis 63 By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
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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? Mx Hydration IV +/- oral 1.5-2L/day (Beware fluid status e.g. IHD/CCF, ESRF) Non-milk feeds as tolerated Correct any electrolyte abnormalities KIV Abx? Most GE are viral but if patient septic (Febrile, Increased TW) or suspicion of bacterial GE (e.g. bloody, mucoid diarrhea) consider Abx e.g. PO cipro (after blood/stool cultures) KIV probiotics KIV an anti-motility agent such as loperamide (usually not required unless multiple episodes of diarrhea, may increase risk of HUS in EHEC)
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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 coffee ground vomitus or malaena for you to inspect (they may not be able to differentiate Fe stools from malaena etc.), exclude hemoptysis, PV bleeding etc. Differentiate upper BGIT (malaena, haemetemesis) vs LBGIT (PR bleed) Assess if there is a need for urgent intervention (e.g. transfusion, endoscopy) Assess for complications associated w/ BGIT (e.g. ACS) Causes (risk factors) Peptic ulcer disease (NSAIDS, prev PUD, corticosteroids, alcohol, smoking) Varices (liver cirrhosis chronic hepatitis, alcohol) Diverticular disease (known diverticular dz, painless fresh PR bleed, chronic constipation) Hemorrhoids proctoscopy to avoid embarrassment Cancer gastric, colon AVMs gastric, colon
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Orders (as indicated) Hrly para + SpO2 Large bore IV cannulas + IV fluids, NBM FBC, UECr, PT/PTT/INR, GXM +/- LFTs ECG +/- cardiac enzymes Stool/vomit chart 65
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Consider insert NGT if pt stable (unless high suspicion of varices) diagnostic if aspirate bloody Check eIMR take off anti-platelets, anti-coagulants, antihypertensives IV nexium 40mg BD For varices, IV somatostatin 250mcg STAT + 250mcg/hr infusion If dx of BGIT questionable or patient VERY stable KIV refer GS/GE CM for elective endoscopy If unstable call for senior ASAP, urgent bloods If unstable UBGIT refer GS/GE for emergency endoscopy If unstable LBGIT arrange for urgent CT mesenteric angiogram (Duty radio: 8131, IR suite: 8157) KIV angioembolisation (will need green plug) KIV prophylactic intubation for massive hematemesis
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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 secondary importance
PE Peritonitis?: board-like rigidity, tenderness/rebound Masses? E.g. palpable bladder PR: Any BGIT, impacted Stools
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Hx Characterizing the nature of pain: Visceral pain (dull, poorly localized), parietal pain (sharper, better localized) Colicky (hollow organs) GI symptoms: Nausea, vomiting, constipation, abdominal distention (?I/O) NSAIDs use: Perforated PUD Jaundice, Dark Urine, Acholic Stools: HBS pathology Drinking history, history of gallstones: Pancreatitis Prev surgeries, hernias: I/O Fever/chills/rigours: Intra-abdominal abscess, peritonitis Sexual History, LMP: Ectopic Pregnancy
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Ix (as indicated) FBC, UECr, LFT, amylase cardiac enzymes bld c/s, PT/PTT, GXM, ABG/lactate (R/O ischemic bowel) Erect CXR (80% perf viscus have air under diaphragm), AXR (supine), CTAP ECG UPT, UFEME, urine c/s Mx Treat underlying cause Treat symptoms analgesia ladder (avoid NSAIDS) As required, NBM + IV drip, hrly para + SpO2 68
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Causes based on location of pain RHC Epigastric Cholecystitis Cholecystits Cholangitis Pancreatitis Pancreatitis PUD Gastritis/GERD ACS Right lumbar Umblical/Diffuse Renal Colic AAA Pyelonephritis Ischemic bowel RIF Suprapubic Psoas abscess ARU Appenidicits Gynae Renal colic Ectopic Diverticulitis pregnancy Ectopic preg Hip (referred)
LHC Cholecystitis Pancreatitis
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Left Lumbar. Renal Colic Pyelonephritis LIF Renal Colic Diverticulitis
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 bowel and IM/PO Buscopan for colicky pain relief Have a high degree of clinical suspicion for ischaemic bowel, especially if the patient has high arteriosclerotic/embolic risk factor. Remember pain is out of proportion of physical signs. If in doubt, do serum lactate/ABG When to call a surgeon Peritonitis Severe/Unrelenting without relief Complete/High grade Obstruction Patient is Unstable: Tachycardic, Hypotensive
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Post procedure review Assess the patient for possible complications of the procedure e.g. nausea, vomiting, drowsiness from sedation, perforation from procedure Follow the POT in the endoscopic report Generally, for OGD, sigmoidoscopy, colonoscopy hrly para x 4 then 4hrly if well, feeds to DoC as tolerated when round (BEWARE of contraindications to start feeding e.g. Forrest 1a ulcer found and clipped, should keep the pt NBM in case rebleed) If suspecting perforation, may consider escalating and send pt directly for CTAP (instead of erect CXR) higher sensitivity
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Risks for endoscopic procedures OGD perforation (0.01%), Colonoscopy perforation (0.1%) ERCP perforation(0.1%), bleeding(1-2%), infection, pancreatitis (<5%), cholangitis
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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, list + consent ERCP FBC, PT/PTT/INR, GXM +/- UECr, ECG, LFTs day before procedure, NBM 12mn, list + consent
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Endocrinology A. HYPERGLYCEMIA CTSP: High CBG (>20), new case poorly controlled DM, DKA/HHS Ask over phone: mental status, vitals Usually just a case of poorly controlled DM If pt well, avoid prescribing additional insulin or OHGAs after dinner time may get nocturnal hypoglycemia If CBG >20, can review CBG trend non-urgent KIV give small dose soluble insulin (check CBG 4hrs later eg 2am)
Ppt factors: infection/sepsis, inappropriate OHGAs/insulin, non-compliance, ACS, CVA, pancreatitis, drugs e.g. corticosteroids Ix FBC, UECr, HCO3,Cl, ABG, serum Osm, plasma glucose, BHOB (green tube) ECG + CEs (MI, T and U waves) CXR KIV septic w/u (bld c/s, UFEME, urine c/s) Initial Mx Principles for DKA/HHS D/w senior transfer to HD/ICU for unstable Fluid and K+ replacement
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If unstable, e.g. drowsy, signs of acidosis/ketosis diabetic emergency DKA: Hyperglycemia >14, Ketosis e.g. BHOB > 2 mmol/L, urine ketones, HAGMA pH <7.3, HCO3 <15 HHS: Hyperglycemia >30, High serum Osm >320, No acidosis (or mild lactic acidosis), HCO3 >15, normal AG *calculated Serum Osm=2(Na+K) + glucose + urea
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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 and serum electrolyte levels. Aggressive IV K+ replacement once serum K+<5mmol/L except renal failure / anuria Eg IV K+ (in infusion) 10 mmol/hr if initial serum K+4, 20mmol/hr if serum K+3 Rpt U/E/K/HCO3 in 2 hrs then 4 to 6hrs NS is used if Na+ >150 mmol/l D5 containing fluids when CBG <14mmol/l
Appropriate rate of glucose decline 3 to 4 mmol/hr Intensify insulin scale if necessary

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Guideline for conversion of IV to SC insulin. Acidosis and ketosis has resolved - Bicarb >15, BHOB -ve, pH normal CBG readings stable and <14 mmol Alert and able to take orally PPT event has resolved Conversion is safest during dayshift
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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 400ml of sterile H2O and infuse at 200ml/hr for 2 hours. Treat underlying ppt factors
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**When ordering sliding scale SI in eIMR for e.g. TDS+10pm pls indicate BSL frequency tds+10pm but dosing frequency to be only tds (pre-meal)
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Review all anti-hyperglycemics (i.e. insulin, OHGAs). Type 1 DM will require retitration of basal insulin but not complete omission Ppt factors: poor oral intake, worsening of hepatic, renal function, infection, drugs, alcohol, adrenal insufficiency
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B. HYPOGLYCEMIA CTSP re: low CBG (will be called if CBG <4) Ask over phone: pt GCS/mental status If alert and able to take orally, can order oral glucose 15g drink over phone, and repeat CBG in 15mins then CBG as frequently as comfortable (e.g. CBG hrly x 4, then Q4H if well). Give light meal or diet within one hour If symptomatic (e.g. drowsy, tremulous, diaphoretic, seizure, coma) or persistent/recurrent, large bore IV plug, IV D50 40ml stat, recheck CBG once patient responds or within15mins. Set up IV D5% or 10% maintenance. Patient should respond promptly, otherwise repeat IV D50 and consider other causes for impaired consciousness.
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Complications e.g. fractures/dislocation, intracranial bleed PE Inspection - bruising, cuts, joint deformities Neuro: pupils, reflexes, power, Babinski, gait Abdo: tenderness, digital rectal exam Musculoskeletal: Spine, hips, wrist and other joints Cardio: murmurs, carotid bruit Orders (as indicated) Hrly para, CLC monitoring, postural BP, CRIB FBC, UECr, Ca+Alb/Mg/PO4, capillary blood glucose +/PT/PTT, GXM ECGs +/- cardiac enzymes 76
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Causes Intrinsic co-morbidities, deconditioning/muscle weakness, poor vision, poor balance, postural hypotension, vestibular dysfunction, peripheral neuropathy, dementia, poor safety awareness Extrinsic drugs, environmental hazards, poor footwear Precipitating acute medical illness (e.g. sepsis, ACS, stroke), AMS (see pg 16), giddiness/syncope (see pg 14), mechanical (e.g. trip/slip)
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B. FALLS Medical emergency, see the patient ASAP Assess vitals, ABCs and mental status (compare with baseline if possible) Assess for cause (perpetuating and precipitating factors) and complications of fall Hx: mechanism of fall, etiology, extend of injury, sinister symptoms after fall (BOV, nausea/vomiting, severe pain)
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
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- Update relative (main spokesperson) - Inform MO if needs escalation or needs scans
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 ADLs (DEATH - dressing, eating, ambulating, feeding, toileting, hygiene) iADLs (SHAFT shopping, housework, accounting, food preparation, transport, medication, telephone) Swallowing Cognition DSM IV definition of dementia 1. Amnesia (long/short term memory loss) AND 2. One of the following Aphasia (communication, word finding difficulty) Agnoisa (recognition of familiar items/faces) Apraxia (dressing, buttoning) Loss of executive function (planning, goal-directed activity) 3. Interferes with work, social activities 4. Exclude delirium Urine/bowel continence Vision/hearing impairment Sleep disturbances Behavioral disturbances Mood disturbances Hx from patient (but can be challenging) Hx from caregiver (preferably staying with patient)
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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 exam, abdo exam (look for palpable bladder), digital rectal exam (masses, fecal impaction), bedsores and wounds Swallowing assessment Risk factors for swallowing impairment: e.g. stroke, pneumonia/recurrent chest infection, Parkinsons dysphagia Beside swallowing test (30mls of H20 in small plastic cup with patient seated upright) o Look for drooling, coughing, spluttering, change in quality of voice, SOB, delayed or multiple swallows, desaturations on Sp02 monitoring If unsafe to feed: NBM + IV drip Can modify diet (see pg 8) and pound medicines (note: some medicines cannot be pound) KIV NGT, ST referral
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Mx - Identify and treat reversible cause (e.g sepsis, electrolyte abnormalities, stop offending meds)
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Orders (as indicated) FBC, U/E/Cr, Ca+ Alb/Mg/PO4, Folate, VB12, TFT, LFTs, anaemia panel, blood c/s, ABG if indicated ECG +/- CE Capillary glucose monitoring CXR/AXR CT brain / MRI brain I/O charting PT/OT gentle as tolerated, ST if needed Fall precautions Behaviour chart
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AMT 1. Recall of address given (e.g. 37 Bukit Timah Road) 2. Age 3. Date of Birth 4. Address 5. Where are you now? 6. What year is it? 7. What time is it? 8. Recognition of 2 persons 9. Who is the current Prime Minister? 10. Serial subtraction of 1 starting from 20 Gait if possible
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 expectations and many other factors
Important information to include when clerking Premorbid/functional assessment Underlying condition (only patients with Ca are supposed to be admitted under palliative, but things do fall through sometime) and investigations (diagnosis, latest scans, histo) and management so far (surgery, chemo, radio, symptom meds) Thorough history and examination (including oral cavity and PR where indicated) Reverse reversible factors contributing to symptoms (e.g. constipation for abdo colic)
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E.g. Patients with newly diagnosed Ca may sometimes be admitted under palliative medicine simply because they are on follow-up with palliative medicine for e.g. symptom control. If the premorbid and prognosis is good, more aggressive management may be indicated
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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 wellcontrolled symptoms) the nurses can be instructed to serve the breakthrough medication first, but patient must be reviewed if symptom is severe, of a different nature or is still not relieved in spite of breakthrough medication When possible and appropriate, try to reverse the cause of the symptom Opioids are HIGH-ALERT medications which should not be prescribed unless one is familiar. The senior should always be informed and approval sought before initiating or escalating the dose of opioid. Some general principles regarding the use of opioids: 1. Verify indication 2. Communicate with patient and/or relatives before initiating opioids to explain indication, benefits and potential side effects 3. Choose the lowest effective dose, particularly for those who are opioid-nave, elderly and frail or at high risk of respiratory depression e.g. COPD with chronic type 2 respiratory failure 4. Review the patients comorbidities to decide on the appropriate type and dose of opioids e.g. fentanyl instead of morphine should be used in patients with significant renal impairment 5. Review symptom again after medication is administered to assess if there is improvement
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Suggested starting dose of morphine (the most commonlyused 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 doctor-on-call should always be consulted.
Patient is imminently dying Besides symptoms such as pain and dyspnoea, the patient may have noisy breathing from secretions and may be agitated. Principles of management: 1. Communicate with the carer/family 2. Empathize and be sensitive to their needs remember that this is a difficult moment (DO NOT DISREGARD THE PATIENTS SYMPTOMS OR THE FAMILYS DISTRESS) 3. Manage the symptoms: o Terminal secretions S/C buscopan 20mg PRN up to Q4H o Terminal agitation S/C haloperidol 1-2mg PRN up to Q4H 4. Review symptoms in the next hour to assess if there is improvement 5. Discuss with the senior to cease non-essential medications If family requests for terminal discharge, inform senior & 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)
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Connective tissue diseasess Pts are usually admitted for 1. Flare / activity of the underlying condition (e.g. lupus nephritis) 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 By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
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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 Allergy/ADR (including reaction if pt remembers) Obtain a complete medication list (pts may obtain their meds from different sources), careful of step doses Use the homunculus for joint involvement. Shade = Swelling, Cross = Tenderness, Box = Limitation in movt Print the last discharge summary if available Print the lab results (in small font format) and file under relevant section Order UFEME + dipstick instead of UFEME alone Justify all investigations ordered. Serologies and special investigations do not need to be ordered at night as they will not change management Some medications are taken on specific days of the week. Check that you have ordered them correctly. Stop immunosuppressants (except hydroxychloroqine) if the patient is being admitted for a severe infection Do not be intimidated by the complexities of some cases. Follow up on the interesting ones & learn from them
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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 2. Patients with lupus/vasculitis and have diarrhoea may be having gut vasculitis if bowel sounds are sluggish or there is significant tenderness, keep them NBM 3. Patients who are immunosuppressed may not mount high fevers, err on the side of caution and culture and cover if there may be an infection Arthritides General approach involves determining 1. Onset and duration of joint pain 2. Number (mono-, oligo-, polyarthritis) and pattern of joints involved (Axial vs peripheral, symmetrical vs asymmetrical) 3. Inflammatory symptoms (early morning stiffness, constitutional symptoms) 4. Presence of extra-articular manifestations 5. History of inflammatory arthritis and treatment If there is a suspicion of septic arthritis, diagnostic tap should be performed with blood cultures Remember to take sexual history and look for possible sources of infection Empiric abx can be considered if suspicion of underlying infection is high (preferably after joint aspirate) Some tips:
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If rash is present, - describe it correctly to differentiate mechanism (eg maculopapular rash vs urticarial) - if there are blisters/bullae look for Nikolskys sign or 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
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Ask if this has occurred before and if pt has been investigated Detailed food / medication history is required in chronological order (get exact timing) Ask if there is relation with physical activity History of atopy in patient and family
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Allergy related reactions May be related to food / medications / insect bites or unknown / idiopathic Common complaints include: Angioedema, Urticaria, Maculopapular rash Ask for other signs & symptoms of anaphylaxis: SOB, syncope or low BP, abdominal cramps, etc
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1. as a general rule, not more than prednisolone 10mg/day is given for inflammatory arthritis 2. higher doses will be needed in gout if colchicine/NSAIDS are contraindicated 3. use colchicine in gout only if the patient presents within 48h of onset of attack, remember that it requires renal dose adjustment 4. do not discontinue allopurinol during a flare if the pt is already on a stable dose, it may worsen the flare
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Initial Mx of anaphylaxis Assess ABCs Epinephrine (IM) is the first line drug for anaphylaxis e.g. IM epinephrine 0.3ml of 1:1000 (i.e. NEAT from vial) Inform senior Check for response to epinephrine may need to intubate, continue IV fluids resus, O2 supp
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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
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 *Fever may be only indicator of serious infection (other markers may be absent)
Ix: >2 sets blood cultures If no CVC: 2 sets (separate sites); If CVC: each lumen + peripheral culture simultaneously. o Differential Time to Positivity >120 min suggests CVC source FBC, UECr, LFTs, plus tests based on findings: CXR, sputum GS & cx, stool cx & CDiff toxin (if diarrhea) 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
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Hx/PE - THOROUGH: lines, catheters, sinuses, fundus, perirectal, skin, mucosa (AVOID PR)
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High risk: Anticipated prolonged (>7 days duration) neutropenia Profound neutropenia (ANC <100 cells) Hypotension, pneumonia, hypoxia, chronic lung disease, oral/GI mucositis, new abdominal pain, N/V/D, new neurologic changes, hepatic (>5x normal) or renal insufficiency (CrCl<30)
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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 (severe disease) - Add IV vancomycin 15mg/kg q12h if CVC(+), mucositis(+), skin/soft tissue with high MRSA risk, clinical / hemodynamic instability (KIV stop vancomycin in 48 hours if Gram(+) unlikely and not identified) - Continue abx for >7 days (even if culture negative) until fever resolves and ANC >500 x 2 days (serial addition of antifungal, antiviral as needed) G-CSF (filgrastim) expensive, check w/ senior; not routine treatment of established febrile neutropenia
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Transfusion reaction workup includes: Filling up transfusion reaction form 2 pink tubes, 1 yellow tube (this is for LDH and bilirubin, which is to be ordered separately if hemolysis is suspected) 5 mls urine Blood bag with remaining blood product 90
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B. ACUTE TRANSFUSION REACTION Febrile non-hemolytic transfusion reaction Frequency For red cells not leukocyte depleted 0.5-6%, for platelets not leukocyte depleted 1-38%. For leukocyte depleted red cells and platelets 0.1-1%, more frequently associated with platelets. Symptoms fever (>1 deg C above baseline) usually during transfusion but may occur 1-2 hours after the end of transfusion. Mx o Stop transfusion, ABCs o Exclude hemolytic reaction (re-check transfusion slip and re-ascertain patient identity and that correct blood is given to the correct patient, perform transfusion reaction workup), sepsis and TRALI (ensure that patients SpO2 is still normal). o Paracetamol should be given if no allergies o Another unit of packed red cells can be transfused once the symptoms have subsided. Do not re-use the same unit of blood unless there is difficulty obtaining blood for the patient, in which case the transfusion should be discussed with the haematologist-on-call. Incidence of febrile non-hemolytic transfusion reaction can be reduced by leukodepletion using a leukocyte filter.
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Anaphylactic transfusion reaction refer to treatment of anaphylaxis (pg 85.) Urticarial transfusion reaction Frequency 1-3%, more frequently with blood products containing significant quantities of plasma Mx o Stop transfusion, ABCs o IV diphenhydramine 25-50mg or PO piriton 4mg. For severe urticarial reactions, may require IV 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
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Acute hemolytic transfusion reaction Frequency ABO and Rh mismatch occurs in about 1:10000-20000 transfusions Symptoms and signs Most common is fever with/ without chills and rigors. Patients can also have abdo pain, flank pain, chest and back pain, pain at infusion site. More severe patients can develop hypotension, dyspnoea and dark or red urine. Mx o Stop transfusion, ABCs o Normal saline infusion (avoid lactated ringer or dextrose-containing solutions) to keep urine output >100-200ml/hr KIV inotropes (e.g. dopamine) for BP support o Recheck transfusion slip and re-ascertain patient identity and that correct blood is given to the correct patient, perform transfusion reaction workup. o Monitor electrolytes (e.g. K) and PT/PTT/INR
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with anti-histamines. If recurrent even with premedications, 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 Symptoms and signs High spiking fever, chills and hypotension shortly after transfusion. Mx Stop transfusion, ABCs, exclude hemolytic reaction (recheck transfusion slip and re-ascertain patient identity and that correct blood is given to the correct patient, perform transfusion reaction workup) If this is suspected, perform blood cultures and start broad spectrum antibiotics as per ARUS-C guidance for empiric therapy for Severe Sepsis Or Septic Shock Without Clear Source.
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AURORA Renal panel has no urea, chloride, bicarbonate; LFT has no AST, GGT (need to key in separately) 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 By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
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Controlled drug prescription sample intranet -> e-bulletin -> pharmacy notice board-> CDs -> prescription sample Antibiotics renal adjustment dose intranet -> e-bulletin -> pharmacy notice board -> Antimicrobial Stewardship Programme-> ASP guidelines -> renal dose OR eIMR > parenteral > ARUS-C guidance > renal dose adjustment (automatic) IVIg guidelines intranet -> e-bulletin -> pharmacy notice board -> Drug administration Guidelines -> RAI protocol IVIg Warfarin/heparin guidelines intranet -> e-bulletin -> pharmacy notice board -> anticoagulation guidelines
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Miscellaneous Blue letter - which to call? CALL all URGENT blue letters CALL for following non-urgent blue letters - ALL surgical disciplines, Anaesthesia, RAI, Respiratory Medicine (Secretary: 7861), Haematology, Endocrinology, Neurology, Oncology, Radiation Oncology FAX/LIST for following non-urgent blue letters General Medicine, Cardiology, Gastroenterology, Infectious diseases, Renal Medicine, Palliative, Psychiatry, Dermatology, Dental Check with nurses or ward clerk if in doubt
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Passing report times sacred timings for the nurses before they can go home after a long shift, usually means DND and the nurses will need the case notes - 7-8am (night AM shift), 2-3pm (AM PM shift), 9-10pm (PM night shift)
UpToDate can access from home! Login to intouch.nhg.com.sg click lotus notes client access http://intranet - bottom right hand corner UpToDate Online
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eIMR Help nurses obtain prn meds for patients when the patient asks for it- order e.g. paracetamol prn (instead of qds prn) and put Up to Q6H special instructions. Otherwise they can only serve those meds during specific times Drug serving times - OM - 8am, BD - 8am/8pm, tds 8am/2pm/8pm (vs Q8H 12pm/8pm/12mn), qds 8am/12pm/4pm/8pm (vs Q6H 8am/2pm/8pm/2am). st Administer 1 dose > eIMR > parenteral medicine (one of the tabs near the top) > administer order (near the bottom) > check appropriate buttons (it is still the Drs responsibility, 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 with water for injection as some may ppt w/ N/S)
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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
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Tower B (ICU/B2/C class) Level 2 Wards 26 (MICU) Level 3 Wards 36 (SICU) Level 4 Ward 45 (renal centre), Ward 46 (isolation ward) Level 5 Wards 55,56 (Geriatric and medical overflow wards) Level 6 Wards 65, 66 (medical wards) 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)
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Wards Tower A (A1/A2/B1 class) Level 5 Wards 51,52 Level 6 Wards 61,62 Level 7 Wards 71,72 Level 8 Wards 82
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Tower B Level 1 (learning centre) Lecture rooms (for modular specialty teaching sessions) Level 2 Diagnostic Radiology (note: MRI operates after office hours at the diagnostic radiology, CT scan/XR operate both here and at the A&E)
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KTPH Important locations Tower A Level 1 A&E department Level 2 Endoscopy centre and board room (for IM modular teaching sessions) Level 4 staff lounge (there is pool table, fuss ball, carrom, library and comfy seats)
*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) Request for either Tower A or B on-call room for general medicine (depending on your call coverage areas) there will always be spare rooms on level 10. 2 HOs on call each night - 1 follows MO2 (covering wards 56,75,76,95,96) and 1 follows MO4 (covering Tower A, wards 66,86,105) MO3 will tag on MO1 (covering wards 55, 65, 85) 2 registrars on call each night (1 covers ICU and A&E, 1 covers general ward and blue letters) Most of the time, the medical registrar buys dinner.. but ask around.. a couple don't! Always keep your MOs informed of any sick passive case i.e. desaturation or typical chest pain Food options Tower B B1 level: kopi kaki. Sells drinks, toast and mee rubus, mee siam. Level 1: subway, Mr Bean, edo sushi Food fare food court (Tower C, level 1): recommended food- ayam penyet, wanton mee, fish and co, kampong fried rice Outside: northpoint, coffeeshop opp safra yishun (nice chicken rice and zi char!), coffee shop near to northpoint. Higher end: Eatzi (Jack's place) at Safra Yishun IT system
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Daily Work flow: Morning after rounds - Phlebotomist service comes 3 times a day, of which the timing depends on which ward you are in. they do not do blood cultures or ABG or GXM. Latest blood taking timing range from 7 to 8 plus. - GXM/antibodies screening cannot be ordered in the system. You need a manual form. Need to sign on the tube, 2 stickers on the top and the ordering dr blank, altogether 4 signatures. Another staff needs to counter sign on the form before u can despatch. - 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
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- KTPH uses sunrise clinical manager - Vitals: located in the flowsheet tab or in the patient summary tab if u want to see graphical view - Discharging patients: need to ensure the primary diagnosis is filled up right at the bottom option of summary completed or not. If these 2 fields are not completed, patients summary copy of the discharge will not be printed out. (it will come out as a blank page) - Investigations ordered on arrival will be printed out together with the patients copy of discharge summary. - To assess the ward occupancy rate and the details of a booking from ED, you can use BMS-live mozifire webpage. Password and ID is common to the wards. For eg: ward b66 ID would be wardb66 and password would be wardb66. - You are required to annotate all results by pressing down on the middle scrolling button.
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the ward phones. The booking will then appear on BMSlive 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 of the workflow in each work, find out where it is! Some services need calling, some faxing only, some call and fax. PSYCH referrals have to be made before 11am sharp and must call the on-call. or else it you will get a scolding and patient will not be seen on that day. Certain services like RAI, derm, neurology have fixed blue letter days (not every day), so replies may not be as prompt (because its reviewed by visiting consultants). Services like hematology will need to call TTSH. All scans with contrast and MRI (with or without contrast) need consent. HOs can sign consent (unlike in TTSH) Scans done during office hrs till abt 9-10pm will be charged at normal rates. Scans outside these hours will be more expensive, so decide if they are warranted or urgent. CT brain/MRI brain when ordered, will usually be done on the same day. No need to call radiologists. If urgent, can try calling the CT/MRI dept staff first. When discharging patients, the IMR can be ticked during the rounds, so that the nurses can send off the IMR to the pharmacy in the morning. Give your signature to sign off. Remember to look at the top left hand corner where 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
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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. Must be punctual! - Thursday lunch time teachng at 1pm is at Kaizen room 1 at the learning centre. - Tuesdays IM modular teaching at 730am will be videoconferencing with TTSH. Venue either at boardroom (tower A level 2 office) or at tower B level 1 main office. - Monday and Tuesday 7.30am emergency and core acute st tutorials will be for the 1 3 months - Departmental meeting on Friday mornings 7.30am: Mortality rounds alternate with combined teaching
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List of Impt Numbers in KTPH KTPH prefix = 6602 + ____ (see below) Lab main 2322 MicroB 2335 Biochem 2322/2325 Hemato 2338 Blood bank 2321 MSW 2588/2599 MOT 2760/2770 MRO 2466/2464 ITD helpdesk 1800 587 4478 Ms Xin Yee (BMU) 91142116 Impt! For transfers of lodgers from Tower A back to Tower B Radiology On call radiographer 91371751 Counter (appt) 2700/01/2698 CT rm 2699 Angio rm 2706 US rm 2693/94/95 MRI rm 2709 Snr SN (Carol) Angio - 2669 Inpt Pharm 2632/33/34 On call Pharm 98550620 Drug Info 2629
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From Kenny Tan, Joel Lee, Quek Zhi Han w/ special thanks to Eugene Chua
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Drugs doses Antibiotics/Antimicrobials Amoxicillin 250mg1g 8h PO Ampicillin 0.250.5g 6h PO; 150-200 mg/kg/day IV Amikacin 7.5mg/kg 12h/15mg/kg 24h (CrCl >90) Augmentin 625mg 8h/12h PO, 1.2g 8h/12h IV bolus/slow inf. Bactrim (Co-trimox) 2 tab (960mg) bd PO [CI: CRF] Cefazolin 1-2g 8-12h IV (2g on call to OT) bolus Cefepime 1-2g 12h IV Ceftazidime (Fortum) 1-2g 8-12h IV infusion [pseudomonas] Ceftriaxone 1-2g om IV bolus (1g)/infuse (2g), 2g bd [meningitis] nd Cefuroxime (Zinnat) 500mg 12h PO [2 gen cephalosporin, PO] Cephalexin 250-500mg 6h PO Ciprofloxacin 500mg 12h PO; 400mg 12h IV infusion (8h if Pseudomonas) Clarithromycin (Klacid) 500mg bd PO Cloxacillin 0.5-2g 4-6h IV bolus/infusion; 250-500mg 6h PO Crystalline Penicillin 4mU 4h IV infusion, [5mU per vial] Doxycycline 100mg bd PO Erythromycin 500mg-1g 6h PO/IV, EES 800mg 12h PO Gentamicin 80mg 8h or120-240mg om IV infus [chk lvls] Imipenem 500mg 6h IV Metronidazole (Flagyl) 400mg 8-12h PO, 500mg 6-8h IV infusion Piperacillin-Tazo (Tazocin) 4.5g 6-8h IV [pseudomonas] Vancomycin 0.5-1g om-12h IV [chk lvls] Others:Acyclovir 800mg 5x/day x 7-10/7 PO (zoster);250750mg 8h IV Chloroquine 600mg base (4 tab) x1 then 300mg [chk G6PD] om PO Quinine: Load (wt x20) in 1 pint D5% IV over 4h then (wt x
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Asthma Aminophylline: Load IV 6mg/kg/20min (not on Theopylline) then 25mg/h. (25mg/ml in D5%, Theophy lvl 10-20mg/L) IV Hydrocortisone 100mg 6-8h Neb Ventolin: Atrovent: N/S 1:(0):3 (asthma), 1:2:1 Q4-6h (COPD) PO Prednisolone 30mg OM x 5/7 Theophylline (Nuelin SR) PO 125mg ON/bd, 250mg ON 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 bdtds 102 By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI
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Allergy/Anti-inflamm/Anti-histamines/Steroids Dexamethasone 4-8mg 6-8h i/v, 0.5-10mg/day PO Chlorpheniramine (Piriton) 4mg 6-8h PO Hydroxyzine (Atarax) 10-25mg tds [itch] Loratidine (Clarityne) 10mg om PO Fludrocortisone (Mineralocorticoid) 50-200mcg OM PO Hydrocortisone 100mg 6-8h IV, 5-20mg OM/5-10mg ON PO Prednisolone 10-30mg om PO then 2.5-15mg/day maint Promethazine (Phenergan) 25-50mg PO/ IM/ IV Synacthen test IV 250 g at 0 min (check 0, 30, 60 min)
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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] TripleRx: Clarithromycin 500mg bd PO + Amoxycillin 1g bd PO x 2/52 + Omeprazole 20mg bd PO x 6/52
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 + High: Calcium: [(40-Alb) x 0.02] + Ca (1) Stop thiazides. (2) IV N/S 1L/hour or 4L/24h (3) Pamidronate (bisphosphonate) 30-90mg in 500ml N/S over 4 hour
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Cardio-Vascular Aspirin 100mg om PO + famotidine 40mg bd Clopidogrel 75mg om PO Clexane 1mg/kg SC om (prophy) /bd (tx) [LMW Hep] Digoxin 62.5-250mcg om po [lvls] Dopamine 3-20mcg/kg/min IV [200mg in 0.1L NS at 27.5ml/h] GTN (0.3g) 1/1 S/L max x3. Patch (Nitrodisc) 5-10mg/24h Heparin (refer to heparin infusion protocol on pharmacy bulletin) ISDN 5-20mg bd-tds po [angina, LVF] ISMN (Imdex 30-60mg om) (Ismo 20mg bd-tds) PO [angina, CCF] Ticlopidine (Ticlid) 250mg bd PO Warfarin: Load 5,5,3 mg OM then check PT, INR. [counselling] Cholesterol/Lipids 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)
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Pravastatin 10-40mg ON Atorvastatin 10-80mg ON Rosuvastatin 5-40mg ON Ezetimibe 10mg ON Constipation Fybogel 1/1 om [bulk] Lactulose 10mls tds, 30mls in hep encephalopathy [osmotic] Senna 11/11 ON [stimulant] Dulcolax (Bisacodyl) PO 5-15 mg (up to 30 mg) PR 10 mg Bowel prep: PEG 2L, PO dulcolax 2 tab BD or 4 tab once, KIV fleet enema
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Diabetes/Hypoglycemia Acarbose (Glucobay) 25-100mg tds 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
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Diarrhoea Lomotil 1/1 tds-qds [Antimotility] Loperamide (Imodium) 2-4mg tds-qds [Antimotility] Lacteolforte 1 sachet BD Activated charcoal 2 tab TDS
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Cough Bromhexine (Bisolvon) 8mg or 1/1 tds (expectorant) Dequalium or Difflam lozenges 1/1 tds/prn (sore throat) Dextromethorphan 10mls tds (black) (suppressant) Diphenhydramine 10mls tds (black) (expectorant) Guaifenesin 200-400 mg Q4H (max 2.4 g/day) (expectorant) Procordin 10mls tds (red) (suppressant, hemoptysis)
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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) Epilepsy/Fits: h/c, U/E/Ca,Mg,P, ABG, drug levels Carbamazepine 200mg OM/ BD PO Diazepam (Valium) 5-10mg IV / rectal over 2 min [acute fit]
Gout Allopurinol 100-300mg om [CI: acute attack] Diclofenac sodium SR 75mg BD Colchicine 0.5mg tds Prednisolone 30mg om x 5/7
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Gastritis/Bleeding GIT/PUD Antacid 2 tab bd-tds PO Famotidine 20-40mg bd PO [with NSAIDs] Mist carminative 10mls tds/prn PO [wind] Magnesium Trisilicate (MMT) 10mls tds/qds/prn PO Omeprazole (Losec)/Pantoprazole 20-40mg om/bd Esomeprazole IV 40mg om-bd Esomeprazole infusion 8mg/h (80mg in 1 pint N/S @ 50mls/h) Somatostatin 0.25mg IV stat then 0.25mg/h infusion (Varices). Mebeverine 135 mg tds (IBS) Fluimucil (Acetylcysteine) 60mg BD x 2/7 (b4 CT scan); PO 140 mg/kg; IV 150 mg/kg over 60 minutes
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Neuro-psych meds Diazepam (Valium) 2-10mg PO, 5-10mg IV/IM Fluoxetine (Prozac) 10-40mg om-bd PO Haloperidol 0.5-5mg bd-tds or on PO, 5mg stat-tds IM/IV Midazolam (Dormicum) 7.5-15mg PO, 1-5mg IV 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]
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Nausea, Vomitting, Giddiness Metoclopramide (Maxolon) 10mg tds/prn PO/ IM/ IV Ondansetron (Zofran) 4mg IV/ 8mg bd PO Prochlorperazine (Stemetil) 5-10mg bd/tds PO, 12.5mg IM Cinnarizine (Stugeron) 25mg tds/prn PO
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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] Frusemide (Lasix) 20-80mg om-bd PO/IV bolus [loop D][+ K+] Hydrochlorthiazide 12.5-50mg om PO [Thiaz D](elderly)[+ K+] Metolazone: 2.5-20 mg OD (edema) or 2.5-5 mg OD (BP) 2+ Nifedipine LA 30-60mg om-bd PO [Ca ] Propanolol 10-40 mg bd-tds PO, 1mg over 1 min max 5mg IV [B] + Spironolactone 12.5-50mg om-bd PO [K sparing D] Hypt Emergency/Urgency (>230/130). Aim 160/100 slowly Amlodipine 5-10mg om PO +/- enalapril 2.5-10mg om-bd Nifedipine 10mg PO Q8H +/- Atenolol
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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 NSAIDS: With famotidine 20mg bd / omeprazole 20mg bd Diclofenac (Voltaren) 25-50mg tds, 75mg IM max bd; supp 25mg Indomethacin 25-50mg tds PO + PPI [gout] Mefenamic acid (Ponstan) 250-500mg tds/prn PO + PPI Naproxen (Synflex) 550mg bd/prn po (EC 375mg BD) Opioids: With Laxative (Senna/Lactulose) + Maxolon 10mg Opioid: Naloxone 0.4mg in 10ml (give 1ml/ time up to 2 mg) Codeine phosphate 15-30mg TDS PO+ laxative (max 60mg Q4H) Durogesic (Fentanyl) patch 6-50 mcg/h over 72h [CD] IV 1-3 mcg/kg to 10 mcg/ml; give 10mcg/ 2 min Mist Morphine 5-15mg 4-6h PO + laxative & Maxolon Morphine 0.5-2mg/h IV or 2-5mg/h SC (AMI: 2-4mg/5min) Pethidine 25-75mg tds/prn IM or 0.5-1mg/kg IV + Maxolon Tramadol 25-100mg tds prn PO + Lactulose Hyoscine butylbromide (Buscopan) 10-20mg tds po, 20mg (1ml) IM Topical: Fastum/Voltaren gel
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Piles Daflon 2 tab (900mg) tds x 4/7 then 2 tab bd x 4/7 then 1 tab bd Fybogel 1/1 bd + Lactulose 10ml tds Lignocaine gel prn for pain 107
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Sodium True Na+ = Na+ + gluc/4 Low: max by 10mM/24h 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 + <120/Fitting: Na 3% + Lasix [3%=514/L instead of 154] NaCl 600mg (10mmol @) PO
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Vitamins/Food IV albumin 20% 100ml over 2hr 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
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Renal Calcium acetate 625mg tds w/ meals PO Ferrous fumarate 200-400mg om-bd PO Renalmin 1/1 om PO Recormon (Erythropoeitin) 2000-4000u 1-3x/wk SC/IV
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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) High: >6 ECG: Tall T,wide QRS, small P Resonium 15-30g 8h PO/ 30g fleet Glucose 50% 40mls (dilute w/ N/S) + insulin 10IV (check h/c stat + hrly h/c) Calcium gluconate 10% 10mls over 10min IV (cardioprotect) with continuous ECG monitoring
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Edited from: HO Drug list ver 4.70716 updated 16/7/2007 Edit history: Gerald Tan, Lim Baoying, Grace Chang This is an informal list only. Always check if in doubt. Updates/corrections: http://www.geraldtan.com/school
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Common calculations 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 MDRD. Glucose: mmol/L = mg/dl x 0.055 Length: 1 cm = 0.394 in = 0.0328 ft Temperature: Celsius=5 x (Farenheit-32) / 9 Weight: 1 kg = 2.2 lb
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Fe: Ferrous fumarate 100-400mg om/bd PO +/- laxative; Sangobion/ Neogobion 1-2 tab om/bd PO; IV Venofer 100200mg in 200ml N/S over 1 hour (check Fe after 48h) 23x/week Folate 5-10mg om PO (check for B12 def before replacement) Neurobion 1-2 tab om Vit B Co 1-2 tab OM Vit C: 100-500mg om PO, 100-500mg/ml IM/IV Vit K: 10mg OM IV x 3/7 for raised PT Thiamine (Vit B1) 10-30mg PO, 100mg OM PO/IV (alcoholic) IM Vit B12 1mg OM x 3/7 then PO Princi-B forte 1 tab om
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Important phone numbers Lab Biochem Haemato MicroB Histo Immuno Imaging Duty Radio Interven. Radio CT Room US Room MRI NNI (MRI) NNI (CT brain) EMG / EEG Miscellaneous BTS MO Drug Info TTSH prefix Operator ITD Help desk Surgical Main OT EOT OT Fax Endo centre
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Ward numbers = 2(XX)(Y) where XX is ward level and Y is ward letter (A=1 or 5, B=2 or 6 etc) - e.g. Ward 5A = 2051/5, Ward 12C = 2123/7
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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, Dr Charles Vu, Dr Stephen Tsao, Dr Quan Wai Leong, Dr Daniel Chew, Dr Lieu Ping Kong, Dr Wu Huei Yaw, Dr Faith Chia, Dr Ong Kiat Hoe, Dr Goh Kian Peng Our chief residents Dr Endean Tan, Dr Chen Shiling, Dr Seow Cherng Jye Our Program coordinators (i.e. baby-sitters) - Ms Selvia Kosim, Ms Melody Kuan, Mr Winson Low And many others who have come together to make this book possible With contributions by:
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R1s 2010/11 Jacqueline Foo, Goh Wen Yang, Ho Quan Yao, Violet Hoon, Raphael Lee, Joel Lee, Andrew Leong, Raymond Liang, Joel Lim, Brenda Lim, Lin Huiyu, Mahaboob Shariff, Mogilan, Mok Kwang How, Ivy Ng, Quek Zhihan, Emily Tan, Tan Seng Kiong, Kenny Tan, Valliammai, Daniel Yap, Yeo Chong Ming, Zeng Shanyong
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111

Residency: Called - To.See - Patient V1.1

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Residency: Called - To.See - Patient V1.1

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With contribution from TTSH, KTPH and NNI

Miscellaneous Drug list

Rheumatology, Allergy, Immunology

Important contact numbers

- Ix as appropriate for causative factors - Treat causative and reversible factors

Call senior for help if vitals unstable, looks ill

Evaluation Hx (chest pain, SoB), PE (include assess fluid status, DRE)

Points 3 3 1.5 1.5 1.5 1 1

Document IDC insertion indicate if there were difficulties with catheterization

Extra-renal GI, skin loss

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

Symptoms: Increased thirst, AMS, coma, seizures

Change in serum Na = (Infusate Na - Serum Na) (#Total Body Water + 1)

Identify HAGMA vs NAGMA AG = Na HCO3 Cl (HAGMA = AG>12)

Metabolic Acidosis CTSP: hyperglycemia, hypotension, AMS, renal failure, drug OD

Remember extra-abdominal causes of abdominal pain e.g. AMI, pneumonia, DKA

LHC Cholecystitis Pancreatitis

Appropriate rate of glucose decline 3 to 4 mmol/hr Intensify insulin scale if necessary

If no IV lines and desperate KIV NGT feeding with glucose solution

- Update relative (main spokesperson) - Inform MO if needs escalation or needs scans

COMMON SITUATIONS ON-CALL

When in doubt, press 0 or 63571000 if using workphone

8131 8157/3 8142/3 8145 8163/4 7053 7056 7070

8938/9 8955 8968/9 8976 8464

9186 4133 2016 6357 xxxx 0 1800 4834 357

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