Break Your Leg Intern

Break your leg - Intern!
Jean Cheng
th
7 edition, 2014
Break your leg - intern!
Content
Content
Preface
Daily clinical work

page
Vitals abnormalities
1) Hypotension 6
2) Hypertension 7
3) Tachycardia 8
4) Bradycardia 9
5) Desaturation 10
6) Fever 12
7) Hypothermia 14
Lab abnormalities - hematology

8) anemia / HB drop 16
9) Polycythaemia 17
10) Neutropenic 18
11) Leucocytoiss 20
12) Low plt 21
13) Elevated plt count 21
14) INR elevated 22
15) APTT increased 22
Lab abnormalities - biochemistry

16) Hypernatremia 24
17) Hyponatremia 25
18) Hyperkalaemia 26
19) Hypokalaemia 27
20) Hypomagnesemia 29
21) Hypercalaemia 29
22) Hypocalaemia 30
23) Acute kidney failure 30
24) Deranged LFT 31
25) Acidosis 32
26) ABG 33
27) Trop T/ Trop I 36
28) Iron profile / folate / B12 37
29) Thyroid profile 37
30) Therapeutic drug monitoring 38
31) Clostridium difficile +ve 38
Jean Cheng class of 2013, CUHK

Content
32) C/st and sensitivity 39

33) Knee tap: urgent gram stain 39
X ray
34) General 41
35) Pneumothorax 41
36) Consolidation / lung mass 41
37) Free gas 42
38) Costophrenic angle 42
39) Prominent / dilated bowels 42
40) Urinary stones 42
41) Fracture 43
42) Osteomyelitic changes 43
43) CT brain 43
ECG
44) ECG - basics 45
45) Sinus tachycardia 48
46) Atrial fibrillation / multi focal atrial tachycardia 48
47) Supraventricular Tachycardia 48
48) Bradycardia 48
49) T wave inversion / ST depression 49
50) ST elevation 49
51) RBBB 50
52) LBBB 50

Content
Ward complaints
Cardiac
1) Chest pain 53
2) Palpitations 53
3) Fast AF 54
4) SVT 54
5) Dizziness 55
Respiratory
6) O2 therapy 58
7) SOB 58
8) Cough 58
9) Sputum 58
10) Sore throat 58
11) Hemoptysis 59
12) Bipap and ventilator alarms 60
13) Matoux test 62
14) Anti-TB drugs
GI
15) Abd pain 64
16) No bowel opening 65
17) Vomitting 66
18) Diarrhoea 66
19) PR bleed: fresh blood vs fresh malaena vs old malaena 67
20) Coffee ground vomitting 68
21) Hemorrhoid 68
Renal
22) Low / no urine output 70
23) Hematuria 71
24) Dysuria 71
25) CAPD peritonitis / CAPD turbid fluid 72
26) Decrease CAPD fluid output 72
27) Increase CAPD fluid output 72
Neurology
28) Headache 74
29) Numbness 74
30) Drop GCS 74
31) Seizure 74

Content
Endocrine
32) H stix low 76
33) Hstix high 77
34) DKI drip 78
35) Insulin pump 78
36) Thyrotoxicosis 79
Hematology
37) Warfarin and heparin bridging therapy 81
38) DVT 83
Infections
39) Antibiotics 85
Skin
40) Skin rash 87
41) Puritis 87
42) Mouth ulcer 87
43) Bruises 87
44) Tinea infection 87
45) Drip site cellulitis 87
46) Herpes 87
Oncology
47) Hypercalcemia 89
48) Cord compression 89
49) brain metastasis 89
50) Transfusion reaction x fever / rash 89
51) Neutropenic fever 89
52) Hiccups 89
53) EOL 90

Content
Others
54) Contrast allergy 92
55) Steroids 92
56) Drug allergy 92
57) Pain 93
58) red eyes 94
59) Red ear 94
60) Nasal congestion 94
61) Gout 94
62) Insomnia 94
63) Abnormal behaviour of patient 95
64) Drug withdrawal 95
65) Certificate and death 95
66) CPR 96

Content
Cases admission
General for case admission
Medicine
Cardiac
1) ACS / chest pain 101
2) CHF 102
3) AF 103
4) Palpitations 104
5) Infective endocarditis 105
Respiratory
6) COPD 106
7) CAP / aspiration pneumonia 107
8) Hemoptysis 108
9) Pleural effusion 109
10) Asthma 110
11) Pneumothorax 111
Neurology
12) CVA(ischemic) 112
13) ICH 113
14) Acute DO 114
15) LOC 115
16) Acute confusion 116
17) Convulsion 117
18) Dizziness 118
19) 3rd nerve / 6th nerve palsy 119
20) Meningitis 120
Gastro intestinal
21) Ascites 121
22) GIB 122
23) GE 123
24) Jaundice 124
25) Hepatic encephalopathy 125
Endocrinology
26) DKA 126
27) HONK 128
28) Thyroid storm 129
29) Hyponatremia / addisoniam crisis 130

Content
Renal
30) Acute renal failure 131
31) Hematuria 132
32) Renal fluid overload 133
33) Renal hyperkalaemia 134
34) Renal CAPD peritonitis 135
Hematology
35) Leukemia 136
36) Multiple meyloma 137
37) Low platelet 138
Medicine - Miscellaneous
38) DVT 139
39) Warfarin overdose 140
40) Decrease GC 141
41) Cellulitis 142
Clinically admission x renal

42) Renal biopsy 143
43) Tenckhoff insertion / removal 144
44) Maunal / Machine IPD 145
Clinically admission X GI
45) OGD 146
46) Colonoscopy 146
Clinically admission X Resp

47) Bronchoscopy 147

Content
Surgery
HBP
48) OJ(obstructive jaundice) 149
49) Cholangitis 150
50) Cholecystitis 151
51) Liver abscess / RUQ pain 152
52) Pancreatitis 153
UGI
53) UGIB: coffee ground vomitting / malaena 154
54) Hematemesis 155
55) PPU / Air under diaphragm 156
LGI
56) LGIB 157
57) RLL pain 158
58) LLL pain 159
Vascular
59) Acute limb ischemia 160
60) Rupture AAA 161
Urology
61) AROU 162
62) Hematuria 163
63) Loin pain(if no fever, suspect stones) 164
64) Pyelonephritis 165
Burns
65) Facial burns 166
66) Other area burn 166
67) Burn over limbs 167
68) Compartment syndrome / circumferential burn 168
Ort
69) #NOF 170
70) Pathological fracture 170
71) Other fracture 171
72) Low back pain 172
73) Shoulder / hip dislocation 172
74) Cellulitis / osteomyelysis / abscess 173
75) Hand laceration 174
76) Septic arthritis (joint pain + fever) 175

Content
77) Cord compression 176

78) Achilles tendon rupture / patella tendon rupture 176
79) ACL tendon rupture / tear 177
80) Ulcer 177
Clinically admission x surgery

81) Surgery 178

Content
Other information
1) For all problems 180
2) Pifalls 181
3) useful materials 183
4) Reminder 184
5) Quotations 184
6) Ethical issues 185

Preface
Preface
I wonder if you have heard how people described their houseman life, they always
felt they are a blood taking machine, clerk, slave... But I can tell, it is actually a
misconcept.
This book is a summary of what I have LEARNT in this intern year. Yes, I did learn
during intern year. I may have learnt the knowledge of this book during my medical
school. But the problem is, I have practised them out until I am a intern. Once you
are in the clinical world, you would find out, to be a doctor not just requite book
knowledge, but also experience.
Experience can take you to the diagnosis, the pattern recognition, the working pace
and more is the confidence. You will grow. It is fabulous.At the end of the year, you
will work like a MO, and this year shapes what kind of doctor you are.
This year is exciting. You will learn blood taking, drip setting, clinical procedures,
clinical way of thinking. You will also meet lots and lots of people. You will sought out
how different people think about medicine, what their values on being a doctor and
what they believe in when making clinical decision.
Yes, this year is tough. 3 days one call, many departments have no post call half day
off for houseman... And sometimes the job nature is quite tedious indeed. Oncall is
harsh, need to work for 30+ hours, and no sleep. The physical exhaustion is only a
small part, the bigger part is oncall need to take up responsibilities. You will feel
incompetent most of the time. Your failure is not just about your failure, but will
affect your patient, MO, and may be worse the whole department.
But this is part of the learning. You are not only asked to learn the knowledge, gain
the experience. But also how to handle stress.
After this year, you will gain a MO contract, a doctor license. But more, you will be a
real doctor, learn your temper, learn your values, learn how you view life, learn who
you are.
Life in clinical medicine do brings a lot of encouragement and excitement. Those with
pneumonia discharged because you as a HO admitted the case and prescribed
antibiotics; those with fracture hip that can proceed OT because you management
his DM well peri-operatively; those with AECOPD survived because you took an ABG
and recognized there is decompensated CO2 retention and require bipap for his T2
Respiratory failure ; those with acute renal failure and persistent hyperkalaemia and
not responsive to DI drip, you suggest a consultation to ICU for hemodialysis... Many
many such occasions, there is a kind of pay back, not measured by money or time.

Page 1
Preface
But is a kind of satisfactory that you will know and smile when you really experience
one.
Patients are also the cutest one in the world, most of the time. Just a thank you is
already so pleasant. Whey they are so forgiveful and considerate in times we are late,
it is also amazing. They also teach us what is life and enlightens us a lot to think
about our life.
Remains your true color. No matter how hostile people can be, you preserve your
own goodness. Your intrinsic good personalities are something others cannot take
away from you and will be your most influential power you ever have in your life.
May be we are a turtle in medicine filed, learn slow. But just, dont give up.
gift from my dearest patient
4:23
Jean Cheng CUHK 2013

May 2014 (when in my 4th intern rotation)
(jean520116@gmail.com )

Page 2
Preface
Acknowledgment
Dr. Chan Lut Ming (UCH Med): the common treatment orders is my houseman reference source!!!
Thanks for holding a talk for us!!!
Dr. Heyson Chan(PWH Med): thanks for the houseman make easy. I survive my PWH med
internship because of that book. And I learnt a lot.
Dr. Alexander Chan: thanks for letting me attach when pre intern. You taught me to insist in being
responsible. Thanks!
Dr. Bonnie Wong(PWH Med): thanks for teaching me in person. Thanks for letting me do the ward
rounds and giving me all the feedback. Really learnt so much.
Dr. David Dai(PWH Med): Thanks for teaching me what is clinical medicine: is to everyday exam
the patient, see how they really doing dynamically. Not just to look at the labs / xray, which are so
static.
Amy Chan: thanks for your advice and all the support over the years
My colleagues: thanks for walking this year with me. Helping me when in difficult time, all the
abg, drips, discharge etc. The most valuable is all the lunch together.
Many MO: thanks so much for giving me feedback and teaching me how to deal with all the ward
complaints. Thanks for teaching me how to admit case, do the initial management.
Nurses: without you all, I think my workload will be 10 times.
Patients: thanks for always asking me to go back to sleep when in 3am, and asking me to leave
work on post call day(although I cannot). Thanks for coming back to ward to see me after a 3
months promise. Thanks for remembering my name and thanks for saying Thank you to me.
Your encouragement touched me a lot.
Finally, my family. Thanks for your support and be my fall back at difficult times.
Edition:
18th May 2014 1st edition
26th May 2014 2nd edition
28th May 2014 3rd edition
6th June 2014 4th edition
15th June 2014 5th edition
21st June 2014 6th edition
7th July 2014 7th edition

Page 3
Daily Clinical work
Daily clinical work

Page 4
Daily Clinical work
Vitals abnormalities

Page 5
Daily Clinical work
1) Hypotension
No definite treatment threshold, Esp SBP <90
Ask any chest pain!!! (for cardiogenic shock)
Any bleeding source: ? PR malaena, ? Psoas (hip flexed), ?pelvic #, ?post op
leakage(drain fresh blood)
Mx:
BP/P q1h x4, if stable, q4h
Connect to cardiac monitor (if pulse rate abnormal)
Blood x CBC +/- T&S

+/- Trop I ,CK, LDH
+/- ECG, CXR
W/H all anti hypertensives
If cardiogenic: Elevated JVP, bilateral basal creps, lower limb edema, arrhythmia,
ACS(Chest pain)
-dopamine 200mg in 100ml NS, 10ml/ hour, escalate 5ml if needed
If hypovolemic:dry
- Gelofusin 500ml FR x1(if not contraindicated)
+/- NS 500ml Q1H x1 more
If septic shock: peripheral warmth. Fever if septic

- Gelofusin 500ml FR x1(if not contraindicated)
+ IV antibiotics (at least IV tazocin 4.5g q8h or more big guns)
For renal patient / CHF patient:

Consider inotropes
Because difficulty to initiate fluid for them...
Pitfall:
Addisons crisis
For those on steroid, stress as in hospital / illness itself may cause steroid
requirement increase
May stat iv hydrocortisone 100mg
Inotropes
1.) Dopamine : 1gram in 500ml NS (200mg in 100ml NS): give 10-40ml/hr or 4:1,
1-20ml/hr
(**It would be safe to seek help if Dopamine fails)
2.) Adrenaline drip via CVP ( we would give dopamine first)
- 30mg in 500ml NS: give 5-20ml/hr or 6mg in 100ml NS 1-20ml/hr
( Ward : 3mg in 47ml NS, give 5 ml/hr )

Page 6
Daily Clinical work
2) Hypertension
Treat when SBP >180, DBP >90
Mx:
BP/P q1hx4, if stable, q4h
Connect to cardiac monitor
+/- ECG, Trop I( if chest pain)

+/- CT brain(if GCS ? Or found hemiplegic or cotrical signs)
+ good pain control

- norvasc 5mg PO stat x1 or daily
- adalat retard 20mg PO stat x1 or BD
- captopril 6.24mg PO stat x1 or TDS
- betaloc 25mg PO stat x1 or BD
- methyldopa 250mg po x1 or TDS
If NPO
- labetalol 5mg IV stat x1
Or labetalol 5mg iv q1h, if SBP >/= 180 or 200
Or labetalol infusion if needed
100mg labetalol in 100ml NS,start at 30ml/hr, 0-60ml/hour +/- 5ml/hr, titrate agaist
BP
If ischemic stroke, treat only when SBP >220
If hemorrhage stroke, need stricter SBP control. SBP<180 if no ICP increase.

If ICP increased, treat when SBP >200
For labetalol infusion, see ICH (p.113)
+ pain control

Page 7
Daily Clinical work
3) Tachycardia
When HR >100
Mx:
RFT(check latest or take one stat)

Aim K >/= 4
TSH next blood
+/- Trop I ,CK, LDH
ECG
- HR 100-140: sinus tachycardia

Low BP: Gelofusin 500ml FR x1
Normal BP: NS 500ml q1h x1
- HR >140
Low BP: cardioversion
Synchronized shock 100-120 J --> Please call MO before doing so
Normal BP:
AF: load amiodarone 150mg in 100ml D5 over 30min x1
Then maintenance: 600mg in 500ml D5 Q24H
Or Digoxin loading: digoxin 0.25mg Q8H po x 3 or 0.25mg in 50mL NS over 10 min x
3 then 0.25mg daily
Or diltiazem 100mg in 100ml NS, infuse 0-20ml/hour. Usually start at 10ml/ hour
SVT: IV ATP 10mg stat x1 --> some department require you to call MO before doing
ATP (risk of asystolic, but some department allow you to do on your own)
Or amiodarone as above
W/H theophylline, erythromycin, ketoconazole, TCA

Page 8
Daily Clinical work
4) Bradycardia
When HR <60
Mx:
RFT(check latest or take one stat)

TSH next blood
+/- Trop I ,CK, LDH
ECG
W/H beta blocker
Low BP: Atropine 0.4mg stat IV if symptomatic
Normal BP: see ECG. If Morbitz Type II or 3rd degree HB, call MO. May need
percutanous pacemaker
Also see K. Hyperkalaemia need lead to bradycardia. (see any peak t wave in ECG)

Page 9
Daily Clinical work
5) Desaturation
Mx:
May need NPO if severe
Bp/P/Sao2 q1h x4, if stable q4h
Keep SaO2 monitor
Blood x ABG, Trop I, CK, LDH,

(+/- blood c/st, T&S)
ECG,
CXR
Sputum suction PRN

Chest physio
+/- ST assessment if aspiration pneumonia
If pneumonia: (if fever, sputum, chest had creps)

+ antibiotics
E.g. IV augmentin 1.2g q8h
If severe / HAP: IV tazocin 4.5g q8h
If aspiration pneumonia, consider consult speech, RT insertion etc .
If COPD exacerbation: (pmhx of copd)

+ antibiotics
Increase ventolin and atrovent puffs to Int 4puffs q4h
If wheeze: + IV hydrocortisone q8h
If CHF: (clinically fluid overload)

Lasix 40mg q6-8h
If asthma: (wheeze)
Increase ventolin and atrovent puffs to Int 4puffs q4h
If wheeze: + IV hydrocortisone q8h
If ACS (From chest pain, ECG and Trop I):

Aspirin 160mg daily po stat, then 80mg daily po
+/- enoxaparin 0.4ml SC Q12H(if 40kg)
If metabolic acidosis:
NaHco3 8.4% 50ml q30min x1
If pneumothorax:
Chest drain insertion
If pleural effusion:

Page 10
Daily Clinical work
Pleural tap
If anemia:
Transfuse
If no specific cause identified / exclude the above cause, consider pulmonary

embolism
==========
Further management:
Review all investigation result later
Usually for CHF, can treat already before ix result

But for other diagnosis, some may be not that obvious and require review to further
manage
Cxr --> pneumonia / chf / ptx

Trop I / ecg --> ACS
But the most important:

ABG--> need bipap / ventilation
See ABG (p. 33) for result interpretation

Page 11
Daily Clinical work
6) Fever
When fever>38 or WCC markedly high
Or when on antibiotics x >2 days, still fever to >38
Consider post op fever:

Day 1-2: atelectasis --> chest physio, incentive spirometry
Day 3-5: drip site infection, pneumonia, UTI
Day 5-7: sound infection, intra-abdominal abscess
Day 7 or more: DVT / PE
Mx:
Blood x c/st (if not done in current admission or past 3-5 days)
+/- CBC d/c, LRFT, Clotting
Sputum c/st
MSU stix, c/st
NPA x resp virus
CXR
+/- IVF if septic shock

+ po panadol 500mg q4h prn
+ antibiotics / upgrade antibiotics
Antibiotics choice: depends on what infection / previously c/st
Generally:
IV augmentin 1.2g q8h
Can refer impact guide line for 1st line A/B for different infection.
Bite wound / DM foot / AECOPD / Aspiration pneumonia/CAP/ Acute phelonephritis :

IV augmentin 1.2g q8h
HAP: IV superazone 1g q12h or IV tazocin 4.5g q8h
Cholangitis: IV augmentin 1.2g q8h or IV cefuroxime 750mg q8h + IV metronidazole
500mg q8h
Peritonitis / PPU / Diverticulitis: IV cefuroxime 750mg q8h + IV metronidazole 500mg
q8h
Liver abscess: IV ceftriazone 1g q12h + IV metronidazole 500mg q8h
Infective endocarditis: IV ampicillin 2g q4h + IV gentamicin 1mg/kg q8h
Meningitis: IV ceftriazone 2g q12h
Septic arthritis / cellulitis / osteomyelitis: IV ampicillin 1g q6h + IV cloxacillin 1g q6h
Any abscess: + IV metronidazole 500mg q8h

Page 12
Daily Clinical work
Upgrade of antibiotics:
1st line:
IV augmentin
Or PO levofloxacin 500mg daily / iv levofloxacin 500mg q24h if allergy
2nd line:
--> cefazolin 1g q8h if skin infection
--> Cefuroxime 750mg q8h iv if gut / liver / biliary
--> sulperazone 1g q12h iv if liver/biliary
--> ceftriazone 1g q12h iv if CNS
--> ceftazidime 1g q8h iv if neuropenic
--> tazocin 4.5g q8h iv if UTI
3rd line: (considering p. Aeruginosa)

IV tazocin
4th line: (because consider septic shock usually by gram -ve)

IV meropenem 500mg q8h(cheap and with P. Aeroginosa coverage)
IV ertrapenem 500mg q24h (expensive and no P. Aeroginosa coverage)
If suspect gram +ve (e.g. Skin infection)

+ iv cloxacillin 500mg q6h if proximal site, iv cloxacillin 1000mg q6h if distal site
Or iv vancomycin 500mg q6h if MRSA (trough level at 5h dose if renal function normal,
3rd dose if renal function abnormal )
If severe
IV linezolid
Caution
Renal dose: generally cut half
Ampicillin 1000mg q12h iv or ampicillin 500mg q6h
Augmentin 0.6g q8h iv
Levofloxacin 500mg q48h
Cefazolin 1g q12 h
Tazocin 2.25g q8h iv
Vancomycin 500mg q12h / 1g q24h iv
Meropenem 500mg q12h iv
No need renal adjust:

Ceftriazone
Coloxacillin
Erythromycin / azithromycin / clindamycin / doxycycline
Metronidazole

Page 13
Daily Clinical work
7) Hypothermia
When temp<36
Consider overwhelming sepsis
Consider hypothyroidism
Mx:
Blair hugger
Septic workup:
CBC d/c, TSH / fT4
Blood c/st
Sputum c/st
MSU stix, c/st
NPA x resp virus
Cxr
+ Antibiotics
+/- IVF if septic shock(warm saline only in OT... Not in general ward...-_-)

Page 14
Daily Clinical work
Lab abnormalities - hematology

Page 15
Daily Clinical work
8) anemia / HB drop
When Hb <8, do hx, pe, no matter transfused or not
Ot Hb drop <1 to 2 within 1 day
Or post op drop 2
Or normal anemia in pretty normal person: Male <13, female <11
Mx:
See BP: If low BP / acute bleeding --> gelofusin 500ml FT x1
Blood x b12, folate, TSH, iron profile, retic count, Hb pattern (see if done within 3
months...)
FOB x3
See bili result ?hemolytic anemia
W/H any anticoagulants +/- aspirin if clinically bleeding
Stop any bleeding if identified:

(do PR)
Upper GI bleed: IV pantoloc 40mg q24h +/- OGD
Lower GI bleed: IV transamine 500mg q8h +/- colonoscopy
Rectal bleed: adrenaline gauze + IV transamine 500mg q8h +/- colonoscopy
Hemoptysis: IV transamine 500mg q8h +/- bronchoscopy
Hematuria: IV transamine 500mg q8h + foley insertion + bladder irrigation x 1/7(if
gross hematuria) +/- cystoscopy
Hip pain: consider psoas muscle hematoma
Other site bleeding: apply pressure, pressure dressing
Check any drains after post op
Always: if endoscopy not working, embolization of surgical hemostasis
Reverse any coagulation abnormalities

Low platelet: Plt <10 when afebrile, plt <20 when febrile
Abnormal INR: when INR increased and symptomatic(i.e. Active bleeding)
Transfuse when Hb <8

- Transfuse x unit of packed cell q x h (1 unit increase 1 Hb. FR when active bleeding,
q1h, q2h depends on clinically emergency. For non-urgent case / chf / renal patient,
q4h. No longer then q4h or bacteria contamination)
- lasix x mg post packed cell, W/H if SBP</= 110 (usually 10mg, 20mg. If renal patient
not on RRT, 40-60mg.)
- if renal patient: CAPD 4.25 % 2L q2h when transfusion, w/h if SBP</= 110. If HD,
transfuse during HD session
- post CBC, RFT

Page 16
Daily Clinical work
9) Polycythaemia
Common in COPD patients
Usually not much to treat
See if any thrombosis --> +aspirin 80mg daily po

Consider bone marrow exam in pretty normal patients

Page 17
Daily Clinical work
10) Neutropenic
Usually post chemo d7-10
See if fever or not
When ANC <0.5 or <1 with predictable fall to less than <0.5
(Not necessary WCC <4... Only when WCC <1, then consider ANC <1....)
Mx:
If no fever
Reverse isolation
Septic workup
Blood x c/st + hickman c/st x 2 set
Sputum c/st
Msu stix, c/st
Cxr
+ po levofloxacin 500mg daily

+ po fluconazole 200mg daily po
+ acyclovir 400mg bd po
If fever:
Reverse isolation
Septic workup
Blood x c/st + hickman c/st x 2 set
Sputum c/st
Msu stix, c/st
Cxr
+ tazocin 4.5g q8h iv

+/- ivf if septic shock
If not responded to tazocin x 1- 2 days, may consider:

+ gentamycin 3.6mg/kg q24h iv
If not responded in 2 days: big guns

Depends on if c/st result back or possible site of infection
If gram -ve(GI, HBP): meropenem 500mg q8h iv
If gram +ve(skin): if SA only, cloxacillin 500mg q6h iv (or 1g if more distal site of
infection suspected). If MRSA, vancomycin 500mg q6h iv
But usually: septic shock is caused by gram-ve bacteria due to endotoxin, so usually
step up to meropenem.
If no response x 5 days:
+ amphotericin B 0.5-1mg/kg/day (Very hypok effect)
+ amiloride 10mg daily po (for increasing K)

Page 18
Daily Clinical work
+ iv hydrocortisone 100mg q24h pre med

+ iv piriton 10mg q24h pre med
G-CSF 1 day post chemo (given by MO , no need worry)
If fever still not subsided:

Gram -ve: amikacin
Gram +ve: linezolin
(please discuss with MO)
Consult ICU if septic shock

Page 19
Daily Clinical work
11) Leucocytoiss
Consider sepsis / inflammatory / leukemia
Mx:
Septic workup if fever
CBC x d/c
Blood x c/st
Sputum c/st
Msu stix, c/st
Cxr
+ antibiotics

Page 20
Daily Clinical work
12) Low plt

Consider cause
Post chemo: d10-d14
ITP (give steroids)
DIC (treat underlying cause, transfuse may not be useful)
Immuno- phenomenon of CLL (because lymphocyte produce antibiotics) (not ALL as
the cells are not mature enough to produce antibiotics)
Mx:
Transfuse whe pt <10 afebrile, plt <20 when febrile or symptomatic (bleeding
tendency, epitasix, hemoptysis, hematuria etc)
- transfuse x unit of platelet Full rate
(usually 6 units of 4 units)
+ panadol 500mg q4h po prn (for febrile reaction)
For allergic reaction:

+ piriton 4mg po tds prn
Or
+ piriton 10mg iv q8h prn (if PMHx allergy response)
+ hydrocortisone 100mg iv q8h prn (if PMHx allergy response)
Other mx:
If ITP:
pulse steroid:Dexamethasone 40mg daily po x 4 days
Or
IVIG 0.4g/kg/day (consult hematology)
If DIC: Transfuse as if needed

But treat underlying cause is the essence
If Immuno- phenomenon of CLL:

pulse steroid:Dexamethasone 40mg daily po x 4 days
Or
IVIG 0.4g/kg/day (consult hematology)
13) Elevated plt count

Usually no need to treat
+/- aspirin 80 mg daily po if thrombosis
Consult hematology if needed

Page 21
Daily Clinical work
14) INR elevated

On warfarin?
DIC?
Mx:
INR daily
W/H warfarin
INR<5: keep observe
5-9: 5-10 mg vit K1 PO

Usually no need vit k1 if on warfarin or later difficult titration
If acute toxicity from other source, TCM, then PO vitamin k1
9/>9 or Any bleeding tendency

:- transfuse x unit of FFP full rate if needed
Or IV vit K1 10mg
Later when INR returns to normal, titrate warfarin at usual dose or as follow:
Usually restart at warfarin 3mg po x1 day
Then 2mg daily po
If titrate up or down
Do as: increase or decrease 0.5mg per 2 day
E.g. 2mg / 2.5mg alt day
If for procedure e.g. Abd tap, chest tap, interventional radiology procedure
Transfuse 4-6 units of FFP full rate when on call to procedure
15) APTT increased

Only while on heparin infusion
But sometimes may be contaminated by heparin bottle(the green one)
For heparin titration, see Warfarin and heparin bridging therapy (p.81)

Page 22
Daily Clinical work
Lab abnormalities - biochemistry

Page 23
Daily Clinical work
16) Hypernatremia
See any dehydrated or not
Usually die from dehydration rather than hypernatremia
Any seizure?
Mx:
Low salt diet
W/H any NaCl / NaHco3 / Na supplement
IVF 1/2 :1/2 500ml q8h-q12h

RFT q6h -q12h (depends on how high Na is)
Aim decrease Na <10-12mmol / day
If decreasing rate is faster then expected, slow down the IVF infusion rate
if decrease rate is less than expected, escalate to: D5 500ml q8-q12h
If EOT is need next day

D5 500ml q4h x1

Page 24
Daily Clinical work
17) Hyponatremia
Depends on how low
Pit fall: DI case, with DDAVP, DDAVP over dose?
Mx:
DAT
Neuro-obs q4h (if Na <120)
Blood x TSH, spot cortisol, osmolarity

Urine x osmolarity, sodium
CXR
+/- CT brain if Na <120
(Fluid restriction if strongly suspect SIADH. If not, dont do so or later will be difficult
therapy and difficult for others to initiate treatment for other problem)
IVF: 1/2:1/2 500ml q8-12h or 2D1S q8h or 2D2S q8h NS 500ml q8-12h
Actually, any fluid therapy is ok, just no D5 500ml q8-12h
Monitor RFT q6h-q12h, depends on how low
(Na 125-134: RFT q12h. Na 120-125, q8h, Na <120, q6h)
Aim increase Na <10-12mmol per day
+ NaCl 900mg BD/TDS po

Or NaCl 1800mg BD/TDS po
If not elevate fast enough:

1/2:1/2 --> NS or add sodium tablet
If elevate too fast, NS --> 1/2:1/2
+ consult medical if Na <120

IV hydrocortisone 100mg q8h if Na <120, and suspect Addison crisis
Na <110, consult ICU

Page 25
Daily Clinical work
18) Hyperkalaemia
ECG
+/- cardiac monitor if K <6
W/H any K supplement

W/H any ACEI / ARB / spirolactone
W/H amiloride / moduretic (have amiloride in it!!!)
K 5-6
Resonium A/C 15g PO /PR q6h x3
Resonium A is sodium base
Resonium C is calcium base
Recheck RFT afterwards
K >6
Calcium gluconate 10% 10ml over 3 min x1
DI drip: D5050ml + actrapid HC 8-10 units q30 min x1
+/- resonium
Recheck RFT afterwards, H stix

Page 26
Daily Clinical work
19) Hypokalaemia
No matter what is the cause still need to treat -_-
See any diuretics, vomitting, high colostomy output, cushings
Pitfall: theophylline use
Ix: if K <2.5 and in no obvious cause

Spot urine K
Urine x toxicology
Spot cortisol, TSH , anion gap / chloride, VBG, Mg
K 2.8-3.5
KCL syrup 2g po (can escalate 0.2) q2h x1-3
If persistent for few days
+ slow K 600mg daily / BD / TDS po
+ check Mg next blood
K 2.5-2.8
ECG
KCL 10mmol in 100ml water q1h-q2h x1
KCL syrup 3g PO q2h x3
Recheck RFT, Mg afterwards
K<2.5
ECG
KCL syrup 3g PO q2h x3
Recheck RFT,Mg afterwards
For IV K supplement: must follow this 3 rule

1. Max infuse 40mmol K/ hour
2. Simultaneously only can have 20mmol K on the drip stand
(i.e. Cannot infuse KCl 20mmol in 100 water and KCl 10mmol in NS 500ml together
into 2 arms / 1 arm)
3. Max 40-120mmol K / day through IV
If patient NPO
K3-3.5
Add 10mmol to each pint of originally IVF
10mmol in 500ml NS 6-8h
Recheck RFT mane
K 2.8-3:

Page 27
Daily Clinical work
Recheck RFT mane
If K <2.5:
ECG
Recheck RFT,Mg afterwards

Page 28
Daily Clinical work
20) Hypomagnesemia
Treat especially when persistent hypokalaemia, hypocalcemia, arrhythmia
Mx:
+/- ECG
4ml 50% MgSO4 in 100ml NS infuse 30 min

+/- 10ml 50% MgSO4 in 500ml NS over 6 ours
+/- Magnesium trilisilate 10ml TDS PO daily
21) Hypercalaemia
Corrected Ca: 0.02 * (40-albumin) + Calcium
See symptomatic or not: polyuria, polydipsia, constipation, arrhythmia, mental
disturbance
Mx:
ECG
W/H any calcium supplement
IVF: 2D1S Q8H or 2D2S Q6H (depends on fluid status, CHF or renal history)
====for oncology houseman======

If calcium of malignancy:
Pamidronate 60mg in 500ml NS infused over 4-6 hours
Or
Zometa 1-4m,g in 100ml NS over 15 min
Depends on Renal function!!!
CrCL
>60 4
50-60 3.5
40-49 3.3
30-39 3
<30 Not recommended
(these drugs takes days to act!!!)
==============================

Page 29
Daily Clinical work
22) Hypocalaemia
In patient with:
Renal failure
Post thyroid surgery(parathyroid injury)
See symptomatic or not
Mx:
+/- ECG
Caclium gluconate 10% 10ml in 100ml NS infuse over 30min IV (can by nurse)
(or you can do that Caclium gluconate 10% 10ml iv over 3-5 min, by yourself)
If renal failure patient on CAPD, persistent low, can change CAPD regimen from low
calcium to normal calcium
+/- caltrate 600 1500mg PO daily
23) Acute kidney failure

Sudden Cr increased or Urine <0.5ml/kg/hour
Usually dehydration
Or in pretty normal patient, may need workup...
Mx:
Bladder scan, if RU >350ml, foley to BSB
Or on foley: flush foley
Urine x multistix, c/st

+/- KUB
W/H metformin / NSAID if severe

NS 500ml Q1H / Q2H x1, then recheck RFT
If very severe, or not specified cause identified or not respond to fluid challenge:
Blood x
CBC, LRFT, bone, RG,
ANCA, Anti-ANA, Anti-ds DNA, Anti-GBM
Complement 3, complement 4
HbsAg, , Anti-HCV
Serum protenin electrophoresis, Bence Jones protein, Ig pattern
Urgent USG urinary system to rule out post-obstructive cause
see case admission for Acute renal failure(P.131)

Page 30
Daily Clinical work
24) Deranged LFT

Any drug cause?
Cholangitis?
Hepatitic picture (ALT increased >ALP increased)

Mx:
Blood x HbsAg, anti HCV(if not known hep B/C status) , Anti-HAV, Anti-HEV
GGT, AST, LDH, amylase
W/H panadol, TB drugs
Treat other liver cirrhosis complication(see GI part)
Cholangitic picture (ALP increased >ALT increased)

Mx:
NPO
Blood x HbsAg, anti HCV(if not known hep B/C status) , Anti-HAV, Anti-HEV
GGT, AST, LDH, amylase
Blood x c/st if fever
MSU stix, c/st
CXR,AXR
+/- antibiotics if fever

Urgert USG HBP (for any drainage component: i.e. CBD obstruction or liver abscess )

Page 31
Daily Clinical work
25) Acidosis
Metabolic / alkalosis acidosis?
pH<7.35 is acidosis
See bass excess, if <-2 is metabolic acidosis
See HCO3. HCO3 decrease is metabolic acidosis
See CO2 . CO2 elevates is respiratory acidosis
Mx:
Hstix x1
(if no specific cause identified)

Blood x RG, BAHA, Anion gap(CL), Lactate
Urine x toxicolgy
If metabolic acidosis, pH <7.25, HCO3 <18:

NaHco3 8.4% 50ml Q1H x1
If respiratory acidosis:
(usually have CO2 retention)
+/- ABG
- need hyperventilation
- may need bipap / ventilation
(see ABG p.33)

Page 32
Daily Clinical work
26) ABG
Most important is CO2 value!!!

Ph, HCO3, Bass excess --> can be monitored by VBG
Po2--> can be monitored by SaO2
So the only thing that is unique in ABG is CO2 value
Usually took in following situation

1. Patient not on any ventilation /bipap
a) desaturation in AECOPD, CHF or any other patient.
b) Not desaturation: MG patient with FVC lowered
2. 1-2 hours post bipap / ventilation begins
3. Trying to wean off bipap / ventilation
For situation 1:
ABG is took to decide if current O2 is enough and to see if any CO2 retention or
respiratory failure Type II (esp COPD patient, giving them O2, may remove hypoxic
drive, and so CO2 retention)
See pH if <7.35 + CO2 retention --> may need bipap / ventilation

But also see previous CO2. If COPD, may be chronic CO2 rentetion, so may not need
bipap / ventilation
Can have few solutions

1. Keep observe
a) If CO2 is only mildly elevates, pH is 7.3-7.35
b) Or chronic elevates CO2, CO2 now at baseline only
2. Interval ABG to see if CO2 progressively increase or not. Usually interval like 2
hours later, or before MO leave hospital or before patient sleep
a) If static: may consider, keep observe
b) If increased: need bipap / ventilation
3. Put on bipap / ventilator
a) Bipap setting
i. I 14
ii. E 6, if home bipap, then E can be to 8
iii. RR 10-14
iv. FiO2 usually can start with 0.4 / Or calculate with current O2. 21% +
currnet L x3 e.g. On 3L = 21+3x3 = 29% =0.3
b) Ventilator setting
i. Mode: usually SIMV ok
1. SIMV mode (spontaneously intermittent mechanical ventilation) if
spontaneously breathing
2. CMV mode ( continuous mandatory ventilation) if resp muscle
paralysis.

Page 33
Daily Clinical work
ii. Tidal volume: 0.5L (500ml/50kg)

iii. IE ratio:
1. 1:2
2. 1:3 for COPD
3. 1:1 for restrictive airway disease
iv. PEEP(positive end expiratory pressure): 4-5 cmH2O
v. PFR: 40
vi. Pressure support 8-10
vii. Sensitivity +/-2
viii. FiO2 50-100%. Usually at 100%
ix. RR 12-15 (if need hyperventilation e.g. Increased ICP,18-20)
For situation 2
ABG is took for bipap / ventilator adjustment
If co2 ok, continue management.
If CO2 still high / pH still acidotic
Bipap: do any 1 of the following: (with 1st is the most common people do)
1. Decrease FiO2 if Oxygenation is enough
2. increase RR
3. increase I by 2
4. Increase I by 4, increase E by 2
5. Or do 1 ,2and 4 together
Recheck ABG 1-2 hours later
Ventilator: do any 1 of the following: (with 1st is the most common people do)
1. Decrease FiO2 if Oxygenation is enough
2. Increase RR
3. Increase PEEP
4. Increase I:E ratio
Recheck ABG 1-2 hours later
For situation 3
For bipap wean off sequence:

Put on bipap x2 days --> try wean off during meal time --> try wean off day time (only
with nocturnal bipap)--> try wean off whole day , standby bipap whole day--> try
wean off whole day , standby bipap nocturnal --> wean off bipap
Usually will take ABG just before putting back on bipap:

1. try wean off during meal time : when meal time finished
2. try wean off day time: when before sleep, or sometimes at 1500-1600 so the case
MO can see the result before leaving work
3. try wean off whole day: at morning 0600-0700 so morning round can see ABG

Page 34
Daily Clinical work
For meal time abg:

Co2 retention: no immediate action, because usually already put back on bipap
But guide further management: e.g. Cannot proceed to next stage of wean off, have
to continue meal time bipap next day
Co2 ok: no immediate action
But can try wean off day time next day(await MO decision)
For day time abg:

Co2 retention: can consider put back on bipap earlier as planned
Co2 ok: no immediate action, but can try wean off whole day next day (await MO
decision)
For 0600/0700 abg:

Usually can leave to case MO for decision
Co2 retention: can consider put back on bipap or interval ABG
Co2 ok: continue wean off bipap (await MO decision)
For ventilator:
SIMV/CMV --> PS (CPAP mode)-->T-piece
SIMV / CMV = ventilator is on

PS / CPAP = only provide pressure support to open up the airway
T- piece = only O2 is provided
If on CPAP mode
CO2 retention: Put back on SIMV or interval ABG
CO2 ok: no immediate action
But can try t-piece next day (await MO decision)
If on T-Piece:
CO2 retention: Put back on CPAP or interval ABG
CO2 ok: no immediate action
But can try extubate next day (await MO decision)
Also see resp part: Bipap and ventilator alarms(p.60)

Page 35
Daily Clinical work
27) Trop T/ Trop I

1. See chest pain or not
2. See vitals stable or not
3. See ECG any ST changes: STEMI --> must call MO
Trop T
<14 no need action
>14 repeat Trop T, CK, LDH, ECG q8h x3
If double rise: MI
If increased, but not double rise, can consider continue repeat until double rise /
downtrend
If static or downtrend: consider other cause for elevated of trop I
If >14 and eleavated to like ~1000: must MI la, see ECG , usually STEMI if so high
Trop I
<0.03 no need action
>0.03: repeat Trop I, CK, LDH, ECG q8h x3
If >0.3: MI
If after repeat: increasing trend but not exceeding 0.3 can continue repeat until
downtrend
If after repeat: static or downtrend, consider other cause for elevate of trop I
Other causes of elevating of MI: sepsis, renal failure, CHF etc.
Mx:
Prop up
Bed rest
Cardiac monitor
O2 0-2L prn, aim SaO2 >/= 95%
Aspirin 160mg po stat x1, then 80mg daily po

+ TNG 500microgram stat sl prn
+/- enoxaparin 0.4ml q12h SC
(must check any Bleeding history!!!)
If high blood pressure + chest pain not responded to TNG:

- Isoket infusion 50mg in 100ml NS, start with 4ml/hr (usually 0-10ml/hr, max
20ml/hr)
- Nitrocine 25mg in 100ml NS, start with 4ml/hr (Other dosage: 1mg / 1ml NS, 1ml /
hr)
NSTEMI --> above is enough, can inform MO for starting of enoxaparin if not sure
STEMI --> inform MO , need CCU bed

Page 36
Daily Clinical work
28) Iron profile / folate / B12

Can ignore and let MO decide
But you can still treat if want to
Fe deficiency:
Iron low, TIBC high, % sat low
Give FeSo4 300mg BD PO x 4-8/52
Folate deficiency:
Folate 5mg daily po (rule out any B12 deficiency 1st)
B12 deficiency:
B12 5000microgram intramuscular alt day x 5 doses
Check RFT after 3rd dose (may cause hypokalaemia)
Then 1-3 monthly injection of 5000microgram B12 IM
29) Thyroid profile

Usually no need to care, leave to CMOs decision
TSH elevated / lowered: check symptomatic and fT4 also
TSH low TSH normal TSH high

nd
fT4 low 2 hypothyroidism Primary hypothyroidism
fT4 normal Subclinical Normal Subclinical
hyperthyroidism hypothyroidism
Sick euthyroid Sick euthyroid
fT4 high Primary hyperthyroidism 2nd
hyperthyroidism
(rare)
For TSH abnovmal, but fT4 normal: repeat thyroid function(TSH +fT4) 6-8/52 later
For primary hyperthyroidism: drugs / RAI / surgery

See if any acute complications: thyroid storm / chf / hypokalaemic paralysis, if no,
leave to CMOs decision
If complication: call MO, may need ICU admission
For primary/2nd hypothyroidism:

Thyroxine 50-100microgram daily po
Recheck TFT 6-8/52 interval time
If more acute, recheck 2-4/52
But need rule out any cardiac diseases first
Leave to CMOs decision

Page 37
Daily Clinical work
30) Therapy drug monitoring

For gentamycin adjustment:
For vancomycin:
Check trough level
If normal renal function, trough at 5th dose
If abnormal renal function, trough at 3rd dose
For digoxin/ theophylline

W/H if higher then therapeutic range
31) Clostridium difficile +ve

Stool x Clostridium difficile +ve, ask still any diarrhoea
Contact precautions
+ flagyl(metronidazole) 400mg tds po x 1/52
Also if any other patients has diarrhoea symptoms, be careful.

Remeber, hand washing!!!!

Page 38
Daily Clinical work
32) C/st and sensitivity

Can check if patient is feverish, or what antibiotics is on
Change according to sensitivity
Change antibiotics or not, depends on how severe the infection is.
For changing, please see fever (p.12)
If blood c/st: usually very accurate, change according report

just gram stain already see bacteria, can write into CMS.
Or not await identification of organism and sensitivity
= if staphylococcus epidermiditis ==> usually contamination, dont change
antibiotics, await CMO assessment
= if MRSA==> consider continamination: repeat 2 more C/ST at different site and
different time
Also consider any chace of infective endocarditis. ?heart murmu or may need echo
= ESBL ==> all others are useless.
Use meropenem 500mg q8h IV
= streptococcus / gram -ve ==> usually true infection, change accordinlyt
--> choose one which is not allergic and less side effect profile
If urine c/st: see any WCC in urine specimen)usually mention in the same report) +
fever or not
If both, then may be true infection
If not, may be contamination
For MSU, sputum c/st, tracheal aspirate, wound swab, many are contamination. Must
correlates with clinical findings. Can await MO assessment
If see TB positive for inpatient patient

- isolation(air borne)
- prescribe anti drugs if LFT normal
see Anti-TB drugs (p.62)
If see TB positive for discharged patient, go back to CMS check if NDORS or not. If
NODRS-ed, then that meants treating / finished treatment. If not, then may need to
call back patient.
33) Knee tap: urgent gram stain

Urgent gram stain +ve: NPO, inform MO
(may need knee lavage and urgent consult ORT)
If c/st +ve: NPO, inform MO

(may need knee lavage and urgent consult ORT)

Page 39
Daily Clinical work
X ray

Page 40
Daily Clinical work
34) General
CXR:
ptx / free gas / consolidation +/-
Costophrenic angle sharp / blunt
+/- surgical emphysema, airway stenosis (any medistinal mass /retrosternal goitre)
+/- rib #
AXR / KUB:
Bowels not dilated / prominent / dilated
Rectal gas +/-
Stone +/-
Limb #
Fracture / dislocation +/-
Gas formation / osteomyelitic changes
35) Pneumothorax
Mx:
O2 4-6L
SaO2 monitoring
Call mo
Need chest drain
36) Consolidation / lung mass

Check if fever/ WCC and on antibiotics or not
Mx:
Blood x c/st if fever
Sputum c/st
Sputum cytology if suspicious
+ IV augmentin 1.2g q8h (if fever / WCC elevated)

Sputum sunction prn if needed
Chest physio if needed

Page 41
Daily Clinical work
37) Free gas

See if immediate post laparotomy: if so, normal
Causes: PPU, perforation post endoscopy
Mx:
NPO
BP/P Q1H
UO Q1H
Blood x VBG, Amylase, T&S

AXR
Call MO: need intervention

Urgent CT A+P or EOT
38) Costophrenic angle

if blunt and desaturation --> may need pleural tap, but usually not urgent
39) Prominent / dilated bowels
Prominent bowels
Mx:
NPO
Dilated bowels
MX:
NPO
RT to BSB if vomitting, aspirate q4h
Blood x VBG, Amylase, CRP
40) Urinary stones

Mx:
MSU stix, c/st
+ IV/IM tramadol 50mg q6h prn if pain

Encourage fluid intake

Page 42
Daily Clinical work
41) Fracture
See fracture(p. 170-171)
Mx:
NPO
42) Osteomyelitic changes

See cellulitis(p.173)
May need EOT
43) CT brain
Any hemorrhage / SOL /MLS
Ventricles dilatation?
Compare with old CT brain
Inform MO when unsure

Page 43
Daily Clinical work
ECG

Page 44
Daily Clinical work
44) ECG - basics

Basic Measurements
Parameter Measurement Interpretation
HR Normal: 60-100 Normal /
abnormal
Rhythm Sinus/ atrial/ junctional/ supraventricular(artial Normal /
or junctional)/ ventricular abnormal
Tachycardia / bradycardia / normal
Regularly/ irregularly
Regular / irregular
PR Normal: 0.12-0.2 seconds (3-5 small box) Long / short
QRS Normal:0.08-0.09 seconds Long / short
(2 small box)
QTc Normal:365-440 milliseconds Long / short
P direction 0-90
Inferior and leftward
QRS 0-90 Normal
direction Inferior and leftward LAHB
LPHB
-45: LAHB (no QRS lengthening) RBBB
LBBB
90-180: LPHB
QRS: 0.10-0.11 / 0.12

+ last part of QRS direction
RBBB: last part points right and anterior
LBBB: last part points left and posterior

Page 45
Daily Clinical work
Evaluation for Ischemia or infarction

ST elevation Diffuse (can be pericarditis)
Lead x?
Pattern?
T wave Check old ECG + ECG done in later!!! Determine: unstable angina,
inversion new NSTEMI or old NSTEMI!!!
Diffuse
Lead x?
Pattern?
ST Check old ECG + ECG done in later!!! Determine: unstable angina,
depression new NSTEMI or old NSTEMI!!!
Diffuse
Lead x?
Pattern?
Q waves or Diffuse
equivalent Lead x?
Pattern?
Evaluation for Systemic effects: note if present

RAA / LAA RAA:
P wave amplitude lead II, III, AVF > 2.5 little box?
P wave axis, -90105?
Biphasic P wave in lead I
LAA:
Broad and notched P wave in lead II
P wave negative in V1?
RVH / LVH LVH
For Frontal plane: S in lead III + R in lead I > 25 little boxes
For Horizontal Plane: S in lead V1 + R in lead V5 > 35 little boxes
RVH (Right ventricular hypertrophy)

For Frontal Plane: QRS axis rightward
For Horizontal plane: QRS axis rightward or anterior
Drug effect Digitalis:

Short QT
Cheshire cat smile
Other drugs
Long QT
Page 46
Daily Clinical work
Hyper/Hypo Hyperkalemia:
kalemia Peaked T wave
Flattening of p wave
T wave with Sine wave pattern
QRS>2.0
Hypokalemia:
QT prolonged
Low amplitude T wave
U wave
Hyper/Hypo Hypercalcemia
calemia QT shortened
Heart block
Hypocalcemia
QT prolonged
Ventricular tachycardia / ventricular fibrillation
Low voltage QRS in lead I + II + III < 15 little box

Or
QRS in lead V1 +V2 +V3 < 15 little box
Yes / No
DDX:
COPD
Pericarditis Sinus tachycardia
Injury mimic ischemia
PT segment depression
SI / PE?
QTIIIpattern
Hypothermia J wave or Osborne wave

Page 47
Daily Clinical work
The following is something that I think is essential for HO for recognize. But for other
minor detail, ok not to pick up from ECG(e.g. Hyperkalaemia, usually you will notified
by lab results hyper K rather than by pick t wave)
45) Sinus tachycardia

See tachycardia (p.8)
Any S1QT3 --> any desaturation / DVT
Or else, impending shock? --> give IVF if not cardiogenic shock
46) Atrial fibrillation / multi focal atrial tachycardia

HR >140 = Fast AF --> may need management. If hypotension, synchronized shock. If

normal BP, rate / rhythm control i.e. Amiodarone
AF rate 60-100 --> usually no immediately action. Can check if known in PMHx or not,
or check if on anticoagulants or not(aspirin / warfarin) or onset >2 days. If new onset,
not on any anticoagulants, can write in case notes, wait MO assessment.
AF rate <60 --> usually no immediately action. Can check if known in PMHx or not, or
check if on anticoagulants or not(aspirin / warfarin) or onset >2 days. If new onset,
not on any anticoagulants, can write in case notes, wait MO assessment.
47) Supraventricular Tachycardia

Usually not seeing this rhythm on ECG, but will be called to see patient as
tachycardia.
See 3) Tachycardia
48) Bradycardia
See bradycardia (p.9)
Any morbiz type II heart block or complete heart block
--> call MO if so
If not, then usually ok

Check clinically stable or not

Page 48
Daily Clinical work
49) T wave inversion / ST depression

See Trop T/ Trop I(p.36)
Check previous ECG, if same, then not need care
If new: check any chest pain, Trop results. If 2 out of 3 criteria --> NSTEMI
Need treatment then
Need treatment then
But if RBBB or LBBB present, cannot say if T wave inversion / ST depression / ST

elevation.
50) ST elevation
If new: check any chest pain, Trop results. If 2 out of 3 criteria --> STEMI
Must call MO
Need CCU
ST elevation vs high take off

ST elevation looks like a sad face, but high take off looks like a smile
ST elevation:
High take off:

Page 49
Daily Clinical work
51) RBBB
No matter new or not, no need care...
Not ACS
52) LBBB
Need treatment then

Page 50
Ward complaints
Ward complaints

Page 51
Ward complaints
Cardiac

Page 52
Ward complaints
1) Chest pain
see if sounds like MI or not
Mx:
Blood x Trop, CK, LDH, ECG q8h x3
+ TNG 500microgram SL Stat x1
+ pepcidine 20mg bd po
See if Trop elevate or not, and is ACS or not

Acs: chest pain / ECG changes / Trop, must have 2 out of this 3
If ACS, see lab abnormalities: Trop T/ Trop I (p.36)
2) Palpitations
See if real or not... Check pulse
Mx:
ECG + long lead II

Page 53
Ward complaints
3) Fast AF
Mx:
Cardiac monitor
+/- blood x Trop, CK, LDH
+/- blood c/st if fever
ECG
Amiodarone
Loading: Amiodarone 150mg in 100ml D5 Q30 min x1
Maintainence: Amiodarone 600mg in 500ml D5 Q24H
W/H amiodarone if HR <60
Or
Digoxin (when BP low)

Loading dose: 0.25mg in 10ml NS infusion stat, then Q8H x3
Maintenance: 0.125-0.25 mg QD po (0.0625mg for elderly)
W/H digoxin if HR<60
If already on amiodarone, still AF.

Can have following few options:
1. Reload: Amiodarone 150mg in 100ml D5 Q30 min x1
2. Increase maintanence dosage to:
--> Amiodarone 750mg in 500ml D5 Q24H
Further up to
-->Amiodarone 900mg in 500ml D5 Q24H

Page 54
Ward complaints
4) SVT
Mx:
Cardiac monitor
+/- blood x Trop, CK, LDH
ECG
ATP 10mg IV push stat x1, also pre e-trolley, may cause cadiac arrest.
Not responded, repeat ATP 10mg IV push stat x1
Can consider ATP 20mg IV push stat x1
ATP is for seeing rthythm, usually not sustained
After ATP, still need maintenance:

Amiodarone
Loading: Amiodarone 150mg in 100ml D5 Q30 min x1
Maintainence: Amiodarone 600mg in 500ml D5 Q24H
W/H amiodarone if HR <60
But for those sepsis induced SVT, need to control sepsis...

Page 55
Ward complaints
5) Dizziness
See if BP/P stable
Vertigo or not
Cerebellar sign?
Mx:
Postural BP x3
Hstix stat x1
ECG +/- long lead II
CT brain if suspected cerebellar stroke. If not, no need
+/- stemetil 5mg tds po prn

Page 56
Ward complaints
Respiratory

Page 57
Ward complaints
6) O2 therapy
- O2 X L through nc / mask
- O2 0-x L prn, aim SaO2 >/= x
Usually COPD 88-92% is ok
7) SOB
Ask SaO2, if desaturation, see desturation part
If subjective SOB, check VBG for any acidosis (DKA, renal acidosis etc)
If chest pain, MI?
If wheeze, asthma
If pallor, anemic
If end of life care, may need morphine drip (see pain part)
8) Cough
See if fever, purulent sputum
If possible:may need septic workup
Blood c/st, sputum c/st, cxr
MES 10ml TDS PO prn (expectorants)

Phensedyl 10ml TDS PO prn( may cause AROU) (cough supressants)
Promethazine 10ml TDS po prn
Cocillana 10ml QID PO prn
Elixir Benadryl 10ml QID PO prn
9) Sputum
+/- Sputum c/st, cxr
Fluimucil A 200mg tds po

Bisolvon 8mg tds po
10) Sore throat

NPS x resp virus if suspected viral infection
Dequadin 500microgram qid po prn
Cepacol tab 1 QID PO prn
Strepsils tab 1 QID PO prn
+/- mouth wash preparation

- 0.2% Chlorhexidine MW 10ml LA TDS
- Thymol gargle MW 10ml LA TDS
+/- cough medication

+/- piriton

Page 58
Ward complaints
11) Hemoptysis
?TB
?Tumor
Mx:
Air borne precaution (suspected TB)
NPO
IVF
O2
IV access
Blood x CBC, LRFT, Clotting,

+/- ABG, Trop if desaturation
+/- T&S if massive
Sputum x c/st
Sputum / cytology x3
W/H aspirin / anti-coagulants

+ IV transamine 500mg q8h
If severe call MO.

May need airway protection i.e. Intubation
Also may need ICU admission
Need further ix and mx: CT thorax, embolixm, bronchoscopy, CTS surgery

Page 59
Ward complaints
12) Bipap and ventilator alarms

For setting and adjustment: see ABG(p.33)
Bipap usually no alarm

1. Decreased SaO2
- disconnected --> reconnect
-sputum plug --> sputum suction
- pneumothorax --> stop bipap, chest drain
- not tolerating bipap --> ?
Mx:
ABG
CXR
Increased Fio2
Sputum suction prn

Chest physio
If cxr found ptx: stop bipap!!!
Ventilator:
1. Decrease SaO2
- disconnected --> reconnect
- blocked tube --> sputum suction
- Pneumothorax --> stop ventilator, chest drain
- Fight ventilator --> dormucum
Mx:
ABG
CXR
Increase FiO2 (keep max <60%)

Increase PEEP (increase recruit alveoli, decrease dead space)
Increased CO2
Increase RR
Increase tidal volume (wash out CO2)
Sedation (more synchronized breathing): dormicum 100mg in 100ml NS: 1ml/hour
infusion IV
2. high pressure / peak pressure ; small TV

- blocked tube --> sputum suction
- pneumothorax --> stop ventilator, chest drain
- fight ventilator --> dormicum
Mx:

Page 60
Ward complaints
ABG
CXR
3. low pressure; high TV

-Leaking air => check
-BP low
-Must check whether pneumothorax
4. Small TV
-cuff leak (discrepancy between TVin and TVo)
-tube kink/biting tube
-coughing
-peak pressure
5. Disconnect
Reconnect
6. Apnea (only seen in spontaneous mode)

Change to CMV mode

Page 61
Ward complaints
13) Matoux test

0.1ml 2 unit PPD, read result 48-72 hours later
14) Anti-TB drugs

Check LFT
Check visual acuity before prescribing
Check body weight
Warn about side effect: visual acuity, hepatitis etc
- Rifampicin 450mg if <50kg, 600mg if >50kg

- Isoniazid 300mg
- Pyrazinamide 1.5g
- Ethambutol 800mg <-- the visual acuity affecting one
- Vit B6 10mg QD
Duration:
6 months of normal cases
9 months for DM cases, pleural effusion cases
12 months for CNS cases
W/H TB meds if hepatitis

After LFT normalized
+ levofloxacin 500mg daily po
Resume ethambutol
Later attempt isoniazid and rifampicin (this 2 is really important in treating TB)
Indications that will treat TB with dexamethasone:

1. TB meningitis (usually high fever, headache, visual disturbance)
2. TB laryngitis (remember ddx: NK T cell lymphoma!!!)
Other conditions to remember, any AIDS?

Don contact tracing. Ask any children at home

Page 62
Ward complaints
Gastro intestinal

Page 63
Ward complaints
15) Abd pain

Where: cholecystitis, cholangitis, appendicitis, pancreatitis, diverticulitis, others
When: sudden / subacute
How: colicky, dull, constipation pain
Any vital abnormalities / vomitting / malaena / No bowel opening / flatus
PE: soft vs guard abdomen
Mx:
NPO
BP/P q1h x4, if stable q4h (for unstable cases)
Blood x (CBC, LRFT, Clotting) , VBG, Amylase, CRP

+/- T&S if EOT may be needed
+/- c/st if fever
CXR, AXR
If dyspepsia: pepcidine 20mg bd po, mg tri 10ml TDS po, gasteel 1 tab tds po
If conspitation --> laxatives
If colicky --> IO? See x rays. If vomitting, RT to BSB. Dont give laxatives . Buscopan
tab 1 tds po prn / buscopan 20/30/40mg IV/IM q6h prn
If RUQ pain --> cholecystitis / cholangitis? If fever, need antibiotics( IV Zinnacef
750mg q8h and IV flagyl 500mg q8h)
If RLQ pain --> appendicitis? (no need antibiotics) May need T&S and EOT
If LLQ pain --> usually non specific. But fever and elevate WCC, may need
antibiotics( IV Zinnacef 750mg q8h and IV flagyl 500mg q8h)
If guarding --> may need urgent CT +/- T&S, EOT
If free gas under diaphragm--> PPU, need T&S and EOT
+/- tramadol 50mg q6h iv/im/po prn

Page 64
Ward complaints
16) No bowel opening

Must rule out IO
See previously x ray
Ask any abd pain / vomitting / flatus
Mx:
DAT / NPO
+/- blood x VBG, Amylase, CRP
+/- AXR, CXR
Laxatives:
Oral:
Lactulose 10ml po bd prn
Senna 7.5mh / 15mg daily po prn
Angiolax 10ml bd po prn
Pr:
Dulcolax 10mg daily pr prn
Fleet enema 1 tube daily pr prn

Page 65
Ward complaints
17) Vomitting
Mx:
+/- NPO
If IO case: RT to BSB, aspirate q4h
Iv maxolon 10mg q8h prn (if significant vomitting)

Po maxolon 10mg tds po prn
18) Diarrhoea
Mx:
+/- IVF if dehydrated
+/- blood x RFT(hypoK?)
+/- AXR
Stool x c/st, norovirus, CD toxin

+/- immodium (loperamide) 2mg aid po prn

Page 66
Ward complaints
19) PR bleed: fresh blood vs fresh malaena vs old malaena
Fresh blood: (anorectal bleeding)

Protoscopy
Mx:
If only blood stained, keep observe
If significant:
Blood x CBC, LRFT, Clotting urgent, T&S
Adrenaline gauze (dip adrenalize in gauze, use a suture to tie it. Put PR into the
bleeding site via protocscope. The suture remain out so when need remove of
adrenalize gauze, can put it)
+/- gelofusin 500ml FR x1 if significant blood loss
+/- blood transfusion
+/- IV transamin 500mg q8h
Altered blood:(bleeding from LGIB)

Mx:
If significant:
+/- gelofusin 500ml FR x1 if significant blood loss

+/- blood transfusion
Fresh malaena: (fast bleeding from UGIB)

Call MO
May need urgent consult surgery
Mx:
NPO
CXR, AXR
+/- IVF: gelofusin 500ml FR x1

+/- Blood transfusion
Old malaena (bleeding from UGIB)

Page 67
Ward complaints
NPO
NPO
CXR, AXR
+/- IVF: gelofusin 500ml FR x1

+/- Blood transfusion
+/- IV pantoloc 40mg q24h
May need consult surgery
20) Coffee ground vomitting

See case admission: UGIB(p.154)
21) Hemorrhoid
+ anusol ointment la bd prn
+ faktu tab 1 bd or ointment la tds
+/- laxatives
If significant bleeding see case admission LGIB (p.157) or UGIB(P.154)

Page 68
Ward complaints
Renal

Page 69
Ward complaints
22) Low / no urine output

Aim 0.5ml/kg/hour
Usually 50kg for chinese people, so ~25ml/hour is great.
For women, thinner, 20ml/hour is also ok
Check hydration status, if CVP available check

Remember: ESRF no urine, no need treat
PR for any malaena
Mx:
+/- UO q1h x4, if stable, q4h
Bladder scan +/- foley insertion

If on foley: flush foley
Low BP:
Gelofusin 500ml FR x1
Normal BP:
NS 500ml q1h x1
Or NS 500ml q2h x1
If fluid over load, normal BP:

Lasix 10mg IV stat x1
Or lasix 20mg IV stat x1
(lasix last for 6 hours, so usually ok result)
If fluid over load, low BP:

Dopamin 200mg in 100ml NS, 5ml/hour(renal dose)
If given 1-2 time fluid challenge already, consider lasix or dopamin. If still low UO,
consider CVP insertion for further guidance of management.
+/- RFT, KUB
Note: lasix and dopamin had no clinically proven usage in renal function, just surgeon
like to treat numbers
If AKI from RFT , see case admission for Acute renal failure(P.131)

Page 70
Ward complaints
23) Hematuria
Mx:
See vitals: if grossly hematuria? Shock
CBC
MSU / CSU stix, c/st
Urine x cytology x 3
EMU x AFB x3
KUB
W/H aspirin, anticoagulants
If gross hematuria
Foley to BSB
Bladder irrigation x 1/7
Consult urology x assessment +/- flexible cystoscopy
24) Dysuria
MSU stix , c/st
Pyridium 200mg TDS po prn
+/- augmentin 1g po bd (depends on stix result)

Page 71
Ward complaints
25) CAPD peritonitis / CAPD turbid fluid
Mx:
PDF fluid c/st
Rapid flushing of PDF fluid 2Lx3, + IP heparin 500-1000 units/ L
Increase CAPD regimen to 4 bags per day(may consult MO before administrating this,
or wait for case MO to decide)
+ IP heparin 500-1000 units/L PRN
If no fever:
+ IP (fortum)ceftazidime 1g + cefazolin 1g stat, then daily x 13 days
If not responded:
D3 add gentamycin (require monitoring, dosage please consult MO)
D5: change fortum and cefazolin to vancomycin
If fever / chills / rigors / systemiatic sign:

IV (fortum)ceftazidime 1g + cefazolin 500mg stat then a24h
26) Decrease CAPD fluid output

Capd peritonitis?
Laxatives to increase bowel motion sometimes help
If fluid overload
CAPD 4.25% q2h x2
27) Increase CAPD fluid output

W/H capd if hypotension
Or give back some fluid in terms of encourage fluid intake / IVF

Page 72
Ward complaints
Neurology

Page 73
Ward complaints
28) Headache
Exclude significant one
E.g. Hemorrhage, hemorrhagic transform post stroke
Check GCS, 4 limbs power
Mx:
Consider CT brain
If not: analgesics
29) Numbness
Exclude stroke / cord lesions / radiculopathy / plexopathy
If not: keep observe
+/- gabapentin 300mg nocte if intractable
30) Drop GCS

Consider Hemorrhage, hemorrhagic transform post stroke
Also beware SLE case, Leukemia case
Mx:
Neuro-obs q1h
CT brain
31) Seizure
See case admission: Convulsion

Page 74
Ward complaints
Endocrine

Page 75
Ward complaints
32) H stix low

Mx:
H stix q1h x4, if stable q4h
W/H DM drugs
Orange juice po
D50 40ml IV /PO stat x1
If persistent low:
+ 1/2:1/2 500ml q8-12h
Or upgrade as follow:
1/2:1/2 --> D5-->D10 -->D20

Page 76
Ward complaints
33) Hstix high

If too high, consider DKA / HONK
Blood x RG, BAHA, VBG, Osmolarity, RFT, Hba1C

Urine x stix
If not:
H stix Actrapid HM
14-18 4 units
18-22 6 units
>22 8 units
The above for stat.
Can omit if after dinner.
No need treat <22 hstix
If >22 after dinner, can consider giving 4-6 units. Risk of hypoglycemia and not
detected at night.
To solve the problem of high h stix and dont want people to call you:
Insulin scale:
- Version 1:
Hstix Actrapid HM
<13 0
13-15 4
15-20 6
20-25 8
>25 Inform
- Version 2:
Hstix Actrapid HM
<11 0
11-14 2
14-17 4
17-21 6
21-28 8
>28 10 +inform
- Or just order single strength according to Hstix reading, e.g.

- Actrapid HM 6u sc tds prn if Hstix >16 (or omit if Hstix <10)

Page 77
Ward complaints
34) DKI drip

D10 500ml Q6-8H, plus the followings:
Hstix Actrapid HM KCL
4-7 0 0
7-11 5 5
11-17 10 10
17-22 15 15
>22 20 20
(e.g. D10 500ml + 10u Actrapid HM + 10mmol KCl Q8H/pint)
35) Insulin pump

For DKA
insulin pump: 49.5ml + 0.5 units of actrapid HK(1 unit in 1 ml)
Insulin pump sliding scale
H stix Actrapid HM(units / hour)

> 4.2 6.7 0.5
> 6.7 8.9 1
> 8.9 11.1 2
> 11.1 16.7 3
> 16.7 27.8 4
> 27.8 6 + inform
For HONK

> 4.2 6.7 0.25
> 6.7 8.9 0.5
> 8.9 11.1 1
> 11.1 16.7 1.5
> 16.7 27.8 2
> 27.8 3 + inform

Page 78
Ward complaints
36) Thyrotoxicosis
See if any ?thyroid storm
GE symptoms, tachycardia, fever / hyperthermia, labile mood
Ivf fluid for rehydration
Beta blocker for palpitations

Propranolol(inderal) 10 or 20mg BD or TDS PO O (beware of asthma!)
Anti Thyroid drugs:

- Propylthiouracil 100mg TDS PO (check allergic history) or
- Carbimazole 10mg TDS PO
ICU consult if severe
Others, please see case admit: Thyroid storm(p.128)

Page 79
Ward complaints
Hematology

Page 80
Ward complaints
37) Warfarin and heparin bridging therapy
Case 1: uncomplicated AF
For uncomplicated AF, no need bridge therapy.
Just ask patient to self stop warfarin 4 days before.
Check INR, if INR <1.8. Then ok.
Proceed to procedure
Post procedure restart warfarin when bleeding site secure
Case 2: Complicated AF / stroke / DVT / Valve replacement

To stop warfarin (require 4 days of admission before invasive procedure)
Monitor INR
Start enoxaparin / heparin when INR <1.8
Enoxaparin for DVT/ AF (for INR aim 2-3)
Heparin infusion for valve replacement (for INR aim 2.5-3.5)
enoxaparin 0.4ml SC q12h (if 40kg)

Or heparin infusion if valvular replacement done
Heparin infusion
IV heparin 70 units / kg stat x1 (around 5000 units )
Then infuse as 500 units per hour
Usually at 15 units / kg / hour intravenous
Aim APTT 60-80
Check APTT Q6H
Titrate as follow
APTT Action
<40 Repeat IV heparin stat 5000 units
Increase 100 units / hour
40-60 Increase 100 units / hour
60-80 No action
80-100 Decrease 100 units / hour
100-120 Stop infusion x 0.5 hour
Decrease 100 units / hour
>120 Stop infusion x 0.5 hour
Decrease 100 units / hour
To re-start warfarin / start warfarin

Start enoxaparin 0.4ml SC q12h (if 40kg) or heparin infusion as charted above
Start warfarin with originally dosage (or with 3mg for d1, then 2mg daily po)
Stop enoxaparin / heparin infusion if INR >1.8
Aim INR 2-3 if DVT, stroke, AF ; 2.5-3.5 if valvular replacement done

Page 81
Ward complaints
Titrate warfarin
If INR overdose: w/h warfarin
Restart with like this with decrease 0,5mg in 2 days
E.g. Originally 3mg daily po , then to 2.5mg / 3mg alternative day
If INR under warfarinization: increase by 0.5mg in 2 days

E.g. Originally 2.5 mg daily po , then to 2.5mg / 3mg alternative day

Page 82
Ward complaints
38) DVT
Usually from doppler report
Mx:
Bed rest
ECG
Start enoxaparin
Start enoxaparin 0.4ml SC q12h (if 40kg)
Start warfarin with 3mg for d1, then 2mg daily po
Stop enoxaparin if INR >1.8
Aim INR 2-3
Other option for low molecular heparin:

Innohep 10000 AXA international units SC q24h (more expensive, but daily dose)
If contraindicate with enoxaparin / warfarin: consider IVF filter

Page 83
Ward complaints
Infections

Page 84
Ward complaints
39) Antibiotics
See fever (p.12)
See C/st and sensitivity(p.39)
Also see impact guideline for empirically tx for different infections
A) when to step down from IV to PO antibiotics

- afebrile x 24 hours
- WCC is normalizing
- clinically improving
- GI tract is functional
B) Consider checking HIV

a) In young patient with infection, rash, unknown febrile disease
b) With TB
c) With STD
C) For HIV patient, consider the following:

a) Resp:TB , Pneumocystis jiroveci
b) CNS: Toxoplasma / cryoptopcoccus
c) Eye: CMV retinitis
d) GI: candidiasis
e) Lymphoma
f) IRIS for those who start HAART recently, and have TB etc
D) Must ask travel history

a) Influenzae A H7
b) MERS(Middle east respiratory syndrome)
==> may need EDORS...
- ask how to go there, by car or what, how many passenger
- any contact with poultry, went to market, eat any raw meats
- when symptoms, partner any symptoms
E) Traveller fever
Ix: malaria blood smear x3 +/- HIV
Others ix, is ok if you dont know
Other ix:
Cbc d/c, retic count, DAT
HbsAg, Anti-HCV, Anti HAV IgM
Urate, LDH
D-Dimer
Leptospira serology
Dengue serology

Page 85
Ward complaints
Skin

Page 86
Ward complaints
All dermatology problems, can consider consult dermatology
40) Skin rash

See if allergy, Stop the suspected drug and enter into CMS
aqueous cream la bd
eurax la bd (antihistamine cream)
Synalar 0.005%/ 0.025%/0.05% la bd prn
Hydrocortisone 1% la bd prn
Piriton 4mg tds po prn
41) Puritis
eurax la bd prn
Piriton 4mg tds po prn
42) Mouth ulcer

Bonjela la bd prn
Acyclovir Cr LA TDS
Thymol gargle 10ml qid MW prn
43) Bruises
Hirudoid cream la bd prn
44) Tinea infection

Trosyd (Tioconazole) la bd / Ketoconazole 2 % cream la bd
+ Canesten cr la bd
+ Zinc oxide la bd
45) Drip site cellulitis

Treat as cellulitis, remove the drip
+ IV/po ampicillin 1g q6h/qid
+ iv/po cloxacillin 1g q6h/qid
46) Herpes Anti-viral po/iv in:

Airborne isolation - ophthalmic zoster (po + tropical)
Vesicular fluid x HSV, VZV, c/st, fungal c/st - dissemnated
Blood x VZV IgG, IgM, HSV titre - immuno compromised
Acyclovir cream 5% la 5x/day - immunocompetent: <72 hours onset,
Or age >50, non truncall involvement,
Oral acyclovir 800mg po 5 times per day or moderate to severe complication
valaciclovir 1000mg TDS po x 7 days
Or
IV acyclovir 10-12mg/kg q8h x 7 days
(must check RFT before prescribing PO/ IV acyclovir, to q12h if renal impairment )

Page 87
Ward complaints
Oncology

Page 88
Ward complaints
47) Hypercalcemia
See lab abnormalities, hypercalcemia (p.29)
48) Cord compression

Usually from MRI report.
Call MO, see any urgent RT
(If previously no RT to that site, usually have RT. If not extensive disease, sometimes
may have ORT intervention)
if no contraindication
Dexamethasone 4mg qid po / dexamethasone 8mg bd po
Pantoloc 40mg daily po
Beaware of steriod psychossis
49) brain metastasis

Call MO
if no contraindication
Dexamethasone 4mg qid po / dexamethasone 8mg bd po
Pantoloc 40mg daily po
May need consult neuro-surg (if increased ICP)
50) Transfusion reaction x fever / rash

if fever before transfusion, just manage the fever, e.g. Septic workup, antibiotics
Then give panadol.
After fever down (no need total subside, just down so patient is more comfortable),
start transfusion
If fever <1.5 degree increased, even temp >38: panadol 500mg q4h po prn
If rash, not shock: piriton 10mg iv prn
But if fever>38, can consider blood c/st
If fever >1.5 / chills / rigors / septic, stop transfusion

+ tazocin 4.5g q8h iv (as pseudomonas is the most common in contaminated blood
product)
(can choose to send the blood products to blood bank for c/st)
51) Neutropenic fever

See : neutropenic (p.18)
52) Hiccups
Paper bag for self re-breathing ()
Stemetil 5-10mg TDS PO PRN

Page 89
Ward complaints
53) EOL
Mx:
+/- NPO
O2 0-100%
Keep comfort
Call relatives
PRN visit
No more blood taking
+/- no more drip setting
Morphine drip:
Morphine 5mg +/- midazolem 5mg in 500ml NS Q8-12h iv
Or
Mophine 10mg q24h via syringe driver SC
+/- haloperidol 1.5mg q24h via syringe driver SC
+/- buscopan 60mg q24h via syringe driver SC (if colicy abd pain)
+/- midazolam 5mg q24h via syringe driver SC
+/- dexamethasone 4mg q24h via syringe driver SC
+/- maxolon 20mg q24h via syringe driver SC

Page 90
Ward complaints
Others

Page 91
Ward complaints
54) Contrast allergy

Urgent scan with contrast
IV hydrocortisone 200mg on call to CT
IV hydrocortisone 200mg q4h x3 post CT
Non urgent scan

Prednisolone 40mg po stat day before CT (6-18 hours before IV contrast)
Prednisolone 40mg po stat on day of CT (2 hours before IV contrast)
Paedi:
Urgent scan with contrast
Hydrocrotisone 4mg/kg stat
2mg/kg q6h x 2 more does pot CT
Non urgent scan:

Body weight (kg) Prednisolone dosage (mg)
10-16 10
17-24 15
25-32 20
33-40 25
41-48 30
49 or above 40
55) Steroids
Hydrocortisone strength =1 <== for replacement use

Prednisolone strength =4 <== for inflammatory response
Dexamethasone = 25 <== for reduce edema / mass effect
56) Drug allergy
IV piriton 10mg q8h prn

IV hydrocortisone 100mg q8h prn
If anaphylasix
Adrenaline 1:10000 1mg IV / 1:1000 1mg IV +
Resuscitation: ABC, drip setting, blood taking, consult ICU

Page 92
Ward complaints
57) Pain
General:
Panadol 500mg q4h po prn
Tramadol 50mg q6h po/im/iv prn
Musculoskeleta pain:
Naprosyn 250mg TDS PO (for MSK pain)
Or
Diclofenac (voltaren) 50mg daily/bd po
Or voltaren SR( prolonged release) 100mg daily po
If neropathic pain:
Gabapentin TEVA 300mg nocte
Escalate: gabapentin TEVA 300mg TDS +/- nocte
If colicky pain
Buscopan IV 8mg q8h prn
If tumor / intractable pain

Im pethidine 50mg stat x1
DF118
May need morphine

Morphine 5mg q4h po+ morphine 5mg q4h po prn
Dose escalation: 5mg --> 10mg --> 15mg etc
SC dosage = oral /2
IV dosage = oral /3
Morphine drip (for End of life patient)

500ml NS + 5mg morphine q8-12h
Local analgesics
- Analgesic balm LA tds prn
- Voltaren gel LA tds good for post-traumatic inflammation
- Hirudoid LA tds prn good for drip site wound
Also, for placebo effect, your presence sometimes work

Page 93
Ward complaints
58) red eyes

Exclude glaucoma, if so urgent c/o eye
Hypromellose 1 drop q4h la prn
59) Red ear

Sofradex 1 drop la tds
60) Nasal congestion

piriton 4mg tds po prn
Budesonide intranasal 2 puffs bd prn
Other anti histamine

cetirizine (zyrtec) 1 tab daily PO / Clarityne (loraditine)1 tab daily PO
henergan (promethazine) 25mg TDS PO (** can be very sedating, avoid in Geri)
61) Gout
Mx:
Low pruine diet
Colchicine 0.5mg bd po, omit if diarrhoea

Allopurinol 300mg daily po
62) Insomnia
Piriton 4mg nocte po
Imovane 3.75mg / 7,5mg Nocte PO ( zopiclone 1 tab = 7.5 mg)
or
Ativan 0.5-1.0mg Nocte PO x 1

Page 94
Ward complaints
63) Abnormal behaviour of patient
Restrain prn
Urine x toxicology
Consider alcohol with drawal
Haloperidol 2-10mg Q4H-Q8H (max 18mg daily) IMI/IV;

usually 5mg IMI Q6H prn; half dose for elderly (try Haldol drops 0.1mg x1 if frail)
Violent patients
- Haloperidol 2.5mg IMI x 1
- Ativan 0.5 mg 1mg PO x 1
- Dormicum 2 4 mg SC x 1
- Pulse oximetry, cardiac monitor, BP/P Q1H x 4
64) Drug withdrawal
Heroin
Physeptone (methadone) 10 or 15mg tds po prn
Morphine 10mg iv Q6H prn
Alcohol
Valium 5mg po daily
Titrate down
65) Certificate and death

Pupil fixed and dilated
Pulse not palpable
Heart sound not ausculatable
Blood pressure not measurable
No spontaneously breathing
ECG flat
Patient certified on xx, at xx
Cat 1 body

Page 95
Ward complaints
66) CPR
Call MO
Equipment and position

- e- trolley
- connect cardiac monitor
- push out the bed for people to bag the patient
Action
- check pulse --> if no pulse, ask somebody to do cardiac compression
- ask somebody to do the airway
- houseman: set drip and do blood taking(CBC, LRFT, Clotting, CaPo4, RG, Trop I, CK,
ABG, T&S, C/st)
- adrenaline 1mg (1:10000) per every 3-5 min
Every cycle (every 3 min)

- 30:2 (30 compression, then 2 breaths)
- check rhythm per 2 minutes +/- shock if ok
- adrenaline injection per 2 cycle, can alternative with amiodarone if VT/VF
Aim 30min, if not response then stop, futile CPR --> cause of unknown death,
coroner case.

Page 96
Case admission
Cases admission

Page 97
Case admission
General for case admission:

D = diet
A = activity
V = vitals
I = investigation
D = drugs
S = specialist
Diet:
- DAT
- Warfarin diet + avoid IMI injection
- DM 1800 OR 1200 cal diet
- Renal diet
- Low purine diet
- low potassium diet
- low protein diet
- low salt diet
Etc
Activities:
Bed rest
Prop up
Vitals:
BP/P q1h
BP/P q4h
BP/P QID
BP/P BD
BP/P daily
Neuro obs
H stix
Q1h
Q1h x4, if stable, q4h
Q4h
Tds+ nocte
Tds
Bd
Daily
Body weight x, then alternative days

Convulsion chart

Page 98
Case admission
Calf circumference
Investigation
Blood
X rays
ECG
CT brain
Whatever tap / procedure
Drugs:
Resume usual meds
+ pain killers
+ panadol for fever
+ antibiotics
+ drugs titration
Specialits:
- physio
- occup
- speech
- dietician
- consult other specialty
Others:
Restrain prn
Home leave

Page 99
Case admission
Medicine

Page 100
Case admission
Cardiac
1) ACS / chest pain

Bed rest
DAT
Cardiac monitor
BP/P/SaO2 Q1H
Chart I/O
Foley to BSB, UO q4h (if strict IO is needed)
O2 supplement (e.g. 2L O2 through n.c.)
CBC, LRFT, bone, INR, RG

TnI, CE q6h x3 or Repeat TnI 6 hours later if 1st TnI ve
ECG Q6H x 3
Fasting glucose, lipid mane
CXR
Resume usual meds

W/H betaloc
Aspirin 160mg daily po
If NSTEMI Enoxaparine 0.4mL Q12H sc (Q24H for renal failure)
+/- morphine for pain relief (0.4ml if 40kg, 0,6ml if 60kg etc)
if high BP + chest pain may consider iv isoket (start with 2mg/hour then titrate
against BP) may change to oral nitrate e.g. isodil 10mg daily po if BP stabilized
may start beta-blocker after acute episode
Reminder: if AS+ chest pain / symptomatic as --> need echo later

Page 101
Case admission
2) CHF
Prop up
Low salt diet (may need NPO if severe SOB)
FR 1.2L/day
Cardiac monitor
Chart I/O (may require foley to BSB if APO)
BW x 1 then alt day
O2 supplement; keep SaO2 >92%
CBC, LRFT, bone, RG

+/- ABG if requiring high flow oxygen / Hx COPD

ECG Q6H x 3
Hba1c, Fasting glucose, lipid mane

Urine x multistix
Sputum x C/ST (if any)
CXR
ECG
(Must see originality lasix dosage for further management)

Lasix stat (if moderate / severe SOB - e.g. 40mg iv)
Then lasix increase lasix(e.g. 40mg IV Q12H, 40mg IV Q6H)
(Lasix, last for 6 hours, so increase frequency first, if not responsive, then consider
increase dosage also)
(later stepp down to lasix 40mg daily po)
Resume usual meds

(W/H betaloc if severe APO)
if APO may need CPAP 10cmH2O; FiO2 1.0; then slowly wean off
if high BP, nitrocaine 30mg in 50mL NS; 4mL/hr
Consider CVP insertion if needed

Consider Bipap for support if severe resp distress

Page 102
Case admission
3) AF
DAT (warfarin diet if on warfarin)
Cardiac monitor
BP/P/SaO2 Q4H

(pay particular attention to correct hypo/hyperK)
TSH
+/- TnI and CE if chest pain
MSU x C/ST
CXR
ECG (long lead II)
Resume usual meds

Choice of antiarrythmics: amiodarone, digoxin, diltiazem
Amiodarone 150mg in 100mL D5 over 1 hour then 150mg in 100mL D5 over 4 hour,
then 600mg in 500mL D5 over 24 hour (maintainence)
Digoxin loading: digoxin 0.25mg Q8H po x 3 or 0.25mg in 50mL NS over 10 min x 3

then 0.25mg daily
Keep K >/= 4
Treat any underlying exacerbating factors (e.g. Sepsis, ACS etc)
Acute setting may not need anti-coagulation. Only when AF>/- 2 days

Page 103
Case admission
4) Palpitations
DAT
BP/P/SaO2 Q4H
N(euro obs x Q4H x 1/7 if LOC)
Postural BP x 3
+/- cardiac monitor

+/- Trop I , CK if chest pain / arrhythmia
+/- TSH
CXR
ECG +long lead II
Urine x multistix
+/- urine x toxicology
Book IP Holter
Resume usual meds

W/H theophylline, ventolin if tachycardia

Page 104
Case admission
5) Infective endocarditis
(consider especially in IVDA, with fever and new heart murmur)
DAT
BP/P/SaO2 Q4H
O2 supplement (as indicated)
CBC, LRFT, bone, RG

+/- ABG if severe SOB or need high flow oxygen
+C/ST x3 at different site, different time
sputum x C/ST
sputum x AFB x 3 (if indicated)
urine x multistix
CXR
ECG
resume usual meds

+panadol po q4h prn
IV cloxacillin 2g q4h
IV gentamicin 1mg/kg q8h
Echo x embli mane

Page 105
Case admission
Respiratory
6) COPD
DAT (may need NPO if severe SOB)
O2 supplement (keep SaO2 >90%)
BP/P/SaO2 q1h x4, then if stable Q4H
CBC, LRFT, RG, ABG

C/ST if fever >/38 or WCC high markedly
Trop I, CK q6h x3
+/- theophylline level (especially if hypo k)
Sputum x C/ST
Sputum x AFB if indicated
Urine x multistix
CXR
ECG
Resume usual meds

Ventolin (usual dose: 4 puffs Q4H) (or increase dose and frequence if originally on
inhalers)
Atrovent (usual dose: 4 puffs Q4H) (or increase dose and frequence if originally on
inhalers)
Steroid (prednisolone 30mg daily or hydrocortisone 100mg Q8H)
Antibiotics if fever / increase WCC / increase pururlence of sputum (use according to
prev C/ST results / use augmentin 1.2g Q8H iv 1g bd po)
Chest physio
Sputum suction prn
IVF if NPO
BiPAP stand-by if severe hypercapnia or severe SOB

Page 106
Case admission
7) CAP / aspiration pneumonia

DAT
BP/P/SaO2 Q4H
O2 supplement (as indicated)
CBC, LRFT, bone, RG

+/- ABG if severe SOB or need high flow oxygen
+/- C/ST if fever
sputum x C/ST
sputum x AFB x 3 (if indicated)
urine x multistix
CXR
ECG
resume usual meds

+panadol po q4h prn
Augmentin 1.2g q8h IV

Clarithromycin 500mg daily PO
Sputum suction prn

Chest physio
+/- ST assessment if aspiration pneumonia
IV tazocin 4.5 q8h if severe CAP, previously hospitalization, previously c/st p .

Aueoginosa
If young gentleman, requiring up to 3-4L, may need to consult ICU.

Page 107
Case admission
8) Hemoptysis
NPO
Hemoptysis chart
+/- Chart I/O
Suction prn
+/- lie patient latera (lie on lesion side)
O2 supplement
BP/P/SaO2 Q1H
CBC, LRFT, bone, RG

+/- XM
+/- ABG
sputum x C/ST
sputum x AFB x 3
urine x multistix
Resume usual meds

+ IV transamin 500mg q6-8h
W/H anticoagulants
Transfusion if indicated
CXR
ECG
+/- early CT thorax with contrast
+/- urgent bronchoscopy / BAE if failed to stop bleeding
Consult respi x bronchoscopy

Page 108
Case admission
9) Pleural effusion
DAT
BP/P/SaO2 Q4H
O2 supplement
CBC, LRFT, bone, CE, INR, RG

+/- CEA if suspect cancer
Sputum x C/ST
Sputum x AFB x 3
Sputum x cytology x 3
CXR
+/- CXR (decub)
ECG
Resume usual meds

W/H anticoagulants if pleural tap planned
Plan diagnostic / theraputic pleural tap mane

Page 109
Case admission
10) Asthma
DAT (NPO if severe SOB)
O2 supplement
Pulse oximeter
PEFR bd
BP/P/SaO2 Q4H / Q1H if unstable
CBC, LRFT, bone, RG

ABG
Sputum x C/ST
NPA
Ventolin (usual dose: 4puffs Q4H)

Atrovent (usual dose: 4 puffs Q4H)
+/- steroid (e.g. Hydrocortisone / prednisolone)
book lung function test
+/- intubate / consult ICU if severe attack (if tachycardia, RR increase, resp acidosis
etc)

Page 110
Case admission
11) Pneumothorax
DAT
BP/P/SaO2 Q4H
O2 3-4L
CBC, LRFT, INR, RG

CXR
ECG
Analgesics (e.g.panadol 500mg q4h po prn or Tramadol 50mg Q6H po prn )

Chest drain if indicated
Resume usual meds

Consult CTS if recurrent PTx or secondary PTx

Page 111
Case admission
Neurology
12) CVA(ischemic)
NPO except meds until passing swallowing test
Allow puree diet if passed swallowing test
Neuro obs Q4H

CXR
ECG
Urgent CT brain
Resume usual meds

Aspirin 80mg daily (if CT brain ruled out hemorrhage and not massive stroke: e.g
those with cortical sign) (W/H aspiring / warfarin if CT brain not yet done / massive
stroke / high risk of hemorrhagic transform)
W/H anti-HT (unless SBP >220 in ishecmic stroke)
W/H DM drugs when NPO
Inform stroke nurse (in PWH)

Refer physio
Refer occu
Refer speech

Page 112
Case admission
13) ICH
(Usually seen by neuro-surg in AED and not for any neuro-surg intervention)

Allow puree diet if passed swallowing test
Neuro obs Q4H

CXR
ECG
Urgent CT brain
Resume usual meds

W/H anticoagulants
Aim SBP </= 200

Labetalol infusion: 200mg in 100ml NS (Double concentration in stroke unit)
Usually start at 15ml/hr, range 0-30ml per hour+/- 5ml per time , titrate against BP
(also depends on weight, above just reference)
Or GTN infusion: 30mg in 100ml NS

Usually start at 4ml/hr, 0-20ml/hr +/- 2ml per time, titrate against BP
Or isoket infusion: 50mg in 100ml NS

Usually start at 4ml/hr, 0-10ml/hr +/- 2ml/hr per time, titrate against BP

Refer physio
Refer occu
Refer speech

Page 113
Case admission
14) Acute DO
Suicidal precaution (if indicated)
NPO
Neuro obs Q4H
Cardiac monitor

VBG
Paracetamol, salicylate, ethanol level
Urine x toxicology
CXR
ECG
Consult psychi mane
If morphine / opoid overdose:

Naloxone 1mg IV stat
If not responsive, repeat q2 min as follow:
2mg --> 4mg -->8mg-->10mg
Not to exceed 10mg each time
Once drowsy again, start at Naloxone 1mg IV stat

Repeat as above
(because heroin has long half life, but naloxone relatively short half life)

Page 114
Case admission
15) LOC
Bed rest
DAT
BP/P/SaO2 Q4H or Neuro obs x Q4H x 1/7
Monitor Hstix
Postural BP x 3
+/- cardiac monitor

CXR
ECG (+/- long lead II)
Urgent CT brain
Urine x multistix
+/- urine x toxicology
Book IP Holter
+/- Book EEG

Page 115
Case admission
16) Acute confusion

NPO
Neuro obs Q4H
H stix x1
Bladder scan x1, if post void RU >350ml, foley to BSB
CBC, LRFT, bone, RG

+/- VBG
+/- INR if planned LP
bld x C/ST if fever
Sputum x C/ST
Urine x multistix
MSU x C/ST
Urine x toxicology
CXR
ECG
CT brain (urgent, plain)
Resume usual meds

+ Dulcolax / fleet enema if needed
Consult psychi mane

Restrain prn
(check neck stiffness; may require LP if suspect meningitis)

Page 116
Case admission
17) Convulsion
NPO
Neuro obs Q1H / Q4H
Convulsion chart
O2 supplement (maintain SaO2 >90%)
Hstix stat
CBC, LRFT, bone, RG

+/- VBG, Mg, anti-epileptics level
bld x C/ST if fever
CXR
ECG
CT brain (urgent)
Valium 5mg stat if still convulsing

May require dilantin(phenytoin) as maintainence
Phenytoin (Dilantin) 15-20mg/kg IV over 30min, then 300mg po/IV
Correct electrolyte disturbance

Correct hypoglyemia
Book EEG (if indicated)

Inform MO for ICU consult if persistent seizure / status epilepticus

Page 117
Case admission
18) Dizziness
DAT
BP/P/SaO2 Q4H
Hstix x 1
Postural BP x 3
+/- Cardiac monitor and Holter (indicated arrhythmia suspected)
CBC, LRFT, bone, RG

CXR
ECG + long lead II
+/- CT brain
urine x multistix
Resume usual meds

+/- stemetil 10mg Q8H po

Page 118
Case admission
19) 3rd nerve / 6th nerve palsy

Allow DAT if passed swallowing test
Neuro obs Q4H

ESR, CRP
ANCA, ANA, Anti-dsDNA, RF
B12, folate, TSH, VDRL
C/st if fever
CXR
ECG
Urgent CT brain
Resume usual meds

Aspirin 80mg daily (if CT brain ruled out hemorrhage and not massive stroke: e.g
those with cortical sign)
W/H anti-HT (unless SBP >220 in ishecmic stroke)

Refer physio
Refer occu
Refer speech
Consider LP
Consider MRI brainstem and brain

Page 119
Case admission
20) Meningitis
NPO except meds
Neuro obs Q4H
Convulsion chart if needed

HSV serology
C/st if fever
Sputum c/st
Sputum x AFB x3
MSU stix, c/st
CXR
ECG
Urgent CT brain
Resume usual meds

+ Cetriazone 2g q8h iv
+ Acyclovir 10-15mg/kg q8h
Consider LP

Page 120
Case admission
GI
21) Ascites
Low salt diet
FR 1.2L/day
BP/P/SaO2 Q4H
Chart I/O
BW x 1 then alt day
CBC, LRFT, INR, RG

+/- AFP, CEA, CA 125, Ca 125 (if suspect malignancy)
+/- HbSAg, anti-HCV (if suspect chronic liver disease)
CXR, AXR
ECG
Resume usual meds

+ IV cefotaxime 1g q8h if SBP
Plan diagnostic +/- therauptic abd tap mane
If therapeutic tap, connect to BSB, aim output </= 5 L per day
IV albumin 10gm per L

Page 121
Case admission
22) GIB
NPO
Chart I/O
(may need foley to BSB if unstable)
BP/P/SaO2 Q1H (if unstable); Q4H if stable

+/- AFP, HbsAg, anti-HCV (in patients 1st presented with variceal bleed)
XM
CXR, AXR
ECG
IVF (resuscitation + maintanence)

(e.g. gelofusine / NS 500mL FR may repeat until BP better)
Transfusion if indicated (e.g. Hb <8 transfuse packed cells x 2 Q4H / pint)
OGD (mane if stable; inform MO x emergency OGD if unstable e.g. shock /
tachycardia / profuse bleeding)

Page 122
Case admission
23) GE
DAT
+/- contact precaution
Encourage fluid intake
BP/P/SaO2 Q4H
CBC, LRFT, bone, RG

TSH, fT4(consider thyroid storm)
VBG
CXR, AXR
IVF x fluid replacement

Stool x C/ST, noro-virus, ova and cysts
CD toxin, if recent a/b, hospitialization
Resume usual meds

If chronic diarrhea consult GI x colonoscopy

Page 123
Case admission
24) Jaundice
DAT/ Low protein diet
BP/P/SaO2 Q4H +/- neuro obs if encephalopathy
CBC, LRFT, bone, RG

HbSAg, HCV
anti-HAV (if suspected acute hepatitis). Anti HEV
GGT, Direct bilirubin
CXR, AXR
ECG
Urine x multistix
Resume usual meds

if fever / abd pain book urgent USG HBP to r/o biliary sepsis
if suspect encephlopathy add lactulose 10mL bd to maintain BO >3/day
add blood x serum ammonia if suspect encepalopathy

Page 124
Case admission
25) Hepatic encephalopathy

DAT/ Low protein diet
Neuro-obs Q4H
H stix TDS +nocte
CBC, LRFT, bone, RG

HbSAg, HCV
anti-HAV (if suspected acute hepatitis). Anti HEV
GGT, Direct bilirubin
ammonia
C/ST if fever
Urine x multistix
Sputum c/st
ECG + long lead II
CXR, AXR
Urgent CT brain
Resume usual meds

+ lactulose 10mL bd to maintain BO >3/day
+ Fleet enema daily PO PRN

Page 125
Case admission
Endocrinology
26) DKA
DM diet
Neuro-obs q1h
Chart IO
H stix q1h
Foley to BSB, UO q1h
Blood x CBC, LRFT, CaPo4, Mg,Clotting, osmolarity, Anion gap (CL), Lactate, VBG, RG,
BAHA
C/ST if fever
Urine x stix, c/st
Sputum c/st
CXR
Resume usual meds
IVF: NS 500ml +10-20mmol Kcl Q6H - q8h depends on fluid status

If hypernatremia>150: can consider 0.45% NS
If not, continue 0.9% NS
Once Glucose drop to <14, can use 1/2:1/2 or D5 alone
Aim decrease Na <10-12 mmol per day
Insulin pump:
0.15U/kg IV bolus stat x1

> 4.2 6.7 .05
> 6.7 8.9 1
> 8.9 11.1 2
> 11.1 16.7 3
> 16.7 27.8 4
> 27.8 6 + inform
(usually 0.1U/kg / hour infusion)

Aim decrease 3-4 mmol PER HOUR
When glucose drop to <14, decrease dose to 0.05-0.1U/kg/ hour
If acidosis, 6.9-7.0, consider HaHco3 8.4% 50ml q30min x1

Page 126
Case admission
RFT, osmolarity, VBG q6h
ICU consult if needed

Page 127
Case admission
27) HONK
DM diet
Neuro-obs q1h
Chart IO
H stix q1h

Consider CVP
Blood x CBC, LRFT, CaPo4, Mg,Clotting, osmolarity, Antion gao(CL), Lactate, VBG, RG,
BAHA
C/ST if fever
Urine x stix, c/st
Sputum c/st
CXR
Urgent CT brain if HONK
Resume usual meds
IVF: NS 500ml +10-20mmol Kcl Q6H - q8h depends on fluid status

If hypernatremia>150: can consider 0.45% NS
If not, continue 0.9% NS
Once Glucose drop to <14, can use 1/2:1/2 or D5 alone
Aim decrease Na <10-12 mmol per day
Insulin pump:
0.15U/kg IV bolus
> 4.2 6.7 0.25
> 6.7 8.9 0.5
> 8.9 11.1 1
> 11.1 16.7 1.5
> 16.7 27.8 2
> 27.8 3 + inform
Aim decrease 3-4 mmol PER HOUR

When glucose drop to <14, decrease dose to 0.05-0.1U/kg/ hour
If acidosis, 6.9-7.0, consider HaHco3 8.4% 50ml q30min x1
RFT, osmolarity, VBG q6h

Page 128
Case admission
28) Thyroid storm

NPO
BP/P Q1H
Chart IO
Foley to BSB, Q1H
Blood x CBC, LRFT, Clotting, TSH, fT4

CXR
ECG
Sputum c/st
MSU stix, c/st
Resume usual meds

+ IVF 1D1S 500ml q6h=q8h
+ panadol po 500mg q4h prn
+ propylthiouracil 150-200mg q6h po

+ Hydrocortisone 200mg IV stat, then 100mg q6-8h
+ propranol 40-80mg q4-6h / diltiazem 60-120mg q8h
1 hour after propylthiouracil(after thyroid blockage done)

Then iodone solution 6-8 drops q6-8 hours
Consult ICU

Page 129
Case admission
29) Hyponatremia / addisoniam crisis

DAT
BP/P Q4h
Neuro-obs q4h if seizure
Seizure chart
Blood x TSH, spot cotrisol, serum osmolarity

CBC, LRFT, Clotting
Blood c/st
CXR
Urine x stix, c/st
Urgent CT brain if really low sodium(e.g.<115)
IVF:
NS 500ml q5-8h, depends
Or 1/2:1/2 q6-8h, depends
IV hydrocortisone 100mg q6-8h if Na<115)
Consult ICU if NA <115

Page 130
Case admission
Renal
30) Acute renal failure
DAT
Chart I/O
BW x 1 then alt day
BP/P/SaO2 Q4H
CBC, LRFT, bone, RG,

ANCA, Anti-ANA, Anti-ds DNA, Anti-GBM
HbsAg, , Anti-HCV
Serum protenin electrophoresis, Bence Jones protein, Ig pattern
Save urine x inspection

Urine x multistix
Urine x microscopy
MSU x C/ST
CXR
ECG
Post void Bladder scan x1, if RU >350ml, foley to BSB , UO q4h

Urgent USG urinary system to rule out post-obstructive cause
May try fluid challenge if hydration on dry side(NS 500ml q1h or q2h x1, then
recheck RFT)
Resume usual meds

W/H NSAID, gentamicin, ACEI, metformin etc.

Page 131
Case admission
31) Hematuria
DAT
BP/P/SaO2 Q4H
CBC, LRFT, bone profile, INR, RG

CXR
KUB

MSU x C/ST
EMU x AFB x3
Resume usual meds

If massive hematuria, foley to BSB
+/- early USG abd for upper tract screening

Consult urology if not subsided later

Page 132
Case admission
32) Renal fluid overload

Prop up
Renal Low salt diet (may need NPO except meds if severe SOB)
FR 1.2L/day
Cardiac monitor
Chart I/O (may require foley to BSB if APO)
BW x 1 then alt day
O2 supplement; keep SaO2 >92%
CBC, LRFT, bone, RG

+/- ABG if requiring high flow oxygen / Hx COPD

ECG Q6H x 3
Fasting glucose, lipid mane

Urine x multistix
CXR
ECG
If on RRT:
CAPD: 4.25 % 2L q2h x2
HD: see renal team decision
If no RRT:Lasix
(Must see originality lasix dosage for further management)
Lasix stat (if moderate / severe SOB - e.g. 40mg iv)
Then lasix increase lasix(e.g. 40mg IV Q12H, 40mg IV Q6H)
(Lasix, last for 6 hours, so increase frequency first, if not responsive, then consider
increase dosage also)
(later stepp down to lasix 40mg daily po)
Resume usual meds

(W/H betaloc if severe APO)
if APO may need CPAP 10cmH2O; FiO2 1.0; then slowly wean off
if high BP, nitrocaine 30mg in 50mL NS; 4mL/hr
Consider CVP insertion if needed

Consider Bipap for support if severe resp distress

Page 133
Case admission
33) Renal hyperkalaemia

(usually found hyper k during FU, so already got blood results)
Renal diet
BP/P Q4H
H stix x1
Cardiac monitor
VBG
ECG
Resume usual meds

W/H ACEI / ARB / K supplement
DI drip:
D50 50ml+ actrapid 6-10 units actrapid q30min x1
Resonium A/C 15g q6h x3
Recheck RFT and H stix afterwards
(remember, for renal patient, actrapid be cautious. Renal cannot excrete actrapid so
very easily cause hypoglycaemia)
If persisitent Hyper K, may need temp HD

Page 134
Case admission
34) Renal CAPD peritonitis
Renal diet
BP/P Q4H
H stix x1
Cardiac monitor
CBC, LRFT, Clotting, CaPo4, CRP, VBG +/- blood c/st if fever
PDF fluid c/st
Resume usual meds
Rapid flushing of PDF fluid 2Lx3, + IP heparin 500-1000 units/ L
Increase CAPD regimen to 4 bags per day(may consult MO before administrating this,
or wait for case MO to decide)
+ IP heparin 500-1000 units/L PRN
If no fever:
+ IP (fortum)ceftazidime 1g + cefazolin 1g stat, then daily x 13 days
If not responded:
D3 add gentamycin (require monitoring, dosage please consult MO)
D5: change fortum and cefazolin to vancomycin
If fever / chills / rigors / systemiatic sign:

IV (fortum)ceftazidime 1g + cefazolin 500mg stat then a24h

Page 135
Case admission
Hematology
35) Leukemia
Reverse isolation
DAT(low purine diet)
BP/P q4h
Chart IO
Blood x CBC d/c, LRFT, CaPo4, RG, Clotting

Urate, LDH, T&S
Coombs test, D-dimer, fibrinogen
HbsAg, anti-HCV, Anti-HIV, CMV serology
G6PDH
+/- blood x cyto-flowmetry (decide my your MO)
Sputum x c/st
MSU stix, c/st
CXR
Resume usual meds

+ panadol 500mg q4h prn
+ allopurinol 300mg daily po
+/- IVF if needed
+/- antibiotics if suspect infection
Bone marrow
Memo x blood bank x CMV -ve blood product
Consult hematology

Page 136
Case admission
36) Multiple meyloma

Suspect when hypercalcemia, reverse A:G ratio, osteolytic lesion
DAT(low purine diet)
BP/P q4h
Chart IO

Urate, LDH, T&S
Coombs test, D-dimer, fibrinogen
HbsAg, anti-HCV, Anti-HIV, CMV serology
G6PDH
Serum protein-eletrophoresis, Ig pattern
Urine x bence Jones protein
+/- blood x cyto-flowmetry (decide my your MO)
Sputum x c/st
MSU stix, c/st
CXR
X ray x skeletal survey
Resume usual meds

+ panadol 500mg q4h prn
+ allopurinol 300mg daily po
+/- IVF if needed
+/- antibiotics if suspect infection
Bone marrow
+/- early bone scan
Consult hematology

Page 137
Case admission
37) Low platelet

DAT
BP/P q4h
Chart IO

Urate, LDH, T&S
Platelet in citrate bottle
+/- bone marrow exam
Resume usual meds

+/- transfuse platelet if indicated
Transfuse whe pt <10 afebrile, plt <20 when febrile or symptomatic (bleeding
tendency, epitasix, hemoptysis, hematuria etc)
- transfuse x unit of platelet Full rate
Consult hematology

Page 138
Case admission
Medicine - Miscellaneous
38) DVT
Bed rest
DAT / warfarin diet
BP/P/SaO2 Q4H
Calf circumfrence x1 then daily
CBC, LRFT, INR, RG

D dimer
CXR
ECG(see any S1QT3)
Urgent Doppler USG LL

(may start enoxaparine 40mL Q12H sc if highly suspicious of DVT)
USG Abd early to see any pelvic obstruction if DVT confirmed

Page 139
Case admission
39) Warfarin overdose

Bed rest
Warfarin diet
Avoid im injection
BP/P/SaO2 Q4H

+/- XM (if need FFP / signs of bleeding)
CXR
ECG
Resume usual meds

W/H warfarin
+/- vit K1 1mg oral ( TCM overdose, and suspicious of warfarin containing. Otherwise,
for patient on warfari, not for vit K1, as later very difficult for warfarin titration)
or +/- FFP (if severe coagulopathy with active bleeding, usually INR >/=8)
look for signs of GIB / abd pain / stroke / hip pain(psoas hematoma)
monitor INR

Page 140
Case admission
40) Decrease GC
DAT
Neuro-obs Q4H
H stix x1
Post void bladder scan, if RU >/= 350ml, foley to BSB
CBC, LRFT, bone, RG, clotting

B12, folate, TSH, VDRL
Blood c/st if fever
Urine x multistix
MSU x C/ST
ECG
CXR, AXR
CT brain (if dull looking / need to rule out ICH)
IVF if dehydration
Resume usual meds

+ lactulose / duocloax / fleet enema if needed
+/- consult OT x MMSE and ADL assessment (if no known history of dementia)

Page 141
Case admission
41) Cellulitis
DAT
BP/P/SaO2 Q4H
Hstix x1
well score for DVT:
CBC, LRFT, bone, RG, Clotting Paralysis, paresis or recent orthopedic casting
of lower extremity (1 point)
Blood x C/ST if fever >38C Recently bedridden (more than 3 days) or
CXR major surgery within past 4 weeks (1 point)
XR of affected area (see any gas Localized tenderness in deep vein system (1
formation / osteomyelitic changes) point)
Swelling of entire leg (1 point)
Ice therapy Calf swelling 3 cm greater than other leg
Elevate limbs (measured 10 cm below the tibial tuberosity)
(1 point)
Resume usual meds Pitting edema greater in the symptomatic leg
Panadol po 500mg q4h prn (1 point)
Collateral non varicose superficial veins (1
Normally: point)
Ampicillin 1000mg Q6H iv Active cancer or cancer treated within 6
Cloxacillin 1000mg Q6H iv months (1 point)
Alternative diagnosis more likely than DVT
Blister / suspicious of necrotising (Baker's cyst, cellulitis, muscle damage,
fascitis: superficial venous thrombosis, post phlebitic
Penicillin G 2 megaunits q6h iv syndrome, inguinal lymphadenopathy, external
Clindamycin 300mg q6h iv venous compression) (-2 points)
3-8 Points: High probability of DVT
Human bite / cat bite / dog bite: 1-2 Points: Moderate probability
Augmentin 1.2g q8h iv -2-0 Points: Low Probability
Cloxacillin 500mg Q6H iv
If soil contamination
Ampicillin 1000mg Q6H iv
+ metronidazole 500mg q8h iv
Sea water:
Clarithromycin 500mg q8h iv
Consult ORT if collection / open wound
Calculate well score for ?DVT and decision for doppler USG

Page 142
Case admission
Clinically admission x renal
42) Renal biopsy

DAT
BP/P QID
+/- hstix
Blood x CBC, LRFT, CaPo4, RG, Clotting, T&S

Biopsy proforma(request renal biopsy in CMS, but dont print job sheet out) (only in
PWH med)
Save early morning urine x1 for Dr. Szeto (if PWH med)
Resume usual med

W/h aspirin and anticonagulants
PPP x renal biopsy

FMN
IVF: 2D1S / 1/2:1/2 q8h when fast
Consent
Premed: valium 5mg PO oncall
Post renal biopsy order

Bed rest x 24 hours
BP/P q15 min x4, then q30 min x4, q1h x4.
If stable, then q4h
CBP mane
Save every urine x inspection
+ analgesic

Page 143
Case admission
43) Tenckhoff insertion / removal

DAT(Renal diet)
BP/P QID
+/- h stix
Blood x CBC, LRFT, CaPo4, RG, Clotting, T&S
Resume usual med

W/h aspirin and anticonagulants
PPP x renal biopsy

FMN
IVF: 2D1S / 1/2:1/2 q8h when fast
Consent
Premed: valium 5mg PO oncall, pethidine 50mg IM oncall, cefazolin 1g iv on call

Page 144
Case admission
44) Maunal / Machine IPD

DAT(renal diet)
BP/P QID
Hstix
Blood x CBC, LRFT, CaPo4, RG
Resume usual meds
IPD regimen: 1.5% 2L Q2H x n cycles
(usually total treatment volume 40-50L, i.e. 20-25 cycles)

(if fluid overload, can change to 2.5%)
( 2 hour cycle = inflow 10 min, dwell 90 min, drain 20min)
(if TK inserted within 2 weeks, use 1L cycles)
RFT, H stix post PD

Page 145
Case admission
Clinically admission X GI
45) OGD
DAT
BP/P QID
Blood x CBC, LRFT, Clotting, +/- T&S(depends on department)

CXR
ECG
Resume usual meds
FMN
IVF after fasting
Consent
HB
46) Colonoscopy
Low residual diet
BP/P QID

CXR
ECG
Resume usual meds
FMN
IVF after fasting
Consent
HB
Klean prep 2L 6pm and 6am mane

Page 146
Case admission
Clinically admission X Resp
47) Bronchoscopy
Low residual diet
BP/P QID

CXR
ECG
Resume usual meds
FMN
IVF after fasting
Consent
HB

Page 147
Case admission
Surgery

Page 148
Case admission
HBP
48) OJ
NPO
BP/P Q1H x4, if stable Q4H
Chart IO
Blood x CBC, LRFT, Clotting, amylase, VBG, HbsAg, anti HCV, GGT, AST, LDH
CXR
AXR(Supine and erect)
+ IVF
+ IV tramadol 50mg Q6H PRN
+ PO panadol 500mg Q4H PRN
If fever:
+ IV zinacef 750mg Q8H
+ IV flagyl 500mg Q8H
Urgent U/S HBP mane

If septic: urgent U/S HBP now +/- ERCP

Page 149
Case admission
49) Cholangitis
NPO
Chart IO
CXR
+ IVF
Urgent U/S HBP mane


Page 150
Case admission
50) Cholecystitis
NPO
Chart IO
CXR
+ IVF
Urgent U/S HBP mane


Page 151
Case admission
51) Liver abscess / RUQ pain
NPO
Chart IO
Blood x CBC, LRFT, Clotting, amylase, VBG, HbsAg, anti HCV, Anti HAV, Anti HEV,
GGT, AST, LDH
CXR
+ IVF
Urgent U/S HBP mane

Or Urgent CT A+P
If septic: urgent U/S HBP now

Page 152
Case admission
52) Pancreatitis
NPO
BP/P Q1H x4, if stable, Q4H
Chart IO
H stix TDS+ nocte
+/- Foley to BSB, UO q1h
Blood xCBC, LRFT, Clotting, amylase, VBG, HbsAg, AST, LDH

CXR
Chart Ranson Score
+ IVF
If biliary pancreattis(with deranged LFT):

If severe / septic:
+ IV meropenem 500mg Q12H
Urgent U/S HBP mane

Page 153
Case admission
UGI
53) UGIB: coffee ground vomitting / malaena
NPO
BP/P Q1h x4, if stable Q4H
Chart IO
If vomitting, RT to BSB, Aspirate Q4H

Blood x CBC, LRFT, clotting, Amylase, VBG

+/- T&S(depending on pallor / Haemocue)
CXR
+IV Pantoloc 40mg Q24H

+ IVF
+/- transfusion
Consider OGD mane
If hemodynamically unstable: call MO immediately, may need OGD now

Page 154
Case admission
54) Hematemesis
NPO
Chart IO

Blood x CBC, LRFT, clotting, Amylase, VBG, HbsAg, anti HCV

CXR
+IV Pantoloc 40mg Q24H

+ IVF
+/- transfusion
Consider OGD mane
If hemodynamically unstable: call MO immediately, may need OGD now

Page 155
Case admission
55) PPU / Air under diaphragm

NPO
Chart IO
Blood xCBC, LRFT, Clotting, amylase, VBG, T&S

CXR
+ IVF
Urgent CT A+P with contrast or EOT

Page 156
Case admission
LGI
56) LGIB
NPO
Chart IO

Blood x CBC, LRFT, clotting, Amylase, VBG

CXR
+IV Transamin 500mg Q8H

+ IVF
+/- transfusion
(if protocoscopy found bleeding source, may consider adrenaline gauze)

If hemodynamically unstable: call MO immediately, may need OGD / colonoscopy
now

Page 157
Case admission
57) RLL pain

NPO
Chart IO
Blood xCBC, LRFT, Clotting, amylase, VBG, HbsAg, AST, LDH, T&S
CXR
+ IVF
If WCC / Fever, clinically suspicious appendicitis

If male: may need EOT x lap appendicectoy
If women: USG Abd + pelvis mane to rule out gyn cause


Page 158
Case admission
58) LLL pain

NPO
Chart IO
CXR
+ IVF
If WCC / Fever, clinically suspicious diverticulitis

If generally guarding / suspicious of perforation:

Urgent CT A+P with contrast

Page 159
Case admission
Vascular
59) Acute limb ischemia
NPO
Chart IO
Chart radial / DP / PT pulse q6h
Blood x CBC, LRFT, clotting, VBG

+/- T&S(depending on need of surgery)
CXR
Resume usual meds

+ IVF
Start heparin infusion

IV 5000 units of heparin stat
Then 500 units per hour infusion
Check APTT q6h
Aim APTT 60-80
Consult ORT x amputation if no vascular intervention

Page 160
Case admission
60) Rupture AAA

(Usually too emergency, will direct find MO)
NPO
Chart IO
Blood x CBC, LRFT, clotting, VBG, amylase

+/- T&S(depending on need of surgery)
CXR

+ IVF
Aim SBP 100-120

Start labetalol infusion
Labetalol infusion: 100mg in 100ml NS
30ml per hour, 0-60ml/hr +/- 5ml per time , titrate against BP
(also depends on weight, above just reference)
Can double concentration: 200mg in 100ml NS

15ml per hour, 0-30ml/hr +/-5ml per time, titrate against BP

Page 161
Case admission
Urology
61) AROU
DAT
BP/P/SaO2 Q4H

CXR
KUB

MSU x C/ST
Resume usual meds

+ PO augmentin 1g bd if clinically UTI or stix nitrate / leucocytes +ve
+ minipress 2mg daily po or hytrin 1mg daily po
If TWOC failed later x 2-3 times, Consult urology
(try wean off catheter)

Page 162
Case admission
62) Hematuria
DAT
BP/P/SaO2 Q4H

CXR
KUB

MSU x C/ST
EMU x AFB x3
Resume usual meds



Page 163
Case admission
63) Loin pain(if no fever, suspect stones)
DAT
BP/P/SaO2 Q4H

CXR
KUB

MSU x C/ST
EMU x AFB x3
Resume usual meds



Page 164
Case admission
64) Pyelonephritis
NPO
Chart IO
Blood c/st
CXR
+ IVF
+ IV augmentin 1.2g q8h

Of follow previously urine c/st
if servere: iv tazocin 4.5g q8h
If ESBL, iv meropenem 500mg q8h
Urgent USG Urinary system

Or urgent CT A+P with contrast
May need urgent drainage(PCN)

Page 165
Case admission
Burns
65) Facial burns
NPO
Chart IO
Blood xCBC, LRFT, Clotting

CXR
Wound swab
+ IVF x rehydration
Daily dressing
May need intubation if suspected airway problem

If no airway problem, can consider DAT
66) Other area burn
DAT
Chart IO

CXR
Wound swab

Daily dressing

Page 166
Case admission
67) Burn over limbs

DAT
Chart IO

CXR
Wound swab

Daily dressing
Consult ORT x take over

Page 167
Case admission
68) Compartment syndrome / circumferential burn

NPO
Chart IO
Blood xCBC, LRFT, Clotting, T&S

CXR
Wound swab

Daily dressing
Consult ORT x fasiotomy

Page 168
Case admission
Orthopaedics and Traumatology

Page 169
Case admission
69) #NOF
DAT
BP/P QID
Blood x CBC, LRFT, Clotting, CaPo4, RG, T&S

CXR
R/L hip with frog view
ECG
Resume usual meds

+ im tramadol 50mg q6h prn
PPP x AMA / Gamma nail

- FMN
- Consent
- pre med by anes
- ensure T&S
- Marking
- IV cefazolion 1g to OT
70) Pathological fracture

Pathological #: no trauma history, or strange position: e.g. Subtrochanteric # or
tumor history
DAT
BP/P QID
Blood x CBC, LRFT, Clotting, CaPo4, RG

AFP, CEA, PSA/ CA 125
Urine x Bence-Jones protein
Skeletal survey with reporting(adult malignancy)
Resume usual meds

Consider early bone scan
If OT needed, T&S, ECG, CXR(depends on #site)

Page 170
Case admission
71) Other fracture

DAT
FMN
BP/P q4h

Xray with XXX view
Resume usual meds

Ice therapy
Elevate limbs
+/- Arm sling if UL fracture

+/- cast : short arm cast, long arm cast etc
If surgery needed, T&S
# ankle / fibula
If weber Type A, cast is ok
If weber Type B/C , may need surgery
# tibia: usually need Surgery. Esp if compartment syndrome
#calcaneus:?may need surgery depends on premorbid function
#humerus mid shaft / neck: ?may need surgery depends on premorbid function
# Greater tuberosity of humerus:No need for surgery usually
#distal radius: Usually no need surgery
# scaphoid: Usually no need surgery, surgery if not healed
# vertebrae: usually no surger, unless neurological affected + back physio
# cervical spine: depends
# clavicle: usually conservative, unless skin impingement

Page 171
Case admission
72) Low back pain

DAT
FMN
BP/P q4h

LS spine xray
+/- other xray
Resume usual meds

Back physio
73) Shoulder / hip dislocation

NPO
BP/P q4h
Resume usual meds

PPP x closed reduction under LA (CAT A2)

- Consent
- pre med by anes
- Marking

Page 172
Case admission
74) Cellulitis / osteomyelitis / abscess

DAT
BP/P/SaO2 Q4H
Hstix x1
CBC, LRFT, bone, RG, Clotting
Blood x C/ST if fever >38C

CXR
XR of affected area (see any gas formation / osteomyelitic changes)
Ice therapy
Elevate limbs
Resume usual meds

Panadol po 500mg q4h prn
Normally:
Blister / suspicious of necrotising fascitis:

Penicillin G 2 megaunits q6h iv
Clindamycin 300mg q6h iv
Human bite / cat bite / dog bite:

If soil contamination
Sea water:
Levofloxacin 500mg q24h iv
Consult ORT if collection / open wound

If abscess: will need incision and drainage + T&S
(abscess = swelling + pus)

Page 173
Case admission
75) Hand laceration

DAT
BP/P/SaO2 Q4H
Hstix x1
Ice therapy
Elevate limbs
Resume usual meds

A/B
Normally:
Blister / suspicious of necrotising fascitis:

Penicillin G 2 megaunits q6h iv
BIte:
Soil:
Sea water:
Levofloxacin 500mg q24h iv
EOT LA exploration

Page 174
Case admission
76) Septic arthritis (joint pain + fever)

NPO
BP/P/SaO2 Q4H
Hstix x1
CBC, LRFT, bone, RG, Clotting, T&S(as may need knee lavage)
+ blood c/st if fever
+ RF, ANCA, ANA, anti- ds DNA, ASOT, complement 3, 4
Ice therapy
Elevate limbs
Resume usual meds

Or augmentin 1.2g q8h iv
+ colchicine 0.5mg bd po if clinically suspect gout
Knee tap
Urgent gram stain
Send fluid x c/st, AFB, urate crystal
(if septic arthritis on top with implant i.e. Infected implant, try to consult your senior
first before doing knee tap...
You may contaminate the joint...)

Page 175
Case admission
77) Cord compression

DAT
BP/P/SaO2 Q4H

+ CEA, AFP, PSA/ CA 125
Urine x Bence-Jones protein
CXR
XR of T spine / LS spine
Resume usual meds

Tramadol im 50mg q6h prn
Urgent MRI if needed
If metastatic disease, plannign to consult oncology for RT:

+/- dexamethasone 4mg qid or 8mg bd po (check h stix TDS+ nocte also)
+/- pantoloc 40mg daily po
78) Achilles tendon rupture / patella tendon rupture

DAT
BP/P/SaO2 qid
CBC, LRFT, bone, RG, Clotting, T&S

CXR
ECG
X ray to
Achilles -> foot(AP+ lat)
Patella --> knee(AP+ lat)
Resume usual meds

USG ankle / knee if needed

Will need EOT

Page 176
Case admission
79) ACL tendon rupture / tear

DAT
BP/P/SaO2 qid

CXR
ECG
X ray to knee(AP+ lat)
Resume usual meds

Early MRI
80) Ulcer
NPO
BP/P/SaO2 Q4H
CBC, LRFT, bone, RG, Clotting +/- T&S

CXR
XR of local region
Resume usual meds

IV ampicillin 1g q6h
Iv cloxacillin 1g a6h
Dressing daily
May need debridement +/- amputation if needed

Page 177
Case admission
Clinically admission x surgery / ORT surgery
81) Surgery
DAT
BP/P QID
Chart IO
Blood x CBC, LRFT, CaPo4, RG, Clotting +/- T&S (if surgery or required by department)
CXR
ECG
Resume usual meds

W/H warfarin if needed
Consult medical x pre op assessment if needed
Consult ICU x post op ICU care(for major surgery)
PPP x procedure
- FMN
- Ensure T&S
- Anes pre med
- consent
- marking
- IV xx to OT
(Surgery: IV zinacef 1500mg + IV flagyl 500mg
LGI: IV augmentin 1.2g
ORT: IV cefazolin 1g )

Page 178
Other information
Other information
Jean Cheng class of 2013, CUHK Page 179

Other information
1) For all problems
a. Check current admission diagnosis

b. Check PMhx
c. Vitals: BP, Pulse, Sao2, Temp, Urine out, H stix
d. Input and output chart
e. Physical examination
a) Alert?
b) JVP, Chest: basal creps, lower limb edema/erythem / swollen
c) Chest: creps
d) Heart: murmur
e) Abd: tenderness / guarding
f) PR: malaena / mass / tone
g) Neuro: GCS, 4 limbs movement
f. Latest labs(may be within 3 days)
a) CBC
b) RFT
c) LFT
d) Clotting
e) CXR / AXR
g. Drug chart review (to with hold certain drugs, or titrate dosage)
h. Then decide on your management

Other information
2) Pitfall
Call MO when unsure!!!
Medical:
When prescribing antibiotics / any drugs:
- check allergy
- check renal function! (cut half if renal impaired)
- check PMH for any contraindication, must.
Dont prescribe intramuscular drug unless necessary.

Because many patient in medical are on warfarin!
CXR:
Besides checking ptx / free gas / consolidation +/-
Costophrenic angle sharp / blunt
Pitfall is: surgical emphysema, airway stenosis, rib #
For axr, less pitfall.
ECG:
Read carefully.
All the ST segments especially.
Any atrial fibrillation
Surgery:
Post op case is very important!!!
Post op D0 , can tolerated 0-2L O2 PRN.
But if any further desaturation, must require desaturation workup!!!
If unsure, do desaturation workup, have a very low threshold.
For IO case, dont prescribe laxative. No matter any kind.
Post op abdomen drain--> if fresh blood

Urgent CBC, must inform MO!
ORT:
Limb swelling
- cellulitis with abscess?
- DVT +/- PE if desaturation
Sinister:
- nectorizing fascitis
- compartment syndrome!!! When pain is so exaggerated!!!
Hypotension:

Other information
?pelvic # with bleeding?

Inform MO if so
Dont take blood on the injured limb.

Other information
3) useful materials
Guidelines / resources
- common treatment order
- houseman made easy
- HO handbook
- impact guideline
Mobile apps:
- Very basic(CUHK)
- medscape
- impact guidelines
Equipment from yourself

- stethoscope
- torch
- pens (good writing one, or very frustrated)
- tourniquet for blood taking
Equipment from ward

- micropore
-
- KY jelly
- heparin(for ABG)

Other information
4) Reminder
- check allergy before prescribe drugs
- check id when copy MAR
- check ID when doing T&S
- when take blood, consider + T&S / c/st or ABG
- dont use gloves for tourniquet!!!
- help your colleague, be nice to them
5) Quotations
a. you will only in this department for 3 months, it will end one day. Think about
your MO, there are here for 6 years.
b. you only have one time in life to stay in this specialty, unless you want to do your
residence here. Or else, learn the most, dont regret.
c. at least 1/4 of your classmates are oncall with you tonight.
d. you only do houseman for 1 year, enjoy
e. sometimes do countdown is fun. But when you have time, do count up. Cheers
for being a doctor for xxx days.
f. Do you remember your wish in final MB, is to pass and become a doctor. Now,
you do it. Contratz.
g. Houseman are the first to be called to the scene. The initial diagnosis and
management depends on you. You are sometimes more influential than your
MO
h. You are a doctor, you should be respected. But you should also earn your own
respect.
i. You have to stop thinking yourself as a slave. You are a doctor, a doctor in
training. Have your dignity, yet responsibility.

Other information
6) Ethical / moral issues

You will face some issues that you dont feel comfortable.
See also attached: integrity in practice - a practical guide for medical practitioners
on corruption prevention, code of professional conduct
a. Nurses asking you to prescribe drug for them

Under HA, staff can request for certain drug items for their own use if there is
approval of doctor. Some hospitals allowed houseman to do the prescription (e.g.
PWH), while some do not.
For those drug items list, you may obtain from your hospitals pharmacy website or
phone to them. Generally speaking, those drug items are relatively cheap and safe
items. E.g. Panadol, piriton etc.
Generally, for all PRN medications, it is acceptable to prescribe to nurses. As in

clinical situation, doctors prescribe PRN medications to patients, and nurses will give
out the medications in 2 situations:1. The patient request it. 2. Nurses identified
patient need them. If normally you trust the nurses to given out PRN medications
under their judgements, then you will trust them to use the PRN medications on
their own under a reasonable judgement.
However, for certain drug items that you are quite sure cannot be PRN, e.g.
Antibiotics, you could refuse to prescribe it. (usually the drug items list include
augmentin, but not other antibiotics). You may ask them why they want that, and
gently ask them to see AED / GP if needed.
b. Nurses asking you to order certain investigation for them
One question to ask yourself is,who will read the investigation result?
Think about it, you are not responsible to read them.
And if the nurse really need that investigation, he/she should go to AED/GP.
So, gently refuse them, and ask them to see AED/GP if needed.
c. Nurses / friends asking you opinions on certain medical treatment / condition /

relatives medical condition
Although in reality, you have no doctor-patient relation, no duty of care to the nurse
/ nurses relatives / friends, and usually they will seek other medical advice, hence
there will be a break in the chain of causation.
However, you dont want to misconcept people.
Hence one way to answering them is,xxx(medical condition) is a wide spectrum

Other information
diseases. It can range from curative to palliiative. (unless is very minor illness, or
generally all illness have different degree of severity) I dont really know you / your
relatives current stage of diseases, as I havent seen him/her, physical exam, read the
labs / images. Therefore, I cannot say much. May be you ask the case MO will be
much better.
Other questions they love to ask so much,which is better, public hospital or private
hospital?
You dont need to answer them, honestly. Both can have good and bad doctors. You
dont know whom will they encounter.
One wiser way to deal with is ask which one are they seeking medical advice
currently or which one are they planning to go.
Then, say something neutral. Or just tell them both can have good and bad doctors.
d. Gifts
Usually intern doctors are not much troubled by gifts.
Pharmaceutical company seldomly give out gifts to interns and patient usually dont.
But there are always exceptions.
Pharmaceutical company:
Entertainment as food/drink consumed on the spot is not considered as advantage
. So it is ok to eat pharmaceutical company meals.
Other gifts, dont accept as general, no matter expensive or cheap.
Patient:
For thank you card, you may accept them.
For other gifts, dont accept. (but is difficult, i know)
e. How to treat hostile nurses / colleagues

When time goes by, you will find many hostile people around.
Nurses:
Nurses can be hostile with bad attitude:e.g. Bad mouth houseman, force houseman
to give certain treatment to patients etc.
Or they can be very annoying and keep calling houseman for minor things(e.g. Sign
restrain form, K 3.4...)
Keep your true color, dont argue with them, but dont compromise.
When they force you give certain treatment to patient, you think the issue cooly, not
influence by them, not influence by your emotion. Think only about the patient, and
you as a doctor.
When they mal-treat you, no need to scold, no need to explain to them. Just go
ahead to do what you think you need to do.
When receive annoying and minor calls, no need to scold them / be frustrated. Just

Other information
say,ok, i will come later / verbal order the things you want + thank you.
If you remain your true color, you make a difference.
Colleagues:
Many colleagues are very lazy, somehow.
Especially in 3rd / 4th rotation, when people already find jobs.
For those share duty with 1/2 more houseman, you will feel frustrated when you in a
more chur post, while your partner in a more hea post and your partner not coming
to help.
Usually, there will be switch of job duties, and in that time, you face a situation of not
going to help in partner in chur post, but you know how hard it could be(as you have
already been in that chur post)
You choose by yourself.
I normally will still go back to help. It is because it is about my true color and my
personal values. I remain my own dignity, no matter how others are treating me. And
by time goes by, people know you are sincere, and they will be sincere. Let them be
ashamed of not helping you previously.,
f. Dont bad mouth your colleagues / spread rumors

No, dont do that.
Even if you just want to share information out, dont do that.
You may gain popularity among colleagues / MO when talking a lot about your other
colleagues.
But, please, no.
Think about the feeling of your colleague, he/she is likely to feel being bullied. Also,
you may affect his/her job finding process. Even if you are not influential to affect
him/her, he/she may think you make him/her not getting the job he/her wants
Also, you are doing no good to your own self. When time passed, people will start
realize, you are the one spreading rumors. People will start thinking when are you
spreading their rumor. They will be afraid. In long run, you will not gain any true
friendship.
Therefore, please, dont.
g. Criticize your colleagues

We do learn when we discuss with colleagues / MO about certain case, how to deal
with, how to treat.
But do so, with a non-naming basis.

Other information
Dont criticze the issues as a person. Only discuss about the management, in a
educational and beneficial way.
You dont want yourself to be criticised by others, i guess.
h. Temptations!!!
Boys and girls.
This is reality.
No matter how hard you try to avoid.

Or you think there is no chance to encounter something like this.
Ai, all of you are adults, you know how to deal with la.
Just to remind you all there is things going on.

Break Your Leg Intern

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Break Your Leg Intern

Uploaded by

Copyright:

Available Formats

Break your leg - Intern!

Daily clinical work

Lab abnormalities - hematology

Lab abnormalities - biochemistry

Jean Cheng class of 2013, CUHK

32) C/st and sensitivity 39

Jean Cheng class of 2013, CUHK

Jean Cheng class of 2013, CUHK

Jean Cheng class of 2013, CUHK

Jean Cheng class of 2013, CUHK

Jean Cheng class of 2013, CUHK

Clinically admission x renal

Clinically admission X Resp

Jean Cheng class of 2013, CUHK

Jean Cheng class of 2013, CUHK

77) Cord compression 176

Clinically admission x surgery

Jean Cheng class of 2013, CUHK

Jean Cheng class of 2013, CUHK

Jean Cheng class of 2013, CUHK

gift from my dearest patient

Jean Cheng CUHK 2013

Jean Cheng class of 2013, CUHK

Nurses: without you all, I think my workload will be 10 times.

Jean Cheng class of 2013, CUHK

Daily clinical work

Jean Cheng class of 2013, CUHK

Jean Cheng class of 2013, CUHK

Blood x CBC +/- T&S

If septic shock: peripheral warmth. Fever if septic

For renal patient / CHF patient:

Jean Cheng class of 2013, CUHK

+/- ECG, Trop I( if chest pain)

+ good pain control

If ischemic stroke, treat only when SBP >220

If hemorrhage stroke, need stricter SBP control. SBP<180 if no ICP increase.

Jean Cheng class of 2013, CUHK

RFT(check latest or take one stat)

- HR 100-140: sinus tachycardia

W/H theophylline, erythromycin, ketoconazole, TCA

Jean Cheng class of 2013, CUHK

RFT(check latest or take one stat)

W/H beta blocker

Low BP: Atropine 0.4mg stat IV if symptomatic

Jean Cheng class of 2013, CUHK

Blood x ABG, Trop I, CK, LDH,

Sputum suction PRN

If pneumonia: (if fever, sputum, chest had creps)

If COPD exacerbation: (pmhx of copd)

If CHF: (clinically fluid overload)

If ACS (From chest pain, ECG and Trop I):

Jean Cheng class of 2013, CUHK

If no specific cause identified / exclude the above cause, consider pulmonary

Usually for CHF, can treat already before ix result

Cxr --> pneumonia / chf / ptx

But the most important:

Jean Cheng class of 2013, CUHK

Consider post op fever:

+/- IVF if septic shock

Antibiotics choice: depends on what infection / previously c/st

Bite wound / DM foot / AECOPD / Aspiration pneumonia/CAP/ Acute phelonephritis :

Any abscess: + IV metronidazole 500mg q8h

Jean Cheng class of 2013, CUHK