Professional Documents
Culture Documents
A. Urgent !
1. De-sat
2. BP drop
3. Decrease /No urine output
~ First reminder ~
4. Raise BP 1. Attend the patient
5. Haemoptysis 2. Find the cause
3. Treat before deteriorate
6. GI bleed / coffee ground vomit
B. Lab results
7. Hb
8. Decreased Plt
9. Raised INR
10. Hypo K
11. Hyper K
12. Hyper Na
13. Hypo Na
14. Hyper Ca2+
15. Hypo Mg
16. pH < 7.1 ?
C. Cardiac
17. Fast AF
18. Tachycardia
19. bradycardia
20. Chest discomfort (ACS)
21. DVT
D. Endo
22. DKI drip (fasting of DM patients)
23. Hypoglycaemia (H'stix <3.5)
24. Increased H'stix / Sliding scale of Actrapid HM
25. DKA
26. Thyrotoxicosis
27. SST
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E. GI
28. Constipation
29. Dyspepsia
30. Abdominal pain (anti-spasmotics)
31. Diarrhoea
32. Haemorrhoid
33. H pylori Med
F. Neuro
34. Stroke / CVA
35. Epilepsy
36. Seizure attack
37. CNS tumour / haemorrhage with mass effect
G. Resp
38. Cough medications
39. Chest infection / pneumonia
40. Intubation
41. Ventilator basics
42. COAD drugs & Mx
43. Anti-TB drugs
44. SOB in terminal illness / Sputum sound
45. Induce sputum by hypertonic saline
46. pleurodesis
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58. Violent patients
59. Pruritus (+ suspected scabies)
60. Red eye / eye discomfort
61. Drug withdrawal symptoms
62. Nocturnal irritability
63. Oral ulcer
64. Palpitation
65. Hiccups
I. Miscellaneous
66. Contrast allergy
67. Drug overdose
68. Thyroxine replacement
69. Gout
70. Cellulitis
71. DVT warfarin titration
72. Menorrhagia
73. AROU
74. haematuria
75. Unit conversion
76. Creatinine clearance
77. Treatment for M. Chelonae
78. Ertapanem dilution
79. Abnormal lab results / alert
80. Cert 人
3
M
ea
ns
:
A. Urgent !
“p
op
1. de-sat yo
- consider causes: ur
- Cardiac: CHF, AMI, arrhythmia, etc ECG 心 sel
- Chest: pneumothorax, pneumonia, pulmonary embolism,f mucus, COAD, APO etcCXR
- P/E: vitals, JVP, oedema, listen to chest, heart sound up
- Mx: CXR (U&P) / ABG / RLFT; +/- cardiac enzymes/ECG ” (if cardiac causes)
- Give O2 1-6L via NC or 35/50/100% via face mask (not to exceed N/C 4L/min in COAD)
- Suction for sputum
- Intubation ?/ Ambu bag
- +/- Ventolin 2 puff Q4H PRN (for asthma)
- ***Treat underlying causes (Laxis? / Abx? / BiPAP?)
** Pulse oximetry can be deceiving. Assess RR/ pulse (increased pulse often imply genuine
problem). Try warm up peripheries. Check ABG if in doubt.
Day1: Do eat 4
3. Decreased or no urine output (if 4hr < 50ml or 1hr<20ml for 6 hours)
- Check BP/P, I/O, temperature, CVP & drain outputs (if any)
- drug chart for nephrotoxic drugs (aminoglycoside, sulphonamide, NSAID)
- Differentiate between causes of
Post-renal : (? BPH / UTI / block foley) ~ First reminder ~
1. Attend the patient
- feel for bladder +/- bedside bladder scan, check Foley patency 2. Find the cause
Renal: 3. Treat before deteriorate
- creatinine level
Pre-renal:
- P/E: feel peripheries, check hydration status, JVP, basal crep, oedema
- PR exam (if PR bleed / tarry stool),
- CXR (if indicated)
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Day2: Do sleep
- If pre-op / OGD, check try labetalol 5mg IV stat (better ask your MO)
** In practice, the anti-HT dosage and frequency are variable. Those listed are small dosages
which should help during midnights. Usually stat x 1 would be fine.
** don’t give Adalat sublingual, it can cause sudden drop of BP -> CVA
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Day3: When you feel alone, pray to God
chop
means:
You are
responsi
B. LABORATORY RESULTS
ble for it
7. Hb
- Check vitals BP / P (tachycardia means problem)
Look for underlying cause: (GIB, menorrhagia, NSAID, recent Surgery)
- PR exam
- Bld x T&S , iron profile (+/- CBP, PBS, INR, Hb pattern, B12/folate, LDH, retic?)
- Stool x occult blood x 3 ( if no obvious PR bleeding, Sensitive? Specific ?)
- Transfuse if Hb < 7; aim at raising Hb to above 7 after transfusion
(Each unit of packed cells raise Hb for about 1g/dl)
- Can consider giving lasix 20mg iv after each pint of transfusion (PC is good vol expander)
- Check post transfusion Hb (+/- RFT)
- If massive transfusion ( > 4 unit of pack cell), consider to give 1 (PC) + 1 (Plt) + 1 (FFP)
- For MDS anaemia / terminal malignanc: treat only if symptomatic (transfusion has risk !)
If any problems related to blood transfusion e.g. Patient with Group A Rh –ve , only Group A
Rh +ve blood a/v , consult haematologist
9. Raised INR (read Houseman handbook GM7 when you are free...)
- Transfuse 4 units FFP FR x 1, then re-check INR
Platelet > 70 & INR < 1.3 can tolerate procedures. e.g. TACE, ERCP, Abscess drainage,
PTBD insertion & PCN
Note: FFP cannot stay long in the circulation, only give it within an hour before any
procedure. If not, just waste FFP
10 . Hypokalaemia K
- Look for common causes, e.g. diuretics, vomiting, etc
If cause not obvious, or persistent hypoK, or severe hypoK (K<2.5):
- check spot serum K and osm, urine K and osmol (TTKG?), baseline ECG
K >6
- do the above then
- 10 ml 10% calcium gluconate slow IV stat with cardiac monitor (over 3 min) (by you !)
- DI drip: 50ml D50 + 10u Actrapid HM IV over 30 min
- Repeat ECG in 5 min (if original ECG showed hyper K changes)
- H’stix q1h x 4 then Q4h (may prolong hypo-gly after DI drip)
- repeat RFT
12. Hypernatraemia
- hydration status? , clinical sign (palpitation)
- 500ml D5 over 4 hr 沖淡 (Don’t be too aggressive. Too rapid correction can kill.)
- Recheck blood x RFT
13. Hyponatraemia
- hydration status ? (hypo- / eu- / hyper-volaemia?)
14. Hypercalcaemia:
- corrected Ca2+ : (40 – alb ) x 0.02 + serum Ca2+
- off supplements : CaCO3 , vit D
- Bld x RFT, CaPO4, ESR, ALP, Mg, Ig pattern, SPE, +/- PTH
- urine x BJP / SPE
- NS Q6h/pint for rehydration then +/- Lasix
- Pamidronate 60 – 90 mg in 500 mL NS over 4 hrs (weak)
- Zometa 4mg in 100ml NS over 15 min (strong)
- calcitonin / hydrocortisone ?
15. hypo Mg
IV 5 mmol 49.3 % MgSO4 + 100ml NS over 1 hour
PO Mgtri 10ml TDS -> monitor K / Mg / ECG
Day6: 又要愛人如己 9
C. CARDIAC
19. Bradyacardia:
1. Really bradyacardia ? Assess the rhythm yourself
2. Clinically stable? Conscious state, BP, SOB congestive heart failureneed of atropine,
TCP or inotrope as stated in houseman handbook
3. Causes of bradyacardia 12 leads - ECG
a. drugs- beta-blocker / Digoxin review drug chart
b. Physiological: hypothermia
c. Pathological: rhythm sick sinus syndrome & Atrioventricular block 3 degrees,
hypothyroidism, ACS / MI, HyperK, ……
21. DVT :
A. Really DVT ? ( ? Well’s score)
Clinically unilateral leg swelling, warmth, redness, dilated veins (symptoms)
Homan’s sign , any SOB, BP/Pulse (sign)
Risk factors: old age , malignancy, OT esp. pelvic surgery, OC pills
Urgent US Doppler to confirm
B After confirmation
1. Complete bed rest
2. ECGlook for tachycardia, RV strain, S1Q3T3
3. CXR: any linear atalectasis
4. Monitor BP/P/SaO2 Q1H x 4 , if stable then Q4H
5. Enoxaparin 0.4ml SC Q12 H ( for BW < 40kg, 0.5ml for 50kg , 0.6 ml for 60 kg)
6. Consult medical for warfarin dosage (refer item 71) or NOAC
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Day8: Be nice to nurse, they can help you (occasionally)
D. ENDOCRINE
H’stix Actrapid HM
<8 0
8-12 2
12-16 4
16-20 6
>20 8 + inform
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- Actrapid HM 4 unit sc tds prn if H’stix >16 (or omit if H’stix <10)
26. Thyrotoxicosis
- Inderal 10mg TDS PO (beware of asthma!)
- Propylthiouracil 100mg TDS PO (check allergic history) or
- Carbimazole 10mg TDS PO
27 SST
Add 250 mcg tetra-cosactide to 500ml NS
Low dose: 2ml NS -> 1 mcg
Check blood : 0 / 30 / 60 min
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Day9: Do
Day10: Doeat
ask anything you’re not sure
E. GASTROINTESTINAL
28. Constipation
- R/O IO, ileus, dehydration (Hx: usual bowel habit)
- review drug chart (Al/ Ca, antacid, CCB, opiate)
- P/E: Abd palpation +/- PR
- Senokot 7.5 or 15mg Nocte po prn
- Lactulose 10ml bd/tds po prn
- Softon 100mg BD PO
- Dulcolax 1 tab PR x1 stat, or Fleet enema 1 tube PR x 1 stat
- Metamucil 10ml BD/TDS PO (orange powder)
** PR agents are often enough, if fail, repeat. Manual evacuation sometimes very helpful.
31. Diarrhoea
- Chart I/O, +/- IVF supplement
- Look for underlying causes, prescribe the followings only if indicated:
- Lomotil tab 1 qid po prn ( to overcome the side effect of neotigmine in MG)
- Imodium tab 1 qid po prn
- Kaopectate 10ml qid po prn
Day11: 愛是恆久忍耐 14
32. Haemorrhoid (? Cause : constipation / cirrhosis )
- Faktu supp tab 1 BD or ointment LA tds
- Xylocaine jelly LA tds prn
- Anusol 1 tab Daily PR
- laxatives
33 H pylori treatment
Pantoloc 40mg BD + Klacid 500mg bd + amoxicillin 1g bd for 7 days
(substitute amoxicillin with metronidazole 500mg bd in case of penicillin allergy)
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Day12: Treat your patient nicely (even if they make you feel sick)
F. NERVOUS SYSTEM
35. Epilepsy
- ABC, O2, H’stix,
- blood for CBC, LRFT, CaPO4, glucose
- Give D50 50ml iv, thiamine 100mg iv
- Phenytoin (Dilantin) 600mg (10 - 15mg / kg) IV over 30min, then 300mg po/IV
- IV/PR diazepam (valium) 5 mg bolus if convulsion > 10 min
- Consult anaesthetist, ICU (if intubation)
- Monitor BP/P, RR, ECG, temp ; convulsion chart
- Look for infection, poisoning, anti-convulsant withdrawal
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Day13: Take a break
G. RESPIRATORY
38. Cough medications
- Mucolytics: fluimucil 200mg tds ( more expensive) , 橙樹化痰素
- bisolvon 8mg tds ( cheaper) 氣舒痰
- Expectorants: MES 10ml tds 馬尿
- Cough suppressants: phensedyl 10ml tds, promethazine compound 10ml bd, pholcodine
- Others: Elixir Benadryl, Cocillana 10ml QID PO
Antibiotics:
- Augmentin 375mg tds (or 1gram BD) po or Augmentin 1.2g iv Q8H
- Unasyn 375mg BD po or Unasyn 750mg iv Q8H
- Klacid 250mg or 500mg BD po ( Clarithromycin)
- Sulperazon 1g iv Q12H + vit K 10mg daily (Suspect HAP)
- Tazocin 4.5g IV Q8H
- Levofloxacin (Cravit) 500mg daily PO - check sputum x AFB first to avoid partially treated
TB
For Flu
- NPA x flu A/B
- Tamiflu 75mg BD PO x 5 days (treatment for confirmed case) (dose reduction if elderly
or renal impairment)
40. Intubation ( 2 drugs would be given?) (Don’t give muscle relaxant w/o supervision!)
- make sure suction ready
- Suxamethonium 50mg iv (see K)
- rocuronium 25mg IV (for RSI, use only in very experienced hand !!)
- etomidate (if ICU / anesth setting)
- size 7.5 Endotracheal tube , marking at 22-24cm with cricoid pressure
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Increased CO2
- Increase RR
- Increase tidal volume (wash out CO2)
- Sedation (more synchronized breathing)
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Day15: Learn to form Discharge plan
Alarm (high TV; low pressure)
- Leaking air => check
- BP low
- Must check whether pneumothorax
42. COAD drugs & Mx (steroid + bronchial dilator + antibiotics) (please read GOLD)
- Ventolin 2 or 4 puff Q4h or QID (see puff technique if newly use)
- Atrovent 2 puff QID (long term: consider LAMA)
- Bisolvon 1 tab TDS PO or Fluimucil 200mg TDS PO
- MES 10 ml TDS PO
- Hydrocortisone 100mg IV Q8H then Prednisolone 30mg daily PO (when stable)
- Chest physio & PFR BD
46. Pleurodesis
- minocycline 300mg in 50ml NS for intrapleural cavity
- oxytetracycline 250mg in 50ml NS for intrapleural cavity
- talc 2gram in 50ml NS + lidnocaine
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H. UNCLASSIFIED WARD COMPLAINTS
47. Pain 痛
- Panadol 500mg QID prn PO/PR (max: 4 gram / day; 2 gram/d if cirrhosis)
- Naprosyn 250mg TDS PO (for MSK pain)
- Diclofenac (Voltaren) 75-150mg daily PO / Voltaren SR 100mg daily
- Tramadol 50/75mg IMI Q6H prn ( beware of resp distress & nausea, avoid in head injury,
can cause serotonin syndrome if on SSRI)
- Pethidine 50/75/100mg IMI q6h prn (beware of resp distress, avoid if possible)
** Add pepcidine 20mg BD for NSAID use. Consider PPI if resource allows.
Local application
- Analgesic balm LA tds prn
- Voltaren gel LA tds good for post-traumatic inflammation
- Hirudoid LA tds prn good for drip site wound 喜療妥
48. Headache
- Document GCS, brief Hx and P/E to r/o sinister causes
- Hx: aura, vomit, blurred vision, ocular pain, HI, ?most severe headache ever
- P/E: BP/P, facial tenderness, fever, neck rigidity, rash
- Ix: Bld x ESR (if suspect GCA), CRP,
- sinus x-ray, CT brain, ?LP
- Panadol 500mg QID PO prn. (Other analgesics choices as above.)
49. Fever
Common causes:
- post-op causes, resp (pneumonia, URTI), UTI, drip sites, wounds, gynae (in female), GI,
ENT, drug-induced, tumour, etc…
Review medications (? on Abx), lab results (e.g. on Abx already & WCC on decreasing
trend?)
Mx order:
- Septic workup if not done:
- Bld x CBC/DC, LRFT, CaPO4, clotting, C/ST
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- Sputum x C/ST
- MSU x C/ST
- +/- CT brain then LP (if neck rigidity / skin rash / confusion)
- PUO: ESR / viral titre / monospot / Widal / cold agglutinin / malaria / ANA / RF
- CXR
- If indicated, start empirical antibiotics
- Panadol 500mg QID PO prn if temp >=38 degrees
- if NPO: panadol 500mg Q4h PR prn or Indocid 1 tab Q12h PR prn if fever
(For neutropenic fever WBC<1, ANC<0.5: Tazocin 4.5 gram Q8h IV or Fortum 1-2 gram IV
Q8h)
Post-op fever:
- Within 48 hours: usually atelectasis
- chest physio , incentive spirometry, encourage deep breathing
- 48 hours to 5 days: chest infection, UTI, drip sites, etc…
- After 5 days: wound infection, intra-abdominal abscess, DVT
51. Drug allergy (Must see SaO2, if desat or angiooedema -> inform MO)
- Hydrocortisone 100mg IV Q8h ; Piriton 10mg IV Q8h
- if anaphylaxis: + 100% O2, adrenaline 10ml in 1:10000 solution IV / 1ml 1:1000 IM
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- Synalar Cr 0.005/0.025/0.05% LA TDS
- hydrocortisone cream 1% LA TDS
55. Insomnia
- Piriton tab 1 po x 1
- Ativan 0.5-1.0mg Nocte PO x 1
- Imovane 3.75mg Nocte PO x 1 ( zopiclone 1 tab = 7.5 mg)
56. Dizziness 暈
If sudden onset and severe
- Hx and P/E to exclude sinister causes (e.g. stroke) check tone & power both sides
- Non specific ? Vertigo ( Hallpike’s maneuver )
- H’stix stat, postural BP (= erect and supine)
- +/- CT brain (? SOL / haemorrhage / infarct )
- ECG
-Bld x CBC, LRFT, CaPO4, clotting
- Stemetil 1 tab / 5-10mg tds prn, Stemetil 11.25mg IMI q6h prn
- Ser C (Merislon) 1 tab (6mg) tds po prn
Vomiting/ Nausea 嘔
- Look for underlying cause (e.g. S/E of medications)
- ? IO , peritonism , increase ICP, MI, VBG if AF ? metabollic acidosis (? Ischaemic bowel)
- Maxolon 10mg tds po / Maxolon 10mg IM/IV Q6h prn (avoid if suspect IO / MBO)
- Kytril 1mg IV / Zofran 8 gm IV (expensive, seen in chemo / oncology units mainly)
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57. Abnormal behaviour
- For those with psychi history, watch out for drug overdose / drug interaction
- Haloperidol 1 mg Q6H IMI/SC;
half dose for elderly (try Haldol drops 0.1mg x1 if frail)
59. Pruritis 癢
- After excluding allergic reactions / scabies in OAH elders
- Aqueous cream LA tds prn
- Eurax cream LA tds prn 優力斯
- Piriton 1 tab tds po prn
- Atarax 1 tab (25 mg) tds po prn
If suspect scabies:
- Skin scrapping for scabies
- 5% permethrin cream LA, to whole body except face BD for 2 doses
- Benzyl benzoate lotion LA, to whole body except face BD for 2 doses
- Follow by eurax the day after if persistent itchy rashes
64. Palpitation
- Inderal 10mg TDS PO prn ( propranolol)
(only for symptomatic Rx; always look for underlying cause, e.g. arrhythmia, AMI..)
65. Hiccup
1. Paper bag for self re-breathing (布袋法)
2. Stemetil 5-10mg TDS PO PRN
3. largactil 25mg TDS PO PRN (not much ppl use this?)
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8. MISCELLANEOUS
69. Gout
- Colchicine 0.5mg TDS until pain subside /diarrhea (consider 0.25 mg if elderly, better tolerated)
- Naprosyn 250mg BD PO / regular panadol 500mg QID PO
- low purine diet
- withhold diuretics ? / improve hydration
70. Cellulitis
- On exam, note any fluctuation (which indicate underlying abscess),
if +ve, bedside needle aspiration to look for pus aspirates (usually done by MO)
- (DM?) Hstix TDS
- bld x CBP, L/RFT, C/ST;
- wound swab x C/ST
- X-ray of the affected part: to exclude underlying osteomyelitis / septic arthritis
- ampicillin and cloxacillin 500mg iv Q6H
- If mild, ampicillin and cloxacillin 500mg QID PO x 1/52
** Mark margin of erythema with marker if suspect NF. Review yourself / ask nursing staff to
inform in margin grows rapidly.
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71. DVT Warfarin titration
- clexane 0.4 mg SC Q12h x 3 days then start
- Warfarin 3mg daily PO (loading) x 3 days then 1mg daily PO
- if elderly > 70 yrs old or malnutrition or BW < 60 kg, omit loading
- daily INR till stable
72. Menorrhagia
- BP / P Q4h
- CBC, clotting , T&S
- Transamine 500mg QID PO
73. AROU:
- Feel for bladder -> bladder scan
- Bld x CBC, L/RFT, Ca PO4, glucose
- CSU x C/ST
- KUB
- foley to BSB if RU > 400ml
** Do not check PSA during ROU episodes. Look for UTI / constipation, esp. in females
74. Haematuria :
- DAT, Encourage fluid intake
- CBP, L/RFT, CaPO4, Glu, INR/APTT
- Save urine x inspection
- MSU x C/ST
- EMU x AFB x 3
- Urine x cytology x 3
- KUB
- Pyridium 1 tab tds x 1/52 (warn patient for orange urine)
- Nitrofurantoin 50mg QID x 1 /52 if febrile (or other Abx acc to prev C/ST)
- consult uro x cystoscopy +/- IVU
78. Ertapanem
- Ertapanem 1gram daily + 3.2 ml 1% lignocaine for IM
If IV, in 100ml NS over 30 min
80. Cert 人
No detectable blood pressure / pulse
No spontaneous breathing
Pupils fixed and dilated
No oculocephalic reflex
ECG flat
Patient certified death at time, date
Cat 1 body
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(Table below from IMPACT 5th edition)
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Please take good care of yourself, physically and spiritually.
Update on 27/4/2019
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