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CALLED.TO.SEE.PATIENT v1.1
By NHG IM Residents – 2010 batch

With contribution from TTSH, KTPH and NNI
By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI

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Table of contents Prologue General Advice General Medicine Cardiology Respiratory Medicine Neurology Renal/Electrolytes Gastroenterology Endocrinology Geriatric Medicine Palliative Medicine

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Miscellaneous Drug list

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Haematology/Oncology

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Rheumatology, Allergy, Immunology

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Important contact numbers

By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI

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41 45 63 71 75 81 84 88 93 95 101 110
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This book is dedicated to: Our Patients & their caregivers Our mentors and faculty members, seniors and colleagues Our underappreciated nurses, pharmacists, PT/OT/ST/MSWs and other allied health workers Foreword

In response to these needs, the residents have come together to write this booklet that aims to provide a practical guide to many common acute conditions, including survival tips developed from their collective experience in the past one year. Through this booklet, they hope to help the new residents manage the challenges they face on the ground better and ultimately, provide better patient care. These are the features which make this booklet unique and useful. This is our very first edition of CTSP and there will be refinements and changes as our understanding of medicine

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I am sure that we remember our first day of work as a doctor, just fresh out of medical school, and of course, our first call the sense of helplessness, insecurity and anxiety. I had wished then, that there was a manual that will provide tips to survive the call and the day, and also guidance for the management of acute conditions.

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It gives me great pleasure as the program director of the NHG-AHPL Internal Medicine Residency Program, to write the foreword for this booklet entitled Called To See Patient (CTSP), which embodies the work and tremendous effort of the pioneer batch of our Internal Medicine residents.

By NHG IM Residents - 2010 batch with contribution from TTSH, KTPH and NNI

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hence the information presented here should be used in context.2010 batch with contribution from TTSH. always consult the immediate supervisor or the senior staff. I would also like to thank the Internal Medicine faculty from Tan Tock Seng Hospital. Dr. ed ic i ne By NHG IM Residents . Every patient and situation may differ. KTPH and NNI R es id en c 4 y . Khoo Teck Puat Hospital and National Neuroscience Institute for their unfailing guidance and support. When in doubt. I would like to commend the residents on the great effort and thoughts which went into the writing of this booklet. Koh Nien Yue Program Director NHG-AHPL Internal Medicine Residency Program Disclaimer N H G In te rn al M This booklet serves as a brief general guide to the management of acute conditions commonly encountered in the ward.progresses in future years. It is not meant to be exhaustive and the reader should use the standard reference text for further reading.

Impt things to note down: DIL patients. investigations to be performed (eg serial cardiac enzymes.Psych up! Easier said than done though. This can be terribly deceiving though. Extremely impt . KTPH and NNI R es id en c y 5 . pre-call depression has been known to afflict hapless HOs up to 1 WEEK before the call itself. get the numbers of your MOs and contact them early to ask them how they want to work (e. bloods/ECGs/blue letters etc to trace (and WHAT to do/expect with the results – e.g.g. seemingly “full” wards have poor predicative value for the eventual quality of your call .Develop a system of keeping track of the things you have done or not done and prioritizing changes – also useful for you to recall pts because the primary team may call you the next day if they have any doubts about your management and also for you to follow-up on the patients after your night call N H G In te rn al M ed ic i ne By NHG IM Residents .Confirm which level you’re covering. SMS or call? Contact them for new cases or clerk first?) . ABGs).Get your call room early and changed . May be asked to review sick pts but this is usu done by MOs .General Advice On Call PRE-CALL: . keep Hb> what level?).Scout the wards for empty beds.Get HANDOVERS from your friends.2010 batch with contribution from TTSH. Can also look at BMU bed bookings on Intranet.Get enough SLEEP the night before. Think about the wonderful sleep you’ll get post-call (if you get to go post-call) . Best time to eat is around 5 to 6pm when most primary teams are still around and the calls don’t really start flooding in yet .HAVE AN EARLY DINNER.

Learn to PRIORITISE. New cases (generally try to see before your MO) 4.2010 batch with contribution from TTSH. Non-urgent passives (cough syrup. change med order in eIMR. Call seniors early if in any doubt! .g. Patient COLLAPSE 2.Check with a senior first before ordering certain investigations (e. Urgent passives/patient complaints 3.) 8. Tracing labs/investigations and acting on them 5. but if you sieve out what’s impt and deal with those first. nurses are your allies and friends: they can make or break your call in more ways than one. . got water drink. plugs for dopamine etc 7. More urgent if: ARU x long time with high RU/PVRU.KNOW YOUR LIMITS! – both in terms of experience and the capacity to bear responsibility if something goes wrong. got food eat.PLEASE be polite to the nurses! A bad call with incessant calls from the nurses and never-ending admissions/passives will fray the nerves and crush the souls of the hardiest of HOs. listing for scopes) te rn al M ed ic i ON-CALL: .. cardiac enzymes) 6. KTPH and NNI H G In . generally all scans.g. blue letters. 6 N By NHG IM Residents .g. expensive bld ix) and interventions (e. You may be overwhelmed by the sheer amount of work esp during the first few calls. things become much more manageable. sleeping pills.Got time sleep. . etc. No matter what though.In rough order of priority: 1. Time sensitive bloods (e. high risk meds. Procedures (IDCs. Updating/speaking with relatives ne R es id en c y . plugs).

Try to trace all labs/ECGs you’re asked to review – document in case notes as appropriate By NHG IM Residents .Learn how to dispatch your own bloods using the tube system . If you need help with CVM passives should call the CVM MO. 10) – RM and cardio cases – Expect to trace on many ECGs/cardiac enzymes. Always check BP and neurology (don’t miss ICH!!) . calls for abnormal rhythms on telemetry. PSY (W5D). SoB/chest pain o HO4 (Lvl 9.. Gently remind the nurses if they do call you for NNI patients . SpO2.When giving meds/ordering investigations/taking blood: Check it’s the correct patient!! Always check sticky label + order form .Don’t dismiss complaints like headache and giddiness.Taking GXMs: Sign BOTH the sticky label and order form. Indicate on sticky label date and time the blood was taken . 13) – Renal (W9B).Neuro patients – both active and passive are taken care of by neuro MOs.CVM actives are taken care of by MOs but you should help out with taking blds for the new patients. KTPH and NNI R es id en c y 7 . Can be flooded by the sheer volume as all the wards are C class wards (Up to 42 patients per ward) o HO2 (Lvl 7. N H G In te rn al M ed ic i ne . .Simple investigations like CBG. ID generally gets admitted to these levels if beds are available o HO3 (Lvl 8. RAI.2010 batch with contribution from TTSH.Common types of cases encountered: o HO1 (Lvl 5. ECGs can be performed quickly and potentially yield impt information wrt patient complaints. 12) – GM. 11) – GRM. PMD. private/A class patients on lvl 13 generally expect to be attended to quickly .

Patient may also be seeing several Drs – look through at least the first few prescriptions ‐ Can try to ask nurses to prepare items you may need while N H G In te rn al M ed ic i ‐ Accompanying DIL patients down for scans/procedures – know at least what the resus status is and ensure appropriate equipment is available (e.2010 batch with contribution from TTSH. KTPH and NNI R es id en c 8 ‐ Always carry a few add-test form and KY gel with you ‐ Useful to carry green (heparin) for BOHB. check earlier summaries or check with patient ‐ CDMR is a useful place to trace the latest HbA1c. IMH or SingHealth meds may only be reflected in dispensed meds). toxicology. ‐ ePACE can also provide a useful summary for patients who have undergone major surgery recently ‐ Look through both prescribed and dispensed medications (e.g. drugs. fluids. ensure O2 tank has enough O2 to last the journey. Help to push the heavy beds (the Ah-Mahs and nurses will appreciate it) ne By NHG IM Residents .g. working IV plug available) – if for active and unstable may want to carry defibrillator for continuous ECG monitoring.Clerking new cases ‐ Clerk PMHx from CPRS (rmb to click CMRx at bottom right hand corner to get Singhealth notes) & HIDS ‐ There may be mistakes in discharge summaries – if in doubt. lipid panel from polyclinics etc. and grey (floride) tubes for lactate with you – not all wards stock – and may need for acute emergencies ‐ Carry coins with you for a quick coffee/coke break at the vending machines ‐ Save phone numbers into your work phone as you work – it makes future work easier because you do not have to call “0” (for operator) and wait y .

low fat. otoscope/ophthalmoscope. Diet ‐ Fluids – N/S. postural BP. 4. full diet ‐ Type/therapeutic (Dieticians’ realm): e. Management – drugs. pudding. low purine.clerking the patient while you write to save time (e. ‐ NBM. premix etc etc. referrals to PT/OT etc. +/. honey.g.  Supplements: myotein etc. nephro etc. NGT o NGT feeding – usually over 6-8 shares (e. CBG ?frequent. DM. feeds. soft diet.2010 batch with contribution from TTSH. non-milk. D/S. nectar. 200ml x 6 + 50ml H2O flushes)  Types: Ensure.g dressings). soft moist. urine. high protein ‐ Consistency (STs’ realm) o Solids: easy chew.g. Investigations – blds. blended o Fluids: thin.g. nursing interventions (e. fit/behavior/stool/vomit chart 2. low salt. fall precaution etc. tendon tapper. KTPH and NNI R es id en c 9 y . renal. Disposition – CRIB. Monitoring – paras+SpO2 ?frequent. 3.blue letters ‐ Review the patient through the night if the patient is ill (most of the time the MO will do it) N H G In te rn al M ed ic i ne By NHG IM Residents . glucerna. 5. bag of ice for ABG. imaging. CLC. stool. lactate) Have a system when writing orders 1.

. signs may develop.Savour the post-call euphoria while you can.Read up and reflect on your performance that call. You may even end up seeing some of these same cases on your next night call.Try to grab a quick breakfast before AM rounds start . Aim to do better next call! .N H G In te rn POST-CALL: . Be sure to finish up ALL your morning round changes and handover appropriately before you saunter off home. It’s back to work the next day…… al M ed ic i ne By NHG IM Residents .HAND-BACK sick patients you encountered overnight esp those that should be seen by the primary team early in the AM round .Also be sure to HAND-BACK any significantly abnormal lab/imaging results.2010 batch with contribution from TTSH. Responsibility must however be borne when exercising this privilege.It can be of tremendous learning value to re-visit some of your interesting admissions/passives over the next few days when time is available. Diagnoses may change. . KTPH and NNI R es id en c y 10 . cases will evolve.Post-call (ie leave by 1pm or so) privilege has now become more common for HOs unlike in the good (bad) old days. esp if asked to trace them overnight .

GU (pyelo. myositis. heart/lung/kidney dyxfxn. tumour. GP N H G In te rn al M ed ic i ne By NHG IM Residents . GE). lung CAP. nec fasc. HR >90. fornier’s). bloodstream. Non-infectious fever: drugs. RAI dz. SEPSIS/SPIKE FEVER CTSP: new case sepsis. soft tissue (abscess. plug. prostate. large PE etc) ‐ Severe Sepsis = Sepsis + organ dysfxn (mottled skin. GI (Cdiff. low u/o. Abd (peritonitis / perf gut).2 (E) or 37. absess).0°C. immunosuppressed.g. high lactate. altered mentation etc ‐ Septic Shock: Sepsis + large volume IVF/pressor need Note: if Sepsis + Hypotension.5 (R) may be significant). low platelet. HCAP). RR >20 or PaCO2 of <32. or inpt spike fever ‐ Definition: True fever is > 38 C ‐ “Low Grade” fever: query significance (exception: elderly. KTPH and NNI R es id en c General Medicine A. DIVC. pancreatitis. HBS (cholangitis. device ‐ Travel/contact/exposure hx ‐ Recent antibiotics & treatment by e. dialysis pts. Joint (Septic jt). endocarditis. CNS (mening / enceph). WBC >12K or <4K or >10% bands ‐ Sepsis = SIRS + proven OR suspected infection (Nonseptic sirs = burn. HAP. persistent >37. sacral sore). respi (sinus.2010 batch with contribution from TTSH. CNS insult etc y 11 .5°C or <35.Approach: Differentiate isolated fever (have time) from sepsis (urgent) and severe sepsis/shock (emergency) ‐ SIRS: At least 2 of : T>38. cystitis). ‘correct’ antibiotics need to be in vein in <1 hr of low bp (golden hour) Find Source: ‐ Skin (cellulitis. DVT/PE.

old culture data. plug Ix . Also no need to escalate Abx on night call – can wait for primary team to decide CM o If patient has new/worsening sepsis.If diarrhea.2010 batch with contribution from TTSH. Blood c/s x2 from different sites (1 set never enough in adults) procal (esp if uncertain re: bacterial infection). c/s if suspect TB e. standing orders from primary team.Sputum smear and c/s .CXR +/. May repeat blood cx x2 if T>38 and still no diagnosis. LP depending on s/s . (NO stool cx if diarrhea occurs after 72 hrs of adm). KTPH and NNI R es id en c ‐ If existing inpt case – reason for adm.g. GCS. Fresh N H G In te rn al M ed ic i ne By NHG IM Residents . repeat w/u (unless done within 24-48 hours). cavity (oral / PR). NOT nasal swab for flu PCR) . usu no need to repeat septic w/u. LFT.FBC.If new pneumonia: Urine strep / Legionella Ag. current Abx regime.UFEME.Rule of thumb: can never be too many blood cultures done if source / diagnosis not confirmed.Sputum AFB. Ensure pt not in shock (check tissue and organ perfusion) ‐ Look for source: front. SpO2. Influenza PCR (remember deep nasopharyngeal swab or sputum. prev pTB . Stool culture only if <72 hours since admission. creat. r/o fever vs sepsis (see above) o If pt well (fever but not septic) and w/u done within 4 days.AXR . escalate abx y 12 . chronic cough symptoms. back. urine c/s . last septic w/u. CRP. others eg CK. LoW/LoA. PE ‐ Vitals. night sweats.

Remember to adjust Abx for renal function ne By NHG IM Residents . use IV Penicillin 4 MU 6h. droplet (influenza. KTPH and NNI R es id en c stool for ova/cyst/parasite if(+)travel hx. IV Azithro 500mg 24h ‐ HAP/HCAP: IV piptazo + vancomycin ‐ Aspiration: IV / PO Augmentin ‐ Meningitis: Ceftraixone 2g q12h + Vanco ‐ Meningitis if listeria suspect: add IV ampicillin ‐ Meningoencephalitis: add IV acyclovir ‐ Severe HBS: IV cefazolin+PO flagyl+IV Gentax1 ‐ Non-catheterized Cystitis. do periph c/s x2. culture-guided PO bactrim ideal N H G In te rn al M ed ic i Mx .KIV Isolate: Airborne (TB.Wound swabs never helpful (actually harmful b/c confusing). If unstable remove line – send tip for c/s. mumps. unknown severe resp.2010 batch with contribution from TTSH. then periph) – highly suspect line source. contact . Wait for urine culture (no hurry). .Line sepsis – draw bld from line AND periphery. illness). Should ONLY swab if pus seen from draining sinus. KIV CDiff in all (prior abx or not). meningococcal meningitis until 24 hrs abx). chickenpox. . All others: do not swab (await deep biopsy by GS / IR).REFER ARUS-C for empirical antibiotic guidelines . rubella.Common empirical Abx ‐ CAP: IV Augmentin+ PO Klacid (! Prolonged QTc use Doxycyline) ‐ Severe CAP: KIV ICU. y 13 . measles. neurogenic bladder: If pt stable. If st differential time to positivity >120 min (line 1 . IV ceftaz 2g 8h. Foley UTI.

start IV cefazolin plus gentax1. native septic joint: IV cefazolin N H G In te rn al M ed ic i ne By NHG IM Residents .‐ IF UTI pt unstable. KTPH and NNI R es id en c 14 y . prosthetic septic joint: IV vancomycin ‐ Cellulitis. CT) ‐ Line sepsis (e. do imaging (US. perinephric/prostate abscess etc.g permanent catheter).2010 batch with contribution from TTSH. suspect pyelonephritis.

amyloidosis). AS/HOCM o Neuro: CVA/TIA o Postural hypotension: dehydration. loss of continence. old age) o Vasovagal o Situational e. ?coexistence of osteoporosis). Todd’s paralysis) . VB. meniere’s. baroreceptor insensitivity (e. biting of tongue. then consider the following causes: o CVS: Arrhythmias or LVOTO eg. adrenal insufficiency/ panhypopit.central (eg. straining from LUTS 2* BPH) Giddiness: ‐ Differentiate into the following categories o Vertigo . # (if fragility # over typical sites eg. cough.Rule out seizures (need not be GTC. MSA. peripheral vasodilation 2* sepsis.2010 batch with contribution from TTSH.True syncope . contusion. vetebrobasilar insufficiency (VBI) or posterior circulation CVA) or peripheral (BPPV. micturition (e.transient LOC of few seconds with spontaneous recovery .Ensure no HI.g. vestibular neuronitis from URTI/otitis media) 15 N By NHG IM Residents . blood loss. can be atonic seizure) o preictal (aura/palpitations/pallor). pain. ictal (GTC. KTPH and NNI H G In te rn al M ed ic i ne R es id en c y . radius. BP meds.g. hip. GIDDINESS/SYNCOPE ‐ Rule out hypoglycaemia and uncontrolled hypertension ‐ Determine if there was syncope/LOC or not Syncope: .B.g. autonomic failure (DM. veering of eyes) and postictal (drowsiness.

cardiac enzymes.KIV ENT referral for peripheral vertigo for audiometry.g. from hyponatremia/ psychiatric causes (e. sturgeron for vertigo. KTPH and NNI R es id en c 16 ‐ Examine for mumurs. KIV 24-hr Holter monitoring in patients w/ suspected arrhythmias ‐ Symptomatic treatment e.o o o Dysequilibrium: Parkinson’s disease. anxiety) N H G In te rn Orders ‐ Fall precaution ‐ Postural BP monitoring ‐ FBC. CBG monitoring ‐ ECG ‐ X-rays of areas suspected #s +/.2010 batch with contribution from TTSH.BMD ‐ KIV CT head. UECr (depending on Na/K KIV 8am cortisol).g. carotid bruits ‐ Dix-Hallpike maeuveur and otoscopy for vertigo y . peripheral neuropathy Presyncope (approach as per syncope) Non-specific giddiness eg. MRI/MRA ‐ Treatment depends on cause . cervical myelopathy. avoid stemetil in patients with parkinsonism al M ed ic i ne By NHG IM Residents .

behaviourial change Confusion Assessment Method (CAM) ‐ Acute onset and fluctuating course AND ‐ Inattention AND ‐ Disorganised thinking OR ‐ Altered level of consciousness y . CTSP re: pt confused.g. PO tramadol 25mg BD PRN and titrate) ed ic i ne R es id en c C. SLEEPING PILLS ‐ Metabolic ( hypo/hyperglycemia. anticholinergics. encourage family members to stay with patient.2 mg). meningitis) ‐ CVA/ICH ‐ Acute coronary syndromes ‐ ARU/Constipation ‐ Pain (Be cautious with pain meds. KIV low dose e.Ix as appropriate for causative factors .g Antidepressants. pneumonia. PAIN MEDICATIONS.If agitated.g.low dose antipsychotics e. KTPH and NNI N H G In te .5 – 1 mg in total). electrolytes ‐ Infx (sepsis. can give more haloperidol (up to 0. nurse close to nursing counter .. pain meds.2010 batch with contribution from TTSH. o Consider atypical antipsychotics (eg PO quetiapine 17 By NHG IM Residents . review 2 hrs later– if patient still very agitated. thyroid conditions. if need for opoids. o PO syrup haloperidol. DELIRIUM Aka AMS.Treat causative and reversible factors rn al M Causes ‐ Medications (e. Anti-parkinsonism)Exercise caution when prescribing COUGH MIXTURES.1 – 0. starting with 1-2 drops (0.If patient very disruptive or in danger of self-harm .

QTc prolongation in ECG. climbing and falling out of bed y 18 . Ask for behaviour chart so that team looking after patient can better decide on how to continue with antipsychotics. ARU (piriton) ‐ Encourage sleep hygiene ‐ KIV substitutes (e. requesting for sleeping pills or coughing elderly requesting for cough mixture ‐ Advise on S/E e. ‐ Physical restraints as a LAST resort and should be deployed if the patient could potentially get hurt when confused (e.] Watch for hypotension. KTPH and NNI R es id en c 12.5 -25 mg) for patients already having Parkinsonian features.g. fluimucil instead of cough syrup) By NHG IM Residents .2010 batch with contribution from TTSH.g.g. AMS.N H G In te rn al M ed ic i ne Note: May get calls for the elderly being unable to sleep.

After which. be vigilant. ACLS ‐ Start bag-valve-mask with 100% O2 ‐ Ask for stat CBG ‐ Set 2 large bore IV lines +/.e. adrenaline.help to update family In te rn al M ed ic i ne By NHG IM Residents . 1L over 30 mins ‐ Ask nurses to prepare and start appropriate meds – e. contact MO/Reg ASAP ‐ Find out if patient has any resus status – if none = DILactive until proven otherwise ‐ Usually there will be chaos – (Try to) stay calm and assume the leadership position until someone more senior arrives. dopamine (may have to specify exact dilution and dose esp if no experienced nurses are around) ‐ Help to arrange for transfer to HD/ICU ‐ Help to document events and record important events and medications given ‐ +/. pulseless. KTPH and NNI R es id en c 19 D.g. don’t switch off) y . no BP ‐ See patient IMMEDIATELY.e. get E-trolley ‐ Attach ECG leads (not 12-lead) – watch for cardiac rhythm on defibrillator and shock PRN – i. Listen to the senior nurses – they have more experience than you. listen to instructions and help out wherever appropriate (i. patient found unresponsive. “COLLAPSE”/MEGACODE RESUS i.draw all 4 tubes/ABG ‐ Prepare intubation set  intubate if appropriate ‐ Start running IV fluids FAST i.e.2010 batch with contribution from TTSH.N H G ‐ Start BCLS – Start CPR.e.

ppt by exertion and relieved by GTN (2 out of 3). diaphoresis.g. heart sounds (?new murmur). peak 18-24hrs.g. serve GTN if PRN order available N H G ECG – (compare w/ prev ECGs) ST. LBBB) Cardiac enzymes (CEs) – TropI (detectable 4-6hrs. normalize after 1-2 wks). KTPH and NNI In PE – quick head to toe – including GCS. esophagus) y . T wave changes. CHEST PAIN Ask over the phone – vitals. not everyone needs 3 sets of CEs (the third set is indicated when pt has 20 By NHG IM Residents . tension pneumothorax ‐ GI: perf viscus (e.Cardiology A. how bad is the pain? SoB? Sweaty? 12-lead ECG. duration >15mins ed ic i Call senior for help if vitals unstable. peak 1236hrs. O2 if hypoxic. BP on both arms.g. aortic dissection ‐ Respi: PE. RR/R-F delay. CKMB (detectable 4-6hrs. normalize after 36-48hrs). BP on both arms. look for risk factors for IHD) and look at the ECG R es id en c Life-threatening causes ‐ Cardiac: ACS – AMI/NSTEMI/UA. perf peptic ulcer. JVP. acute abdomen. syncope. a/w nausea. radiation to jaw or left shoulder. crushing. new arrhythmias (e.2010 batch with contribution from TTSH. looks ill ne Eyeball the patient Read through the case-notes quickly (e. calves/LL te rn al M Hx – typical cardiac pain – retrosternal. SoB. creps.

anaemia ppt MI). UECr. PT/PTT/INR (will need if pt going for procedure). ABG (if unstable. desat or respiratory distress) st N H G In te rn al M ed ic i ne By NHG IM Residents . Ca/Mg/PO4 (if new arrhythmias). KTPH and NNI R es id en c y 21 . D-dimer (TRO PE in low risk patients. see pg 28).strong suspicion of an ACS but 1 2 sets of CEs are negative) **Trace the investigations you ordered! Consider – FBC (?bleed.2010 batch with contribution from TTSH.

keep SpO2 >95% ‐ Focussed hx and PE: Assess for left heart failure.2010 batch with contribution from TTSH. trace ECG. severe reactive airway dz ‐ IV morphine 2-4mg slow Q5-15mins ‐ Cover with PPI al M ed ic i ne By NHG IM Residents .Inform senior KIV arrange for urgent PCI (within 90mins) te rn ‐ FBC. atenolol 25mg if no heart failure.5mg up to x 3 ‐ PO aspirin 300mg STAT + 100mg OM (if no contraindications – e. baseline neurologic function (to watch signs of ICH later) N If NSTEMI/Unstable angina – Inform senior KIV urgent PCI if hemodynamically unstable or cardiogenic shock. bradycardia. ICH) ‐ Beta-blockers – e. PT/PTT/INR. ACUTE CORONARY SYNDROMES CTSP re: chest pain/SoB. trace CEs ‐ Inform senior immediately ‐ If dx in doubt but suspicion is high – repeat 12 lead ECG up to Q10mins ‐ Assess and stablise ABCs ‐ Supplemental O2 if pt hypoxic. add plavix 300mg STAT + 75mg OM. recent major GI bleed.g. cardiac enzymes.25-2. KTPH and NNI R es id en c 22 y . hypotension. UECr. heart failure. S/C clexane H G In If STEMI . hemodynamic compromise. GXM ‐ S/L GTN 0.5mg.B. bisoprolol 1.g.

8-1L/day. anaemia. iatrogenic (e. arrhythmias (e. hypo/hyperthyroidism. S3/S4.g. LVH. UECr. KTPH and NNI R es id en c y 23 . ACUTE DECOMPENSATED HEART FAILURE CTSP re: SoB.2010 batch with contribution from TTSH. AF). creps.hrly para + SpO2 ‐ KIV vasodilators.g. rhonchi or “cardiac asthma”).C. Low salt diet ‐ Daily weight N H G In te rn al M Ix ‐ ECG – e. ABG ed ic i ne Identify ppt factors ‐ Cardiac: ACS. T wave inversions. neurogenic (e. fluid resus. Q waves ‐ CXR ‐ FBC.g. bld transfusion) By NHG IM Residents . new case: “fluid overload” ‐ Hx/PE – frequently signs/symptoms of pulmonary edema (e. elevated JVP ‐ Consider non-cardiogenic pulmonary edema and other causes of symptoms – ARDS (e.g.g. UECr) – watch for response and titrate ‐ Close monitoring . CVA) Rx ‐ ABCs ‐ Supplemental O2 as required if hypoxic – keep SpO2 >9295% KIV NPPV/intubation ‐ Diuretics IV frusemide 20-80mg STAT + BD (watch BP. noncompliance. SoB. cardiac enzymes. inotropes ‐ Strict I/O – insert IDC if required ‐ Fluid restrict 0. renal impairment. pneumonia). fluid/diet indiscretion.g. progression of CCF ‐ Non-cardiac: severe hypertension.

HYPERTENSION CTSP re: BP >180/120 ‐ Differentiate HTN urgency (w/o end organ damage) vs HTN emergency (w/ end organ damage) Evidence of end organ damage ‐ Neuro: infarct/bleed/encephalopathy/papilloedema ‐ CVS: AMI/APO/Aortic dissection ‐ Renal: AKI Mx for HTN Emergency: ‐ Inform a senior ‐ Monitor hrly para. nausea/vomiting. peripheral pulses.2010 batch with contribution from TTSH.5-25mg ‐ Aim to reduce BP over hrs to days rn al M Quick assessment ‐ Symptoms – e. blds (e. blurring of vision.g.CT brain. lungs for creps. neuro exam. confusion ‐ Signs . vitals and recheck manual BP (on both limbs).g.5-5mg or captopril 12. GCS + initiate supportive Mx for complications ‐ Help to arrange for HD/ICU transfer ‐ Possible meds (will need at least HD usu) o IV GTN 5mcg/min up to 100mcg/min o Labetalol 20mcg bolus then 20 to 80mg Q10mins or 24 N By NHG IM Residents . JVP. review BP trend. KTPH and NNI H G In te Mx for HTN Urgency ‐ Serve anti-HTN meds early if near meds time ‐ Amlodipine 2. cardiac enzymes) +/. chest pain. headache.Assess ABCs. pedal edema.D. UECr. fundoscopy for papilloedema ‐ ECG. GCS. CT aortogram ed ic i ne R es id en c y .

o o 0. KTPH and NNI R es id en c 25 y .2010 batch with contribution from TTSH.5 to 2 mcg/min IV hydralazine 10mg bolus (up to 20mg) st Aim for 10% BP reduction in 1 hr then additional 15% in next 2-3hrs N H G In te rn al M ed ic i ne By NHG IM Residents .

consider inotropes (i. ESRF (i. KTPH and NNI R es id en c 26 E. neurogenic) ‐ Ask other vital signs. GCS.e. dopamine up to 20mcg/kg/min) N H G In te rn al M Ix (as indicated) ‐ FBC.5) but still hypotensive. also obstructive. SoB). end organ damage from any cause (commonly hypovolemic. risk factors for fluid overload) ‐ If pt unstable or doesn’t respond to fluid challenge. PE (include assess fluid status.GXM. 500ml over 15-30mins over the phone and see the pt ASAP/early ‐ Look through case notes looking particular for hx of CCF. PT/PTT +/. CCF/poor EF.Mx ‐ Hrly para+SpO2 ‐ Strict I/O (insert IDC or at least urosheath) ‐ Large bore IV plug (x2 if pt unstable) ‐ Contd fluid resuscitation ‐ Look through eIMR – off anti-hypertensives ‐ If pt already beginning to show signs of pulmonary edema/fluid overload or pt high risk (elderly. septic. septic w/u ‐ ECG + CEs ed ic i Evaluation – Hx (chest pain. DRE) ne By NHG IM Residents .e. UECr.e.2010 batch with contribution from TTSH.e. resus status over the phone ‐ Order a fast drip – i. anaphylactic. ESRF) and already given large volumes of fluid (>1-1. cardiogenic. usual BP trend. inform senior y . HYPOTENSION CTSP re: BP low ‐ Exclude SHOCK i.

pain ‐ Hypovolemia/shock from various causes (e. atenolol 25mg if no cardiac failure.g. sepsis). bisoprolol 1. AV block. electrolyte abnormalities ‐ Drugs (e. severe reactive airway dz ‐ Digoxin (AF w/ cardiac failure) – e. IV 250mcg. hypoglycemia. KTPH and NNI R es id en c 27 y . review 4-6hrs later. Fast AF. see pt soon + ask for ECG Assess for underlying cause. anaemia ‐ Cardiac –e. VT/VF – may be ppt by cardiac or non-cardiac causes ‐ Pulmonary embolism ‐ Hyperthyroidism. 100J. atrial flutter. smoking) ‐ Anxiety/Panic attack Mx of fast AF ‐ Determine if it is new onset – unlikely but if new onset AF KIV pharmacological or electrical cardioversion ‐ If hemodynamically unstable – sedate & electrical cardioversion (50J.F. acute MI. SVT. thyroid dz.g. KIV add 125mcg. GCS. usual trend of HR If unstable. monitor with defibrillator) N H G In te rn al M If ECG not sinus tachycardia. TACHYCARDIA CTSP re: HR >100-120 Ask for other vitals.g. see immediately + ask for E-trolley/defibrillator + inform senior If pt stable. ABCs.g. caffeine. 150J) until sinus rhythm ‐ If stable for rate control consider: ‐ Beta blockers – e. common causes: ‐ Fever.g. inform senior ASAP See ACLS (pg 30) ed ic i ne By NHG IM Residents .2010 batch with contribution from TTSH.25mg. review 4-6hrs later KIV add 125mcg (!caution – if WPW. salbutamol nebs.

‐ Ca channel blockers – e. fast AF) or too slow (e. recent NSTEMI.g. level 8.e. severe hypokalemia) o Look for ischemia on 12-lead ECG (may be missed on telemetry) o Continue Mx . heart block) N H G In te rn al M ed ic i APPROACH TO CTSPS FOR TELEMETRY ‐ If you cover wards with telemetry (e. multiple PVCs. ask for a 12 lead ECG ‐ If unstable or symptomatic – inform senior ‐ If stable o Read through case notes to find out WHY pt is on telemetry (e. sinus bradycardia. 13) – may be called to review pt who had abnormal rhythms detected on telemetry ‐ Can be either too fast (e. sinus pause. verapamil. diltiazem (!caution – cardiac failure.g.g. correct electrolytes ne By NHG IM Residents .2010 batch with contribution from TTSH. heart blocks) ‐ Check pt’s vitals.g.g. GCS and for any symptoms. KTPH and NNI R es id en c 28 y .g.

KTPH and NNI In te rn al M ed ic i ne R es id en c 1 1 1 1 1 1 -2 y . ≤0pts – low Points 1 1 N H G Ix ‐ FBC. (may not change Mx) ‐ US LL venous system Mx ‐ S/C clexane 1mg/kg BD (! Bleeding. erythema Wells Score for DVT Findings Paralysis.g.2010 batch with contribution from TTSH. lupus anticoagulant – for “unprovoked” or recurrent venous thromboembolism or in young pts – need to be done before pt started on anticoagulation. 1-2pts – mod. paresis. Protein C. DVT/PE Hx – Unilateral LL swelling. Baker’s cyst) *Probability ≥3pts – high. D-dimer (to rule out if pt is low risk on Wells score) ‐ +/. pain. 29 By NHG IM Residents .e.Thrombophilia screen (i. anti-cardiolipin. recent ortho casting of LL Bedridden for >3 days or major surgery within past 4 weeks Localized tenderness in deep vein system Swelling of entire leg Calf swelling >3cm other LL measured 10cm below tibial tuberosity Pitting edema greater in symptomatic leg Collateral non-varicose superficial veins Active Ca or Ca treated within 6 months Alternative diagnosis more likely (e.G. PT/PTT/INR. low Hb) ‐ Prevention! – TED stockings etc. APC resistance. cellulitis. Protein S. tenderness.

UECr. ABG. chest pain. inotropes as indicated ‐ If stable . transfer pt to HD/ICU. ABCs. tachycardia. KTPH and NNI In Ix ‐ FBC.5 1 1 y . 2-6 – mod.2010 batch with contribution from TTSH. KIV thrombolysis or embolectomy ‐ hrly paras. fluids.‐ KIV IVC filter if not candidate for clexane (low Hb.S/C clexane 1mg/kg BD (! Renal adjust) 30 By NHG IM Residents .5 1. ≤1 – low N H G Mx ‐ If unstable – Inform senior. DVT symptoms. but will not relief local symptoms) Hx/PE ‐ High index of suspicion – SoB. high fall risk etc. D-dimer (to rule out if pt is low risk on Wells score) ‐ ECG + CE ‐ CXR (to exclude other resp causes) ‐ CT pulmonary angiogram (will need green plug) ‐ KIV 2DEcho te rn al M ed ic i ne R es id en c Points 3 3 1.5 1. relatively clear lungs Wells Score for PE Findings Symptoms of DVT No alternative dx that better explains dz Tachycardia >100 Immobilization ≥3 days or surgery in prev 4 weeks Prev hx of DVT/PE Presence of hemoptysis Presence of Ca *Probability: ≥7pts – high.

H. KTPH and NNI R es id en c 31 y . ACLS protocols N H G In te rn al M ed ic i ne By NHG IM Residents .2010 batch with contribution from TTSH.

N H G In te rn al M ed ic i ne By NHG IM Residents . KTPH and NNI R es id en c 32 y .2010 batch with contribution from TTSH.

2010 batch with contribution from TTSH.N H G In te rn al M ed ic i ne By NHG IM Residents . KTPH and NNI R es id en c 33 y .

KTPH and NNI R es id en c 34 y .N H G In te rn al M ed ic i ne By NHG IM Residents .2010 batch with contribution from TTSH.

shock (e. associated symptoms (e. myasthenia More benign causes (but still must be addressed): ‐ Anxiety.g. stridor/wheezing /silent chest Inform senior early if any doubt!! 35 By NHG IM Residents . chest pain. pain ‐ ARU.g. ascites ‐ Symptomatic anemia. thyrotoxicosis ‐ Others: anaphylaxis w/ bronchospasm. DKA). PE. hyperventilation fever. Pneumonia (maybe aspiration??). upright/tripod position. diaphoretic. short words. COPD/asthma attack. cough. use of accessory muscles and retractions. hypovolemic) ‐ Metabolic: Acidosis (e. Poisons (e. GBS. constipation?? Hx ‐ Onset. arrhythmias.Respiratory Medicine A. salicylates).g.g.vitals (SpO2 especially!!). main diagnoses.2010 batch with contribution from TTSH. any other concurrent symptoms Important (life-threatening) causes: ‐ Cardiac: AMI. KTPH and NNI N H G In te rn al M ed ic i ne R es id en c y . hemoptysis) ‐ Quickly review case notes/CPSS. APO. pleural effusion ‐ GI: BGIT. inability to sustain respiratory effort. ADHF/CCF. SHORTNESS OF BREATH/DESATURATION CTSP pt c/o SoB. pt desaturated on VM50% ‐ Generally should see ASAP ‐ Over the phone . I/O charts. latest bloods/CXR PE ‐ !ALERT – AMS. patient’s general condition. tamponade ‐ Pulmonary: Pneumothorax. DIL status. cyanosis.

fluid resus. predispose to arrhythmias) ‐ Always interpret ABG with knowledge of the FiO2 (key amt of O2 supp pt is on into special instructions of AURORA so other people will know) ‐ To assess the severity of hypoxia. UECr.BNP. review patient frequently prn ‐ FBC.2010 batch with contribution from TTSH. KTPH and NNI R es id en c Orders (as indicated) ‐ Hrly paras.24-50% Non-rebreather mask (NRM) – 60% (2 valve leaflets are taken off). calculate the PaO2/FiO2 ratio. 80%. D-dimer GXM ‐ ECG + cardiac enzymes ‐ CXR ‐ Supplemental O2 (≥95%.e.g. o PaO2/FiO2 < 300: acute lung injury o PaO2/FiO2 <200: ARDS ‐ Type 1 RF: pO2<60mmHg. pCO2 >50 mmHg N H G In te rn al M ed ic i ne Supplemental O2 devices and est. +/. 100% By NHG IM Residents . clear desaturation on SpO2. lasix for APO (Note: Giving nebs to pt with cardiac wheeze without diuresis may worsen CCF.g. ABG (if indicated e. doubt re: SpO2 reading. SpO2 100% on 100% NRM means nothing if the underlying cause is not addressed) e. history of Type 2 RF/ recent deranged ABGs). normal/low pCO2 ‐ Type 2 RF: pO2 <60 mmHg. FiO2 INO2 – up to ~40% .‐ Treat underlying cause (i. 90-92% in COPD pts) y 36 .max 4-6L VM . CRIB.

PE.g.g. pneumonia. background Stage 3-4 COPD) CXR *Sputum c/s not indicated unless there are CXR features suggestive of pneumonia and patient is able to produce good sputum for specimen collection ‐ (Sputum gram stain and C/S is not ordered for infective exacerbation of COPD if CXR does not show presence of consolidation.7 AND Stage 1 FEV1 >80% predicted Stage 2 FEV1 50-80% predicted Stage 3 FEV1 30-50% predicted Stage 4 FEV1 <30% predicted or <50% w/ chronic resp failure ed ic i ne By NHG IM Residents . unknown ‐ Consider other causes of SoB – e.2010 batch with contribution from TTSH. social Hx y 37 . PTX ‐ Other points – LTOT at home? Prev intubations/ICU adm. SoB in existing cases ‐ Acute exacerbation = acute increase in symptoms beyond normal day-to-day variation (cough frequency and severity. bacterial (1/3 to ½ of cases).CEs te rn al M Staging on lung function test: FEV1/FVC<0. asthma.bld c/s ABG (e. ACUTE EXACERBATION OF COPD CTSP new case. bronchiectasis.N H G In Ix ‐ ‐ ‐ ‐ FBC. pulmonary edema/CCF. sputum volume and character/purulence. non-compliance to meds. environmental factors. UECr +/. Urinary Strep/Legionella Ag only ordered for CAP and not COPD exacerbation) ‐ ECG +/. SoB) ‐ Ppt factors: infection – viral (1/3 to 2/3 of cases). KTPH and NNI R es id en c B.

of L of O2) (Very rough estimate .N H G In te rn al M Rx ‐ O2 – aim SpO2 >92% (For pts with chronic T2RF with or without LTOT SpO2 >88% may suffice).g. pCO2 >50 and patient’s clinically worsen eg increasing drowsiness despite Mx) or intubation if severe (inform senior if patient unwell or does not respond to initial Mx) ed ic i ne By NHG IM Residents .g. ‐ PO prednisolone 30mg 1/52 or IV hydrocortisone 100mg 6hrly (if unable to tolerate orally) ‐ Mucolytics (e.dependent on RR of patient) ‐ Nebs salbutamol:ipratropium:N/S (1:2:1) stat and Q4-6H. augmentin/klacid)– if increase sputum purulence + SOB or increase sputum volume ‐ KIV NPPV (e. Up to 2 stat nebs can be given to break bronchospasm. PAO2 >60mmhg – w/ Venturi mask (more precise control of FiO2) or INO2 (more comfortable) FiO2 by INO2 = 21 + Ax4 (where A=No. fluimicil) – no evidence but can be given for symptom control ‐ Antibiotics (e.g. pH <7. KTPH and NNI R es id en c y 38 .33.2010 batch with contribution from TTSH.

g PTX. UECr +/. inability to lie down.ABG ‐ CXR ‐ ECG +/. speak in words/short phrases.2010 batch with contribution from TTSH. Self-rating of asthma Not Poorly SomeWell Complet controlled what e If ACT<20 = not controlled te rn al M ed ic i ne R es id en c C.!!ALERT using accessory muscles. profound diaphoresis. KTPH and NNI In Asthma control test: In past 4 weeks Points 1 2 3 4 5 1.CEs 39 By NHG IM Residents . atopy Ix ‐ FBC. AMS. ACUTE EXACERBATION OF ASTHMA CTSP new case. failure to improve w/ initial Mx. pneumonia. CCF/APO y .N H G ‐ Other points – prev intubations/adm to hosp/EDs (may not be recorded in prev d/c summaries). Wake up at night or earlier than usual >=4x/wk 2-3x/wk 1x/wk 1-2x /mth None 4. How often use rescue inhaler or nebs >=3x/day 1-2x/day 2-3x/wk >=1x /wk None 5. How often asthma limited activity at work or home All the Most of Some of A little of None of time the time the time the time the time 2. How often SoB >1x/day 1x/day 3-6x/wk 1-2x/wk None 3. rising pCO2 ‐ Exclude ddx of SoB – e. cyanosis. SoB in existing cases ‐ Assess severity of attack .

KTPH and NNI R es id en c 40 y . Beware of higher freq of nebs in the elderly).‐ Peak flow (seldom used as pt not always able to cooperate – drop of 20% from normal/personal best =exacerbation. ‐ +/. 1:2:1) ‐ PO prednisolone 30mg OM or IV hydrocortisone 100mg 6Hly (if unable to tolerate orally) ‐ Reassess pt frequently PRN to monitor response ‐ KIV IV MgSO4 2g over 20mins ‐ KIV intubation if severe (inform senior if patient unwell or does not respond to initial Mx) N H G In te rn al M ed ic i ne By NHG IM Residents . drop of >50% = severe exacerbation) Rx ‐ O2 – keep O2 >92-95% ‐ Nebs salbutamol: N/S (1:3 stat and every 4 to 6Hly depending on severity.2010 batch with contribution from TTSH. Up to 3 stat nebs can be given to break bronchospasm if no contraindications.add ipratropium nebs (i.e.

acute neurovascular syndrome ‐ Ascertain time of onset: within 4. AFib /mitral stenosis /prosthetic heart valves /CCF stigmata of IE (all of which may suggest cardioembolic source). Cardiac enzymes (3-4% have intercurrent MI) ‐ Lipid panel/HbA1c CM if not up to date. NBM + IV NS 2L/day unless CCF/renal impairment (risk of asp).5 hours of onset.2010 batch with contribution from TTSH. avoid hyperglycemia which can worsen stroke penumbra. UECr.Orders ‐ Hrly paras. CEREBROVASCULAR ACCIDENT (CVA) CTSP: critical abnormal CT/MRI head result. LFT. IN O2 if SaO2<90% ‐ FBC (before starting antiplatelets). ACA. CLC monitoring. carotid bruit y 41 . thrombophilia evaluation if patient is young ‐ KIV Doppler carotid US + TCD with bubble contrast + 2DEcho CM ‐ Check CBG. Syphilis IgG LIA. <8hours consider MERCI/TREVO) barring contraindications ‐ Determine handedness ‐ Examine patient for focal neurology congruent to site of CVA. KTPH and NNI R es id en c Neurology A. keep CBG between 4-8mmmol (use SC insulin if CBG > 10 mmol/L) N H G In te rn al M ed ic i ne By NHG IM Residents . call Dr if GCS drop >2 (see below). LA. fasting glucose if not evaluated before ‐ PT/INR (should pt need warfarin/thrombolysis and in hemorrhagic CVA) ‐ KIV ESR. fasting homocysteine. inform NL stat as pt may be for IV thrombolysis (<6hours can offer IA thrombolysis.

new CVA. hyperviscosity syndrome and complications of CVA (cerebral edema.N H G In te rn ‐ SAH necessitates urgent NS referral. obstructive hydrocephalus). progression of thrombosis. Consider decompression craniectomy if <48 hours from onset for malignant MCA infarction. ne By NHG IM Residents . load with PO aspirin 300mg stat and subsequently 100mg OM.2010 batch with contribution from TTSH. aspiration pneumonitis). KTPH and NNI R es id en c ‐ If hemorrhagic CVA: Keep SBP ~140-150mmHg with PO amlodipine. electrolyte imbalance. post. arrhythmia. omit BP meds and allow permissive hypertension unless SBP >220mmHg/DBP >120mmHg or hypertensive encephalopathy/crisis y 42 . start PO clopidogrel 75mg OM. (some given PO simvastatin/atorvastatin 80mg stat). history of active PUD or low Hb/plts. AMI.ictal state. infection (UTI. hemorrhagic conversion. consult senior for NSD intervention ‐ If ischaemia CVA: if no BGIT. pt would need to be started on PO nimodipine and require a 4-vessel angiogram KIV clipping/coiling al M ed ic i ‐ Fall in GCS or deterioration in neurological status consider: hypoglycemia. hypotension. otherwise.

acidosis. check vitals. fit chart. turn to left lateral. UECr. Cl. aborted spontaneously or by BZDs/AEDs Causes ‐ Known epileptic: non-compliance. drug interactions reducing [AED] AND also causes listed below ‐ Non-epileptic: infection. alcohol withdrawal. CVA. give INO2 (give IM/IV 2. CLC charting. toxicology screen. drugs. (call dr if GCS drops >2). electrolyte abnormalities. HI Orders ‐ Insert IV cannula (may need for further meds) ‐ Review hypocount results (correct if needed) ‐ ECG after seizure aborted: arrhythmias/heart block (Stokes-Adams attack) ‐ FBC. Ca/Mg/Po4.B. ABG +/.AED levels. sleep deprivation. keep NBM + drip ‐ IV thiamine 100mg in cirrhotics/alcoholics N H G In te rn al M ed ic i ne By NHG IM Residents . recent change in meds.5mg diazepam for GRM pts due to low volume of distribution and lower hepatic metabolism) ‐ Document seizure type (generalized/partial.(anion gap).2010 batch with contribution from TTSH. ‐ KIV CT head plain (to check with MO) ‐ Hrly para. SpO2 . intracranial mets. SEIZURES CTSP pt having seizures . hyperammonemia.?active or aborted Orders over the phone: stat hypocount. hypoxemia. complex/simple). intercurrent illness. uraemia. KTPH and NNI R es id en c y 43 . duration and number of seizures. prepare IV/IM 5mg diazepam (ward does not stock up rectal diazepam or lorazepam).

or recurrent seizures with no recovery of consciousness in between (status epilepticus)  escalate to MO to consider NL referral and to start loading with IV 1820mg/kg phenytoin infusion (must monitor HR. KTPH and NNI R es id en c y 44 . BP. if not consider neuroimaging or flumazenil if more than one dose of BZD given (consult MO) ed ic i ne Also consider phenytoin if there is a known CNS problem (eg. give IV 5mg diazepam again When to be concerned rd . SOL in brain) & this is pt’s 1 seizure – discuss with MO By NHG IM Residents .2010 batch with contribution from TTSH.3 seizure within 30min . st Meningitis.seizure lasts >5 min. RR. Max rate is 50mg/min) N H G In te rn al M *Pt should become more alert post-ictally in a few hours.‐ Usually early EEG done only during office hours If second seizure.

HTN. failed on dialysis or being planned for dialysis. PD. iPTH (if not done for 3 months KIV repeat).e. AVG – if perm cath – date when it was inserted o Last dialysis when – completed? (usually 4 hrs) o Latest dry weight y 45 . NKF AMK Ave 1 1.If PD: o For how long? o CAPD or APD? What regime? o Care-giver? o PD book available – usual UF? Missed exchanges? o Previous peritonitis or problems with PD? ed ic i ne By NHG IM Residents . GN ‐ Follow-up with? ‐ RRT since when? What type of RRT – HD. or allograft dysfunction – previous renal function? o Previous infectious complications? o Previous rejections? Or Allograft biopsies? o Complications from immunosuppression? ‐ Last Ca/PO4/Fe/TIBC/ferritin (if not done for 1 month KIV repeat).e.3. Perm cath. AVF. CLERKING NEW RENAL CASES Things to note for ESRF patients ‐ Reason for ESRF? . transplant? ‐ If HD: o HD where.g. living related from who.g. KTPH and NNI R es id en c Renal/Electrolytes A.5 o HD which vascular access – e.2010 batch with contribution from TTSH. DM nephropathy. which days? . overseas from where? Follow-up where/who? o How long ago was the transplant? o What immunosuppression – usually on three types? o Transplant functioning.g. N H G In te rn al M .If transplant: o What kind of transplant – deceased..

g. blocked TK catheter o Infection: Fever/chills during dialysis. AVF/AVG thrombosis. poor blood flow (QB) ‐ Dialysis centres may change patient’s meds or give meds not reflected in discharge meds (e. such as pericarditis. neuropathy. shortened dialysis times.g. IV calcijex 1x/month) ‐ Non-urgent bloods can be deferred to be taken pre-HD in next HD except PT/PTT/INR Indications for urgent dialysis ‐ Refractory fluid overload ‐ Refractory hyperkalemia or rapidly rising potassium levels ‐ Signs of uremia.summary of previous failed vascular access.Metabolic acidosis (pH less than 7. o Other medical conditions – e. PD peritonitis o Hypotension/giddiness during dialysis – whether high intradialytic weight gain. pneumonia ‐ DO NOT TAKE BLOOD FROM PERM CATH! (OR THE RENAL TEAM WILL KILL YOU) ‐ **esp when writing blue letters – may need to call dialysis centre for more details re: any issues during dialysis e. hypotension.2010 batch with contribution from TTSH.Certain alcohol and drug intoxications N H G In te rn al M ed ic i ne By NHG IM Residents .1) ‐ +/. KTPH and NNI R es id en c y 46 . problems with dialysis o Always assume cardiac event if patient presents with SOB or low BP if on regular dialysis. previous line sepsis and organisms ‐ Common reasons for admission o Mechanical issues: Blocked perm cath.g. or an otherwise unexplained decline in mental status (uraemic encephalopathy) ‐ +/.‐ +/.

PT/PTT. KTPH and NNI R es id en c 47 Assess for causes ‐ Pre-renal (decreased renal perfusion) . GN. ACE-Is/ARBs) ‐ Strict I/O charting ++/. Uncontrolled HTN etc. UECr. urine PCR. ‐ Renal . mental status. vitals . IV hydration for dehydration.2010 batch with contribution from TTSH. drugs ‐ Post-renal – obstruction y . Dehydration). CXR.g.FBC.B.Shock (Sepsis.May be called for rising Cr trend. UFEME. AMS.Differentiate acute vs chronic N H G In te rn Orders ‐ Reverse reversible causes (e. NPU or low urine output.insert IDC ‐ KIV Ix . ACUTE KIDNEY INJURY . fluid overload symptoms (SoB etc) . ECGs +/cardiac enzymes. AIN.Assess ABCs.ATN. ABG. urgent U/S kidneys ‐ May need urgent dialysis (see above) al M ed ic i ne By NHG IM Residents .g. Ca/PO4. Insert IDC for obstruction) ‐ Review medications – take off nephrotoxic medications (e.

can try to deflate balloon and manipulate IDC (!aseptic technique and not to re-inflate balloon in urethra) KIV change IDC N H G In te rn al M Assess for common causes of ARU – constipation. urine c/s) and Mx (e. KTPH and NNI R es id en c 48 y .2010 batch with contribution from TTSH. try different sizes. blockage etc. nelaton catheter but careful not to create false track Sometimes a larger IDC may be easier to insert as the tip is firmer If NPU and IDC in-situ ‐ Assess for blocked IDC ‐ Palpate for bladder.g.order Ix (e. LOW URINE OUTPUT/URINE CATHETERS ‐ If NPU > 12hrs – do random RU ‐ Assess patient’s fluid status If NPU +/. BPH +/.C.g. otherwise can try potting patient. CIC if recurrent ‐ RU <150ml – watch or pot patient If difficult catheterization. clear bowels) ed ic i Document IDC insertion – indicate if there were difficulties with catheterization ne By NHG IM Residents . UTI.palpable bladder + if RU ‐ >300ml – insert IDC ‐ 150-300ml – “gray area”. IDC indicated for: symptomatic patients. repeat until both in and outflow is smooth) ‐ If unable to get smooth flow. along length of tube to urine bag ‐ Flush IDC (using aseptic technique. flush 20-30ml of sterile normal saline with large tipped 50ml syringe. UFEME. bladder scan ‐ Look for kinks.

g. refer uro urgent KIV suprapubic catheterization If NPU + no bladder + dehydrated = hypovolemia ‐ Look through I/Os ‐ Fluid challenge (e. change to a 3-way catheter and perform manual bladder washout (MBWO) until urine clear and flow smooth KIV continuous bladder washout (CBWO) ‐ If all else fails. 500ml N/S over 1-4hrs) ‐ Watch for urine output N H G In te rn al M ed ic i ne By NHG IM Residents .‐ If clots or sediments present and unable to get smooth flow.2010 batch with contribution from TTSH. KTPH and NNI R es id en c 49 y .

KIV dextrose drip if CBG<6 or patient at risk of hypogly o PO/PR resonium STAT and tds x 1/7 o Stop all medications tt can increase K (e. repeat above +/.D. KTPH and NNI R es id en c 50 y . ventolin nebulizer or dialysis (urgent referral to renal). repeat IV Calcium Gluconate dose o Otherwise repeat ECG in 1hr and K in 2 hours rn al M ed ic i ne By NHG IM Residents . hemolysis) KIV repeat K 6-6. or high risk pts (e. IHD): o to do above and o IV Ca gluconate 10% 10ml over 2-3 min (** check if patient is on digoxin o Close monitoring with telemetry bed o Repeat ECG in 10 mins to check for resolution.2010 batch with contribution from TTSH.g.IV lasix.5: o IV soluble insulin 5-10U with IV dextrose 50% 40ml SLOW over 5 mins o D50 can be omitted if CBG>18. if not. ACE/ARB.g.5 or ECG changes. HYPERKALAEMIA Vital signs. K drip) o CBG q1 hr x 6H (12H if renal failure) o Keep hrly para till resolution o Repeat K and ECG in 4 hours N H G If persistent.g. order ECG. CBG and hyperK protocol Exclude spurious result (e. refer dietician if repeated In te K>6.

In te rn If hypokalaemia with metabolic acidosis Think of conditions with both K and bicarbonate loss/H+ retention e. RTA. intracellular shift and renal loss without significant bicarbonate loss e. Hypercortisolic states ‐ Check blood for magnesium. muscle cramps. renal (e. renin-aldosterone levels and ratio.2010 batch with contribution from TTSH.g. KIV additional Ix such as urine K. hyperthyroidism. HYPOKALAEMIA ‐ Look for symptoms and complications: constipation. Conn’s. Acute diarrhoea al M ed ic i E. Beware of digoxin toxicity in the presence of hypokalaemia (Keep K ≥4) ‐ Look for possible source of loss: GI (e. ST depression. especially if the blood is drawn immediately after dialysis ‐ Patients on Peritoneal Dialysis usu need regular K supp 51 By NHG IM Residents . large/wide P wave.if high. increased QT interval. arrhythmia ne R es id en c y . KTPH and NNI N H G If hypokalaemia with metabolic alkalosis Think of hypoMg. weakness) ‐ Check ECG for U waves (V4-6).g. muscle weakness. diuretics) ‐ Look for possible causes of intracellular shift: insulin therapy.g. ‐ Check medications. beta 2 agonist therapy ‐ Check BP . RAS.Other Considerations ‐ Keep K >/= 4 in patient with digoxin ‐ Usual to have hypokalemia after haemodialysis. arrhythmias. diarrhea). Watch for respiratory muscle weakness if hypokalaemia is severe. bicarbonate and creatinine kinase (if muscle aches. ectopics. may need to consider: Hypertension with diuretic use. rhabdomyolysis. T inversion. diuretic use.g. etc.

those with ECG changes or those who need rapid replacement (> 10 mmol/hour) – consider cardiac monitoring (either telemetry or in high dependency) ‐ Review medication list ‐ Correct hypomagnesaemia rn al M ed ic i ne By NHG IM Residents . 2/7) ‐ Correct hypomagnesaemia ‐ Recheck after replacement N H G In te If symptomatic/K<2.5: ‐ PO Span-K 1-2 tab OM to BD (large tablet. then recheck symptoms/ECG/K 2 hrs later ‐ Rate of replacement should not be more than 10 mmol/hour ‐ Patients with critical hypokalaemia (< 2 mmol/l).2010 batch with contribution from TTSH.4 28 10 10 10 If asymptomatic/K>2. cannot be pounded) or mist KCl 5-10ml tds (bitter) for a fixed duration (e.g.6 gram Mist KCL 10 ml Potassium Citrate 10 ml Potassium Citrate 1 tablet IV 7.Potassium Replacement PREPARATION Span K 0.45% KCL 10 ml IV KH2PO4 10 ml K (mmol) 8 13. KTPH and NNI R es id en c 52 y .5/ECG changes: ‐ Replace 3 cycles pre-mixed KCl (10 mmol of KCL in 100 mls normal saline).

Hyperralodsteronism Extra-renal – GI. coma. it is best to correct the sodium slowly to prevent cerebral oedema and convulsion. osmotic diuresis. Correct underlying cause 2.e. Causes Hypervolemic Hypertonic saline. Correct hyperosmolar and hypernatremic state In te Symptoms: Increased thirst. seizures rn al M ed ic i ne Renal loss Diuretics. which can result from a net water loss (majority of cases) or a hypertonic sodium gain.F. KTPH and NNI H G Management: 1. nephrogenic) R es id en c Euvolemic or Hypovolemic y . HYPERNATREMIA Represents a deficit of water in relation to sodium stores. AMS. Cushing’s. developed over a few hours.2010 batch with contribution from TTSH. skin loss N ‐ Rate of Correction: Unless we know for sure that the hypernatremia is acute i. 53 By NHG IM Residents . diabetes insipidus (central.

where F=0.5 in non-elderly women and F=0. Change in serum Na = ((Infusate Na+ Infusate K) – Serum Na) ÷ (#Total Body Water + 1) (#Total body water = F x Body Weight -. Normal saline is used only if there is significant hypotension from dehydration.Serum Na) ÷ (#Total Body Water + 1) ed ic i Step 1: Decide on the infusate and estimate the effect of 1 litre of the infusate on the serum sodium ne By NHG IM Residents .5 in elderly men and 0.45 in elderly women) Step 2: Determine rate of infusion – usual target is to reduce serum sodium by no more than 10 mmol/l over 24 hours Volume of Infusate required = 10/Change in serum Na (Change of Na was determined at step 1) In te rn al M Change in serum Na = (Infusate Na .‐ Maximum rate: 0. INFUSATE Dextrose 5% 0.33% NaCl/Dextrose 5%/10mmol KCl N H G OR if using infusate with potassium. 0.45% NaCl 0.6 in nonelderly men.5 mmol/l/hour or 10 mmol/l/day ‐ Goal: reduce sodium to 145 mmol/l Calculation of Infusate (for those with net water loss) ‐ Preferred route of administering fluids is oral or NG ‐ IV fluids are used if the above are not feasible. ‐ Only hypotonic fluids are appropriate.2010 batch with contribution from TTSH. KTPH and NNI R es id en c Na (mmol/l) 0 77 56 54 y .

2010 batch with contribution from TTSH.5 Litres (to compensate for ongoing obligatory fluid and electrolyte loss) Caution if pt has CCF or CKD (!fluid overload) Monitor the serum sodium closely and adjust the volume and rate of infusate accordingly. N H G In te rn al M ed ic i ne By NHG IM Residents .Step 3: Determine total volume of infusate to be given over 24 hours Total volume to be administered over 24 hours = Volume of infusate required (determined at step 2) + 1. KTPH and NNI R es id en c 55 y .

56 By NHG IM Residents . KTPH and NNI In Pertinent Laboratory Investigations .Exclude errors in collecting the blood sample.Plasma glucose . hyperproteinemia or hyperlipidemia .Assess the patient’s extracellular fluid volume status ne R es id en c G.Thyroid function test and evaluation for hypocortisolism te rn al M ed ic i At the bedside . (Must discuss with senior) Goal to increase serum sodium to abort symptoms eg seizures or to increase serum sodium to >120mmol/l to avoid cerebral edema.Determine the acuity or chronicity of the hyponatremia as this determines the severity of symptoms and the appropriate rapidity to which the hyponatremia should be corrected y . HYPONATREMIA Approach to Severe Hyponatremia .Check for medications which can cause hyponatremia .Plasma osmolality .Urine osmolality .U/E/Creatinine . Exclude pseudohyponatremia: hyperglycemia.Ascertain conscious level and neurological status .2010 batch with contribution from TTSH.Urine sodium concentration . especially in a well patient with an extremely low serum Na+.Take history with regards to fluid intake and loss .N H G Acute Symptomatic Hyponatremia (<48hrs) This is an indication for the use of hypertonic saline.Determine if patient has symptoms attributable to severe hyponatremia .

9% Saline at 60mls/hr may be appropriate. Use of hypertonic saline is not warranted. Rates of correction: ‐ Acute symptoms (eg seizures) 2-4 mEq/L per hr ‐ Symptoms 1-2 mEq/L per hr ‐ Mild symptoms 0.Typical volumes used: Single infusion of 100 to 200 mls of 3% Saline over 1 to 2 hrs.2010 batch with contribution from TTSH. a maintenance IV 0. Frequent monitoring of sodium eg at 2hrs then 4 to 6 hrly. Chronic Asymptomatic Hyponatremia Most patients with a serum sodium concentration greater than 125 mmol/l or with chronic hyponatremia do not have neurologic symptoms. KTPH and NNI R es id en c y 57 . Consider the use of hypertonic saline in severe symptoms.5 mEq/L per hr 1 liter of 3% Saline contains 513 mmol of sodium 1 liter of 0. In hemodynamically stable patient. Treatment is directed at the underlying cause after appropriate investigations. Limits of therapy are to raise the serum sodium concentration by less than 12 mmol/l in the first 24 hours and less than 18 mmol/l in the first 48 hours. do not presume the cause is SIADH*. Frequent monitoring of sodium eg 4 to 6 hrly. (Must discuss with senior) A calculation of the appropriate infusion rate and amount should be made. Rule out true volume depletion/dehydration. Chronic Symptomatic Hyponatremia (>48hrs) Increased risk of irreversible osmotic demyelination.9% Saline contains 154 mmol of sodium N H G In te rn al M ed ic i ne By NHG IM Residents . On a night call.

2010 batch with contribution from TTSH. haemorrhage and brain tumours). SSRIs. endurance exercise and general anaesthesia. pulmonary disorders (eg pneumonia.N H G In te rn al M ed ic i ne The causes of SIADH include medications (eg TCA. By NHG IM Residents . disorders of the central nervous system (eg bleeding and masses such as subdural hematoma. lung carcinoma) and transient causes such as nausea. y 58 . the patient has to be euvolemia and have no other causes of euvolemic hyponatremia such as hypothyroidism and hypocortisolism. The diagnosis is made in a patient with true plasma hypo-osmolality (< 275 mOsm/kg H2O) with inappropriate urinary response to hypo-osmolality (urine osmolality > 100 mOsm/kg H2O). pain. antipsychotics). stress. In addition. tuberculosis. KTPH and NNI R es id en c *SIADH is a diagnosis of exclusion.

malignancy induced osteolytic bone activity Orders: ‐ Assess ABCs. (May contribute to electrolyte disturbances) ‐ Steroids for hypervitaminosis D. KTPH and NNI R es id en c y 59 . ECG (look for shortened QT) ‐ IV fluid hydration is the cornerstone of treatment ‐ In tolerant patients. nephrogenic DI and dehydration ‐ Calculate corrected Ca = [(40-Alb) x 0. HYPERCALCEMIA Symptoms: stones. UECr. groans. aim for total fluid intake >= 3 liters/day ‐ In symptomatic or severe hyperCa >= 3. malignancy associated PTHrp secretion ‐ iPTH independent (PO4 is usually high/normal): dehydration. fluid and neurological status ‐ Paired Ca panel and serum iPTH.5mmol/l. sarcoidosis. Effect peaks in 5 to 6 days) IV Zoledronate 4mg over minimum 15mins OR IV Pamidronate 60mg in 500mls NS as a slow infusion over 4 hrs (Renal impairment is a contraindication) o If well hydrated. Mg. FHH. bone mets & sarcoidosis ‐ Treat underlying etiology N H G In te rn al M ed ic i ne By NHG IM Residents . bones and psychic moans. Consider: o IM/SC/intranasal calcitonin 200 -400 units/day in 2 divided doses (Tachyphylaxis develops in 48 to 72 hrs) o IV Bisphosphonates (Do not initiate in dehydrated patients with renal impairment. vitamin D excess. FBC. thyrotoxicosis. plasma glucose. CXR. Paget’s. ALP. lymphoma. immobilization.2010 batch with contribution from TTSH. consider IV Lasix 20-40 mg to induce diuresis and decrease calcium reabsorption.02] + Ca Causes ‐ iPTH/PTHrp dependent (PO4 is usually low): hyperparathyroidism (primary or tertiary).H. multiple myeloma.

5 X HCO3) + 8 ± 2 ‐ If pCO2<expected. AMS.35 and pCO2>45mmHg: RAcid ‐ pH >7.35 and pCO2<35 mmHg: RAlk *Elevated AG is marker of high anion gap metabolic acidosis even when pH and HCO3 is normal y . concurrent NAGMA In te Identify concurrent respiratory acid-base abnormality ‐ Expected pCO2 = (1. Identify primary abnormality ‐ pH <7. KTPH and NNI R es id en c 60 I. Identify any secondary abnormality by checking the adequacy of compensation 3. concurrent RAcid rn al M Identify HAGMA vs NAGMA ‐ AG = Na – HCO3 – Cl (HAGMA = AG>12) ed ic i Metabolic Acidosis CTSP: hyperglycemia.2010 batch with contribution from TTSH. If pCO2 >expected.35 and HCO3>24mmol/L: MAalk ‐ pH >7. drug OD ne By NHG IM Residents . concurrent MAlk.35 and HCO3<20mmol/L: MAcid ‐ pH <7. concurrent RAlk. hypotension. <22. renal failure. Identify the possible underlying cause N H G Concurrent metabolic acid-base abnormality ‐ Corrected HCO3 = (AG-12) + measured HCO3 ‐ If >28. ACIDS-BASES 1.2.

IV: hyperK) P–Pancreatic fistula (hypoK) Respiratory Acidosis CTSP: respiratory distress. KTPH and NNI H G In te rn al M ed ic i ne R es id en c y . concurrent MAcid Causes . Head injury. Metabolic alkalosis.Causes HAGMA (CATMUDPILES) C–CO. metformin) E–Ethylene Glycol S–Salicylates. respiratory failure. concurrent MAlk. CNS lesions.2010 batch with contribution from TTSH.Expected HCO3: increase 1-2 mmol/l for every 10mmHg increase in PCO2 ‐ Chronic: Expected HCO3: increase 4-5mmol/l for every 10mmHg increase in PCO2 ‐ If HCO3>expected.mainly CO2 retention from hypoventilation ‐ Central causes: Drugs (sedatives. Loss of hypoxic drive in chronic type 2 RF treated with O2 ‐ Airway obstruction: COPD/ asthma 61 N By NHG IM Residents . hypoxia. cyanide A–Alcoholic ketoacidosis T–Toluene M–Methanol. methemoglobin U–Uremia D–DKA P–Paraldehyde I–INH/Iron L–Lactic acidosis (shock. solvent NAGMA (USEDCARP) U–Ureterosigmoidostomy (hypoK) S–small bowel fistula (hypoK) E–Extra chloride (hyperK) D–Diarrhea (HCO3 > Cl loss) (hypoK) C–Carbonic Anhydrase inhibitor (hypoK) A–Adrenal insufficiency (hyperK) R–RTA (I. opiates). HCO3<exp.II: hypoK. AMS Identify the secondary abnormality ‐ Acute .

‐ Thoracic cage abnormalities: Kyphoscoliosis.2010 batch with contribution from TTSH. chest trauma ‐ Neurological/neuromuscular: Myasthenia gravis. Guillian Barre syndrome. KTPH and NNI R es id en c 62 y . cervical/high thoracic spine injury Treat the underlying cause ‐ Ventilatory support: KIV intubate (if pt is drowsy or has upper airway problem) or NIPPV ‐ Supplemental oxygen for patients with known Type 2 RF should be delivered by low flow nasal prongs or fixed systems (venturi mask) to allow accurate titration and prevent suppression of hypoxic drive N H G In te rn al M ed ic i ne By NHG IM Residents . morbid obesity.

blood/mucus with fever and patients tend to be sicker and more febrile o Parasitic GE . Vomiting (Blood/watery/bilious). jaundice ‐ Fever/chills/rigors.2010 batch with contribution from TTSH. Invasive organisms usually causes diarrhea with +/. bacterial or parasitic o Viral GE – most common. difference from normal habits. ‐ Non-infective causes of diarrhoea: e. thyrotoxicosis. C. alternating diarrhea/constipation. diff colitis 63 By NHG IM Residents . IBD Hx ‐ Diarrhea: duration.Suspect if positive contact/travel history and immunocompromised. quality of stools. GASTROENTERITIS Common new GEM case or CTSP re: diarrhea/vomit ‐ Vitals. KTPH and NNI N H G In te rn al M ed ic i ne R es id en c y . tend to be abrupt in nature with vomiting o Bacterial GE: Preformed toxins usually causes both vomiting and diarrhea without fever within hours. abdominal pain. Toxins-forming usually causes watery diarrhea 1-2 days later. ‐ Other GI symptoms: Nausea. GCS ‐ Assessment of the degree of dehydration ‐ Assess for different causes of infective diarrhea and r/o other non-infective causes as well ‐ Infective: viral. LoA/LoW ‐ Travel and contact history ‐ Drug h/x: Recent Abx use can lead to diarrhea. nursing home residents.Gastroenterology A. tumour/villious adenoma.g. any blood/mucus. ABCs.

g. IHD/CCF.g. mucus.g. PO cipro (after blood/stool cultures) ‐ KIV probiotics ‐ KIV an anti-motility agent such as loperamide (usually not required unless multiple episodes of diarrhea. masses felt? Sprurious diarrhea? Mx ‐ Hydration IV +/.oral 1. mucoid diarrhea) consider Abx e. bloody. may increase risk of HUS in EHEC) N H G In te rn al M ed ic i ne By NHG IM Residents .PE ‐ Postural hypotension.5-2L/day (Beware fluid status e. KTPH and NNI R es id en c 64 y .2010 batch with contribution from TTSH. tachycardia can be an early sign of dehydration ‐ Assess hydration status ‐ Abdominal Examination: To r/o acute abdomen ‐ PR: Any blood. ESRF) ‐ Non-milk feeds as tolerated ‐ Correct any electrolyte abnormalities ‐ KIV Abx? Most GE are viral but if patient septic (Febrile. Increased TW) or suspicion of bacterial GE (e.

smoking) ‐ Varices (liver cirrhosis – chronic hepatitis. prev PUD. coffee-grounds vomitus ‐ Vitals. endoscopy) ‐ Assess for complications associated w/ BGIT (e. PT/PTT/INR.g. painless fresh PR bleed. GCS – see pt ASAP if unstable ‐ Assess if the patient is stable ‐ Assess if it is truly BGIT – e. KTPH and NNI In te rn al M ed ic i ne R es id en c y . aspirate NGT. alcohol. UECr.). GXM +/.B. ask the nurse to keep the “coffee ground vomitus” or “malaena” for you to inspect (they may not be able to differentiate Fe stools from malaena etc. malaena. PV bleeding etc.cardiac enzymes ‐ Stool/vomit chart 65 By NHG IM Residents . NBM ‐ FBC. colon N H G Orders (as indicated) ‐ Hrly para + SpO2 ‐ Large bore IV cannulas + IV fluids. chronic constipation) ‐ Hemorrhoids – proctoscopy to avoid embarrassment ‐ Cancer – gastric. exclude hemoptysis. ABCs. colon ‐ AVMs – gastric. transfusion. ‐ Differentiate upper BGIT (malaena.2010 batch with contribution from TTSH. DRE (determine if it is fresh or stale malaena).g.LFTs ‐ ECG +/.g. corticosteroids. BGIT CTSP re: Hb drop. haemetemesis) vs LBGIT (PR bleed) ‐ Assess if there is a need for urgent intervention (e. ACS) Causes (risk factors) ‐ Peptic ulcer disease (NSAIDS. alcohol) ‐ Diverticular disease (known diverticular dz.

antihypertensives ‐ IV nexium 40mg BD ‐ For varices.N H G In te rn al M ed ic i ne ‐ Consider insert NGT if pt stable (unless high suspicion of varices) – diagnostic if aspirate bloody ‐ Check eIMR – take off anti-platelets.2010 batch with contribution from TTSH. urgent bloods ‐ If unstable UBGIT – refer GS/GE for emergency endoscopy ‐ If unstable LBGIT – arrange for urgent CT mesenteric angiogram (Duty radio: 8131. IR suite: 8157) KIV angioembolisation (will need green plug) ‐ KIV prophylactic intubation for massive hematemesis By NHG IM Residents . KTPH and NNI R es id en c y 66 . anti-coagulants. IV somatostatin 250mcg STAT + 250mcg/hr infusion ‐ If dx of BGIT questionable or patient VERY stable – KIV refer GS/GE CM for elective endoscopy ‐ If unstable – call for senior ASAP.

history of gallstones: Pancreatitis ‐ Prev surgeries. peritonitis ‐ Sexual History.making a specific diagnosis is of secondary importance PE ‐ Peritonitis?: board-like rigidity. palpable bladder ‐ PR: Any BGIT. LMP: Ectopic Pregnancy ed ic i ne By NHG IM Residents . KTPH and NNI R es id en c y 67 . better localized) Colicky (hollow organs) ‐ GI symptoms: Nausea. Acholic Stools: HBS pathology ‐ Drinking history.C. tenderness/rebound ‐ Masses? E.Ask for vitals and GCS . poorly localized).if unstable. abdominal distention (?I/O) ‐ NSAIDs use: Perforated PUD ‐ Jaundice. impacted Stools N H G In te rn al M Hx ‐ Characterizing the nature of pain: Visceral pain (dull.e. abdominal pain due to life threatening condition) .2010 batch with contribution from TTSH.g. see patient IMMEDIATELY By bedside ‐ TRO acute abdomen (i. vomiting. constipation. parietal pain (sharper. Dark Urine. ABDOMINAL PAIN Over the phone . hernias: I/O ‐ Fever/chills/rigours: Intra-abdominal abscess.

AXR (supine). amylase ± cardiac enzymes bld c/s. PT/PTT.2010 batch with contribution from TTSH. pneumonia. UFEME. GXM. DKA ed ic i Causes – based on location of pain RHC Epigastric Cholecystitis Cholecystits Cholangitis Pancreatitis Pancreatitis PUD Gastritis/GERD ACS Right lumbar Umblical/Diffuse Renal Colic AAA Pyelonephritis Ischemic bowel RIF Suprapubic Psoas abscess ARU Appenidicits Gynae Renal colic Ectopic Diverticulitis pregnancy Ectopic preg Hip (referred) LHC Cholecystitis Pancreatitis ne R es id en c Left Lumbar.g. CTAP ‐ ECG ‐ UPT. ABG/lactate (R/O ischemic bowel) ‐ Erect CXR (80% perf viscus have air under diaphragm). LFT.N H G Ix (as indicated) ‐ FBC. AMI. Renal Colic Pyelonephritis LIF Renal Colic Diverticulitis y . hrly para + SpO2 68 By NHG IM Residents . urine c/s Mx ‐ Treat underlying cause ‐ Treat symptoms – analgesia ladder (avoid NSAIDS) ‐ As required. NBM + IV drip. KTPH and NNI In te rn al M ‐ Remember extra-abdominal causes of abdominal pain e. UECr.

Rectal Dulcolax to clear bowel and IM/PO Buscopan for colicky pain relief ‐ Have a high degree of clinical suspicion for ischaemic bowel.2010 batch with contribution from TTSH. especially if the patient has high arteriosclerotic/embolic risk factor. KTPH and NNI R es id en c 69 y . If in doubt. Remember “pain is out of proportion of physical signs”.‐ KIV PPI (e. insert NGT + intermittent suction Last Notes ‐ A common cause of abdo pain during night calls is constipation colic. Confirm lack of BO and r/o acute abdomen. KIV AXR TRO I/O. Hypotensive N H G In te rn al M ed ic i ne By NHG IM Residents . do serum lactate/ABG When to call a surgeon ‐ Peritonitis ‐ Severe/Unrelenting without relief ‐ Complete/High grade Obstruction ‐ Patient is Unstable: Tachycardic. IV nexium) ‐ If I/O.g.

PT/PTT/INR. colonoscopy – hrly para x 4 then 4hrly if well. pancreatitis (<5%). sigmoidoscopy. bleeding(1-2%). nausea. cholangitis ne By NHG IM Residents .Post procedure review ‐ Assess the patient for possible complications of the procedure – e.1%). may consider escalating and send pt directly for CTAP (instead of erect CXR) – higher sensitivity N H G In te rn al M ed ic i Risks for endoscopic procedures ‐ OGD – perforation (0.UECr.2010 batch with contribution from TTSH.g. GXM +/. Endoscopic procedures Preparation ‐ OGD – NBM 12mn + drip. for OGD. Forrest 1a ulcer found and clipped. should keep the pt NBM in case rebleed) ‐ If suspecting perforation. ECG. list + consent ‐ Sigmoidoscopy – Fleet enema on morning of procedure. infection. feeds to DoC as tolerated when round (BEWARE of contraindications to start feeding e. drowsiness from sedation. vomiting. ‐ Colonoscopy – perforation (0. 2L PEG + PO dulcolax 20mg ONCE 6pm + NBM 12mn + drip. KTPH and NNI R es id en c D. LFTs day before procedure. NBM 12mn.g. perforation from procedure ‐ Follow the POT in the endoscopic report ‐ Generally.01%). list + consent y 70 . list + consent ‐ ERCP – FBC.1%) ‐ ERCP – perforation(0. list + consent ‐ Colonoscopy – Low residue diet ideally for 1-2 days.

vitals Usually just a case of poorly controlled DM ‐ If pt well. UECr.Endocrinology A. HCO3 >15. can review CBG trend non-urgent KIV give small dose soluble insulin (check CBG 4hrs later eg 2am) N Ppt factors: infection/sepsis. DKA/HHS Ask over phone: mental status.g. UFEME. Ketosis e. No acidosis (or mild lactic acidosis). serum Osm.2010 batch with contribution from TTSH.g. CVA. non-compliance. drowsy.g. HYPERGLYCEMIA CTSP: High CBG (>20). High serum Osm >320. corticosteroids Ix ‐ FBC.Cl. normal AG *calculated Serum Osm=2(Na+K) + glucose + urea ed ic i ne By NHG IM Residents . HAGMA – pH <7. BHOB > 2 mmol/L. HCO3. e. BHOB (green tube) ‐ ECG + CEs (MI. pancreatitis. HCO3 <15 ‐ HHS: Hyperglycemia >30. T and U waves) ‐ CXR KIV septic w/u (bld c/s. signs of acidosis/ketosis – diabetic emergency ‐ DKA: Hyperglycemia >14. plasma glucose. KTPH and NNI R es id en c 71 y . new case poorly controlled DM.3. urine ketones. inappropriate OHGAs/insulin. ACS. urine c/s) Initial Mx Principles for DKA/HHS ‐ D/w senior transfer to HD/ICU for unstable Fluid and K+ replacement H G In te rn al M If unstable. ABG. avoid prescribing additional insulin or OHGAs after dinner time – may get nocturnal hypoglycemia ‐ If CBG >20. drugs e.

2010 batch with contribution from TTSH.0 18. and titrate dose hrly according to CBG ‐ Example of sliding scale for 55kg patient al M 4.1 . KTPH and NNI R es id en c 14. 20mmol/hr if serum K+3 ‐ Rpt U/E/K/HCO3 in 2 hrs then 4 to 6hrs ‐ ½ NS is used if Na+ >150 mmol/l ‐ D5 containing fluids when CBG <14mmol/l ‐ Appropriate rate of glucose decline 3 to 4 mmol/hr ‐ Intensify insulin scale if necessary By NHG IM Residents .1 .1U/kg/hr.1 10 1.5 ne 10. ‐ Aggressive IV K+ replacement once serum K+<5mmol/L except renal failure / anuria ‐ Eg IV K+ (in infusion) 10 mmol/hr if initial serum K+4.5L during the first hour in the absence of cardiac compromise ‐ Subsequent fluid replacement depends on hydration status and serum electrolyte levels.3mmol/L ‐ Start Actrapid infusion at 0.g.18 3.1 –6 ed ic i 6.0 72 y .1 –8 1.1 – 14 2.9% NaCl) at a rate of 15 – 20ml/kg/hr or 1 – 1.0 ‐ HHS fluid deficit may be 5 to 10% BW ‐ Aggressive fluids required if hypotensive + inotropes (e.22 4.N IV actrapid (U/hr) In CBG (mmol/L) te <4 0 rn Insulin therapy ‐ Do not administer insulin if U waves on ECG or initial serum K+ is < 3. dopamine) if in shock ‐ Administer IV isotonic saline (0.0 >22 5.5 8.0 H G 0.

BHOB -ve. ‐ Treat underlying ppt factors y 73 . para + SpO2.Bicarb >15. consider bicarbonate therapy only if pH is <6.2010 batch with contribution from TTSH. Strict I/O chart KIV urinary catheter for oliguric/unstable ‐ Hrly CBG ‐ *in DKA.N H G In te rn al M ed ic i Guideline for conversion of IV to SC insulin. Dilute 100mmol sodium bicarbonate with 20mmol/L KCl in 400ml of sterile H2O and infuse at 200ml/hr for 2 hours.9 despite adequate hydration or if hemodynamically unstable. KTPH and NNI R es id en c ‐ Target CBG maintenance level 8 to 12 mmol/l ‐ Hrly CLC. ‐ Acidosis and ketosis has resolved . pH normal ‐ CBG readings stable and <14 mmol ‐ Alert and able to take orally ‐ PPT event has resolved ‐ Conversion is safest during dayshift ne By NHG IM Residents .

adrenal insufficiency al M ed ic i ‐ If no IV lines and desperate – KIV NGT feeding with glucose solution ne By NHG IM Residents . and repeat CBG in 15mins then CBG as frequently as comfortable (e. IV D50 40ml stat. Give light meal or diet within one hour ‐ If symptomatic (e. Set up IV D5% or 10% maintenance. coma) or persistent/recurrent.g. CBG hrly x 4. can order oral glucose 15g drink over phone.g. OHGAs). then Q4H if well). y 74 . otherwise repeat IV D50 and consider other causes for impaired consciousness. Type 1 DM will require retitration of basal insulin but not complete omission ‐ Ppt factors: poor oral intake.g. recheck CBG once patient responds or within15mins. Patient should respond promptly.2010 batch with contribution from TTSH. worsening of hepatic. infection. large bore IV plug. tremulous. TDS+10pm – pls indicate BSL frequency tds+10pm but dosing frequency to be only tds (pre-meal) N H G In te rn ‐ Review all anti-hyperglycemics (i.‐ **When ordering sliding scale SI in eIMR for e.e. HYPOGLYCEMIA CTSP re: low CBG (will be called if CBG <4) ‐ Ask over phone: pt GCS/mental status ‐ If alert and able to take orally. drowsy. insulin. alcohol. diaphoretic. renal function. seizure. KTPH and NNI R es id en c B. drugs.

‐ If the patient has NG tube feeding and a chest X ray had been done at the A&E department. atypically or in the form of Geriatric syndromes ‐ Common geriatric syndromes: o Functional decline o Falls o Delirium (see pg 16) o Others: Incontinence.2010 batch with contribution from TTSH. KTPH and NNI R es id en c y 75 . call the nursing home staff to obtain the history for the present admission. If the tip of the NG tube is not below the diaphragm and in the stomach. inform the nurses to remove it and re-insert the tube again. inanition/malnutrition etc ‐ Assessment of the premorbid status is key as well as any acute change in the function usually indicate acute pathology (see pg 76 for premorbid assessment) ‐ Effort should be made take a corroborative history from caregiver EVEN on-call especially if the patient is unable to provide history ‐ If the patient is from the nursing home and unable to give any history. CLERKING NEW GRM CASES ‐ GRM cases may present undifferentiated. review the position of the tip of NG tube before commencing feeding.N H G In Geriatric Medicine A. ‐ Always ask the care-givers about any recent drug allergies. te rn al M ed ic i ne By NHG IM Residents .

g. dementia. digital rectal exam ‐ Musculoskeletal: Spine. ACS. postural BP. deconditioning/muscle weakness. giddiness/syncope (see pg 14). poor footwear ‐ Precipitating –acute medical illness (e. trip/slip) ne R es id en c B. nausea/vomiting. mechanical (e. reflexes. power.Complications – e. postural hypotension. see the patient ASAP ‐ Assess vitals.g.bruising. vestibular dysfunction. sinister symptoms after fall (BOV. GXM ‐ ECGs +/. CLC monitoring. hips. capillary blood glucose +/PT/PTT. environmental hazards. gait ‐ Abdo: tenderness. stroke). FALLS ‐ Medical emergency. sepsis. peripheral neuropathy.g. ABCs and mental status (compare with baseline if possible) ‐ Assess for cause (perpetuating and precipitating factors) and complications of fall ‐ Hx: mechanism of fall. fractures/dislocation.cardiac enzymes 76 N By NHG IM Residents . AMS (see pg 16). CRIB ‐ FBC. UECr. Ca+Alb/Mg/PO4. cuts. poor safety awareness ‐ Extrinsic – drugs. joint deformities ‐ Neuro: pupils. KTPH and NNI H G In te rn al M ed ic i Causes ‐ Intrinsic – co-morbidities. severe pain) y .2010 batch with contribution from TTSH. etiology. Babinski. extend of injury. wrist and other joints ‐ Cardio: murmurs. poor vision. poor balance. intracranial bleed PE ‐ Inspection . carotid bruit Orders (as indicated) ‐ Hrly para.

g. KTPH and NNI R es id en c 77 .Inform MO if needs escalation or needs scans y .Update relative (main spokesperson) . MRI/MRA brain Raise incident report (eHor) ± report police Review meds (e. antihypertensives) KIV withhold N H G In te rn al M ed ic i ne By NHG IM Residents .g.2010 batch with contribution from TTSH.‐ ‐ ‐ ‐ CXR. sedatives. XR affected parts (e. wrist) KIV urgent CT brain. hip. anti-coagulants.

toileting. wheelchair bound. KTPH and NNI R es id en c 78 y . bed-bound ‐ ADLs (DEATH .?-man assist.C. eating. One of the following ‐ Aphasia (communication. word finding difficulty) ‐ Agnoisa (recognition of familiar items/faces) ‐ Apraxia (dressing. telephone) ‐ Swallowing ‐ Cognition DSM IV definition of dementia 1. FUNCTIONAL DECLINE “Functional decline” is too vague – need to specify which component of function has deteriorated Functional assessment ‐ Mobility . buttoning) ‐ Loss of executive function (planning. hygiene) ‐ iADLs (SHAFT – shopping. goal-directed activity) 3.g. Exclude delirium ‐ Urine/bowel continence ‐ Vision/hearing impairment ‐ Sleep disturbances ‐ Behavioral disturbances ‐ Mood disturbances ‐ Hx from patient (but can be challenging) ‐ Hx from caregiver (preferably staying with patient) N H G In te rn al M ed ic i ne By NHG IM Residents . social activities 4. WS. feeding. transport. Interferes with work. food preparation. Amnesia (long/short term memory loss) AND 2. walking aids (e. WF). housework. medication. ambulating.dressing.2010 batch with contribution from TTSH. accounting.

change of meds. including neuro exam.g. stroke. desaturations on Sp02 monitoring ‐ If unsafe to feed: NBM + IV drip ‐ Can modify diet (see pg 8) and pound medicines (note: some medicines cannot be pound) ‐ KIV NGT. KTPH and NNI R es id en c 79 y .g. progression of co-morbidities like dementia) Complications (falls/near falls. sepsis. coughing. postural BP. SOB.2010 batch with contribution from TTSH. change in quality of voice. bedsores and wounds ‐ Swallowing assessment ‐ Risk factors for swallowing impairment: e. fecal impaction). Parkinson’s dysphagia ‐ Beside swallowing test (30mls of H20 in small plastic cup with patient seated upright) o Look for drooling. ST referral N H G In te rn al M ed ic i ne By NHG IM Residents . pneumonia/recurrent chest infection. CVA. digital rectal exam (masses. hydration status ‐ Comprehensive physical examination. delayed or multiple swallows.Determine etiology for decline (e. abdo exam (look for palpable bladder). ACS. low mood) ‐ Vitals. spluttering.

ST if needed ‐ Fall precautions ‐ Behaviour chart rn al M ed ic i ne By NHG IM Residents . Age 3. VB12.2010 batch with contribution from TTSH. Address 5. KTPH and NNI R es id en c 80 AMT 1.g. Serial subtraction of 1 starting from 20 ‐ Gait if possible y . stop offending meds) In te Orders (as indicated) ‐ FBC. U/E/Cr. electrolyte abnormalities.CE ‐ Capillary glucose monitoring ‐ CXR/AXR ‐ CT brain / MRI brain ‐ I/O charting ‐ PT/OT gentle as tolerated.g sepsis.N H G Mx . Date of Birth 4. What year is it? 7. What time is it? 8. Recognition of 2 persons 9. ABG if indicated ‐ ECG +/. Ca+ Alb/Mg/PO4. TFT. Where are you now? 6. Recall of address given (e. blood c/s. anaemia panel. Folate. Who is the current Prime Minister? 10. 37 Bukit Timah Road) 2. LFTs.Identify and treat reversible cause (e.

symptom meds) ‐ Thorough history and examination (including oral cavity and PR where indicated) ‐ Reverse reversible factors contributing to symptoms (e. chemo. patient’s prognosis. latest scans. radio. symptom control. If the premorbid and prognosis is good. histo) and management so far (surgery.g. CLERKING PALL MED CASES Palliative medicine ≠ Do nothing! How aggressive the treatment should be determined by the patient’s premorbid. Patients with newly diagnosed Ca may sometimes be admitted under palliative medicine simply because they are on follow-up with palliative medicine for e. KTPH and NNI R es id en c y 81 .g. patient and family’s expectations and many other factors Important information to include when clerking ‐ Premorbid/functional assessment ‐ Underlying condition (only patients with Ca are supposed to be admitted under palliative.g.Palliative Medicine A. more aggressive management may be indicated By NHG IM Residents .2010 batch with contribution from TTSH. constipation for abdo colic) N H G In te rn al M ed ic i ne E. but things do fall through sometime) and investigations (diagnosis.

g. but patient must be reviewed if symptom is severe. KTPH and NNI R es id en c y 82 .2010 batch with contribution from TTSH. ‐ Some general principles regarding the use of opioids: 1.g. COPD with chronic type 2 respiratory failure 4. The senior should always be informed and approval sought before initiating or escalating the dose of opioid. COMMON SITUATIONS ON-CALL Pain and Dyspnoea ‐ Patients admitted under PMD or being reviewed by PMD usually have meds for breakthrough (BT) symptoms (i. Communicate with patient and/or relatives before initiating opioids to explain indication. increased symptoms on a background of otherwise wellcontrolled symptoms) ‐ the nurses can be instructed to serve the breakthrough medication first. try to reverse the cause of the symptom ‐ Opioids are HIGH-ALERT medications which should not be prescribed unless one is familiar.B. particularly for those who are opioid-naïve. Verify indication 2. fentanyl instead of morphine should be used in patients with significant renal impairment 5. benefits and potential side effects 3. of a different nature or is still not relieved in spite of breakthrough medication ‐ When possible and appropriate. Review the patient’s comorbidities to decide on the appropriate type and dose of opioids e.e. Choose the lowest effective dose. Review symptom again after medication is administered to assess if there is improvement N H G In te rn al M ed ic i ne By NHG IM Residents . elderly and frail or at high risk of respiratory depression e.

Patient is imminently dying ‐ Besides symptoms such as pain and dyspnoea. Review symptoms in the next hour to assess if there is improvement 5. Discuss with the senior to cease non-essential medications ‐ If family requests for terminal discharge.5mg PRN up to Q4-6H o Dyspnoea . the senior and/or the Palliative Medicine doctor-on-call should always be consulted. Communicate with the carer/family 2. Manage the symptoms: o Terminal secretions – S/C buscopan 20mg PRN up to Q4H o Terminal agitation – S/C haloperidol 1-2mg PRN up to Q4H 4.PO morphine 2. inform senior & nurses. Principles of management: 1. the patient may have noisy breathing from secretions and may be agitated. Empathize and be sensitive to their needs – remember that this is a difficult moment (DO NOT DISREGARD THE PATIENT’S SYMPTOMS OR THE FAMILY’S DISTRESS) 3.2010 batch with contribution from TTSH.5mg PRN up to Q4-6H If other preparations of opioid or non-enteral route is required and if in doubt.‐ Suggested starting dose of morphine (the most commonlyused opioid) o Pain .PO morphine 2. and consider referring to the home hospice team (if appropriate) N H G In te rn al M ed ic i ne By NHG IM Residents . prepare a good discharge summary to allow the GP to sign the death certificate in the event of patient’s demise at home. KTPH and NNI R es id en c y 83 .

g. Dental works for pt on warfarin – these will be elective admissions and have 84 By NHG IM Residents . Complication of condition / treatment (e. Flare / activity of the underlying condition (e. Follow up on the interesting ones & learn from them rn al M ed ic i ne R es id en c y . 3 types of cases to expect. DVT in APS. Serologies and special investigations do not need to be ordered at night as they will not change management ‐ Some medications are taken on specific days of the week. infxn from immunosuppression) 3. ‐ Stop immunosuppressants (except hydroxychloroqine) if the patient is being admitted for a severe infection ‐ Do not be intimidated by the complexities of some cases. Shade = Swelling. 1) Connective tissue diseases 2) Arthritides 3) Allergy-related ‐ Fill up all fields. Cross = Tenderness. CLERKING NEW RAI CASES Prerequisites ‐ In general.g. KTPH and NNI N H G In te Rheumatology.Connective tissue diseasess Pts are usually admitted for 1.2010 batch with contribution from TTSH. lupus nephritis) 2. IVIg infusion. Allergy and Immunology (RAI) A. Box = Limitation in movt ‐ Print the last discharge summary if available ‐ Print the lab results (in small font format) and file under relevant section ‐ Order UFEME + dipstick instead of UFEME alone ‐ Justify all investigations ordered. careful of step doses ‐ Use the homunculus for joint involvement. especially the pain section and Drug Allergy/ADR (including reaction if pt remembers) ‐ Obtain a complete medication list (pts may obtain their meds from different sources). Check that you have ordered them correctly.g. Treatment related (e.

Think about the disease manifestations as little modules (skin. KTPH and NNI N H G In te rn al M ed ic i ne R es id en c y 85 . oligo-.2010 batch with contribution from TTSH. Patients with lupus/vasculitis and have diarrhoea may be having gut vasculitis – if bowel sounds are sluggish or there is significant tenderness. History of inflammatory arthritis and treatment ‐ If there is a suspicion of septic arthritis. Number (mono-. diagnostic tap should be performed with blood cultures ‐ Remember to take sexual history and look for possible sources of infection ‐ Empiric abx can be considered if suspicion of underlying infection is high (preferably after joint aspirate) Some tips: By NHG IM Residents . err on the side of caution and culture and cover if there may be an infection Arthritides General approach involves determining 1. keep them NBM 3. blood. symmetrical vs asymmetrical) 3. polyarthritis) and pattern of joints involved (Axial vs peripheral. Presence of extra-articular manifestations 5. constitutional symptoms) 4. kidneys etc) and ask about symptoms from each one. Onset and duration of joint pain 2. Patients who are immunosuppressed may not mount high fevers. This will also help you in ordering the appropriate blood tests 2. Patients with SLE: Do not panic.plans laid out) Some tips: 1. Inflammatory symptoms (early morning stiffness.

not more than prednisolone 10mg/day is given for inflammatory arthritis 2. syncope or low BP. mouth. . genitals) . remember that it requires renal dose adjustment 4.describe it correctly to differentiate mechanism (eg maculopapular rash vs urticarial) .Suggest to pt to take photo of their rash to show the 86 N By NHG IM Residents . Maculopapular rash ‐ Ask for other signs & symptoms of anaphylaxis: SOB.‐ If rash is present. it may worsen the flare y . etc ne R es id en c 1. abdominal cramps. do not discontinue allopurinol during a flare if the pt is already on a stable dose.Ask and examine for mucosal involvement (eyes. higher doses will be needed in gout if colchicine/NSAIDS are contraindicated 3. use colchicine in gout only if the patient presents within 48h of onset of attack. Urticaria.2010 batch with contribution from TTSH. as a general rule.if there are blisters/bullae look for Nikolsky’s sign or denudation (danger signs) . KTPH and NNI H G In te ‐ Ask if this has occurred before and if pt has been investigated ‐ Detailed food / medication history is required in chronological order (get exact timing) ‐ Ask if there is relation with physical activity ‐ History of atopy in patient and family rn al M ed ic i Allergy related reactions ‐ May be related to food / medications / insect bites or unknown / idiopathic ‐ Common complaints include: Angioedema.

U/E/Cr. LFT.e. do FBC. UFEME and dipstix (don’t forget SJS/TEN and DIHS have multi-organ involvement ‐ Do not give steroids until allergy consult made y .g.2010 batch with contribution from TTSH. KTPH and NNI R es id en c 87 morning team (in case the rash resolves overnight) ‐ Monitor pt closely for deterioration overnight . O2 supp By NHG IM Residents .3ml of 1:1000 (i.Be wary of delayed reactions ‐ If there is significant MP or purpuric rash. IM epinephrine 0.N H G In te rn al M ed ic i ne Initial Mx of anaphylaxis ‐ Assess ABCs ‐ Epinephrine (IM) is the first line drug for anaphylaxis – e. NEAT from vial) ‐ Inform senior ‐ Check for response to epinephrine – may need to intubate. continue IV fluids resus.

Haematology/Oncology A. NEUTROPENIC FEVER 38.3, or sustained temp >38 for >1hr with ANC <500 (or expected drop <500 in 48h) ANC = Tw x (Neutophils% + Bands%) * If neutrophils dysfunctional, don’t count towards ANC *Fever may be only indicator of serious infection (other markers may be absent)

Ix: ‐ >2 sets blood cultures ‐ If no CVC: 2 sets (separate sites); ‐ If CVC: each lumen + peripheral culture simultaneously. o Differential Time to Positivity >120 min suggests CVC source ‐ FBC, UECr, LFTs, plus tests based on findings: CXR, sputum GS & cx, stool cx & CDiff toxin (if diarrhea) abscess GS and cx, Biopsy of skin findings (very useful); CT, LP etc as needed. Discouraged: stool c/s / CDiff if no diarrhea, urine cx if no symptoms / no catheter / no pyuria, superficial wound swab

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‐ Review old micro data for MRSA, ESBL, VRE etc to guide empiric abx ‐ New onset abdominal pain: suspect typhlitis Rx: (renal adjust!) - IV PipTazo 4.5g Q8h plus IV amikacin 15mg/kg stat, OR - IV imipenem 500mg 6h plus IV amikacin 15mg/kg stat (severe disease) - Add IV vancomycin 15mg/kg q12h if CVC(+), mucositis(+), skin/soft tissue with high MRSA risk, clinical / hemodynamic instability (KIV stop vancomycin in 48 hours if Gram(+) unlikely and not identified) - Continue abx for >7 days (even if culture negative) until fever resolves and ANC >500 x 2 days ‐ (serial addition of antifungal, antiviral as needed) ‐ G-CSF (filgrastim) – expensive, check w/ senior; not routine treatment of established febrile neutropenia

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Transfusion reaction workup includes: ‐ Filling up transfusion reaction form ‐ 2 pink tubes, 1 yellow tube (this is for LDH and bilirubin, which is to be ordered separately if hemolysis is suspected) ‐ 5 mls urine ‐ Blood bag with remaining blood product 90

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B. ACUTE TRANSFUSION REACTION Febrile non-hemolytic transfusion reaction ‐ Frequency – For red cells not leukocyte depleted – 0.5-6%, for platelets not leukocyte depleted – 1-38%. For leukocyte depleted red cells and platelets – 0.1-1%, more frequently associated with platelets. ‐ Symptoms – fever (>1 deg C above baseline) usually during transfusion but may occur 1-2 hours after the end of transfusion. ‐ Mx o Stop transfusion, ABCs o Exclude hemolytic reaction (re-check transfusion slip and re-ascertain patient identity and that correct blood is given to the correct patient, perform transfusion reaction workup), sepsis and TRALI (ensure that patient’s SpO2 is still normal). o Paracetamol should be given if no allergies o Another unit of packed red cells can be transfused once the symptoms have subsided. Do not re-use the same unit of blood unless there is difficulty obtaining blood for the patient, in which case the transfusion should be discussed with the haematologist-on-call. Incidence of febrile non-hemolytic transfusion reaction can be reduced by leukodepletion using a leukocyte filter.

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K) and PT/PTT/INR ne By NHG IM Residents .2010 batch with contribution from TTSH. Patients can also have abdo pain. pain at infusion site. For severe urticarial reactions.) Urticarial transfusion reaction – ‐ Frequency – 1-3%.g. chest and back pain. dyspnoea and dark or red urine.g. ABCs o IV diphenhydramine 25-50mg or PO piriton 4mg. More severe patients can develop hypotension.Anaphylactic transfusion reaction – refer to treatment of anaphylaxis (pg 85. flank pain. For future transfusions. o Monitor electrolytes (e. consider pre-medicating N H G In te rn al M ed ic i Acute hemolytic transfusion reaction ‐ Frequency – ABO and Rh mismatch occurs in about 1:10000-20000 transfusions ‐ Symptoms and signs – Most common is fever with/ without chills and rigors. perform transfusion reaction workup. KTPH and NNI R es id en c y 91 . ABCs o Normal saline infusion (avoid lactated ringer or dextrose-containing solutions) to keep urine output >100-200ml/hr KIV inotropes (e. dopamine) for BP support o Recheck transfusion slip and re-ascertain patient identity and that correct blood is given to the correct patient. hypotension or anaphylaxis occurs – resume transfusion at a slower rate. ‐ Mx o Stop transfusion. may require IV hydrocortisone 100mg o If urticaria wanes and no SoB. more frequently with blood products containing significant quantities of plasma ‐ Mx o Stop transfusion.

perform transfusion reaction workup) ‐ If this is suspected.2010 batch with contribution from TTSH. consider using washed red cells (please consult haematologist-on-call) Transfusion-associated sepsis ‐ Frequency – 1:5000 units for platelets and 1:50000 units for red blood cells ‐ Symptoms and signs – High spiking fever. KTPH and NNI R es id en c 92 y . chills and hypotension shortly after transfusion. perform blood cultures and start broad spectrum antibiotics as per ARUS-C guidance for empiric therapy for Severe Sepsis Or Septic Shock Without Clear Source. If recurrent even with premedications. N H G In te rn al M ed ic i ne By NHG IM Residents . exclude hemolytic reaction (recheck transfusion slip and re-ascertain patient identity and that correct blood is given to the correct patient. ‐ Mx ‐ Stop transfusion. ABCs.with anti-histamines.

Endocrinology. RAI.esp when ordering scans or risk getting a phone call from an angry radiologist ‐ AXR is keyed in as XR. Palliative. chloride.2010 batch with contribution from TTSH. Renal Medicine.ALL surgical disciplines. Neurology.which to call? ‐ CALL all URGENT blue letters ‐ CALL for following non-urgent blue letters . Cardiology. abdomen 93 By NHG IM Residents . Psychiatry. Haematology. Infectious diseases. KTPH and NNI N H G In ‐ Controlled drug prescription sample – intranet -> e-bulletin -> pharmacy notice board-> CDs -> prescription sample ‐ Antibiotics renal adjustment dose – intranet -> e-bulletin -> pharmacy notice board -> Antimicrobial Stewardship Programme-> ASP guidelines -> renal dose OR eIMR > parenteral > ARUS-C guidance > renal dose adjustment (automatic) ‐ IVIg guidelines – intranet -> e-bulletin -> pharmacy notice board -> Drug administration Guidelines -> RAI protocol IVIg ‐ Warfarin/heparin guidelines – intranet -> e-bulletin -> pharmacy notice board -> anticoagulation guidelines te rn al M ed ic i ne R es id en c Miscellaneous Blue letter . Dental ‐ Check with nurses or ward clerk if in doubt y . Respiratory Medicine (Secretary: 7861). Oncology.AURORA ‐ Renal panel has no urea. Dermatology. Gastroenterology. LFT has no AST. Anaesthesia. GGT (need to key in separately) ‐ Remember to fill in the box on the top right hand corner – briefly explain the pt’s situation . Radiation Oncology ‐ FAX/LIST for following non-urgent blue letters General Medicine. bicarbonate.

BD .sg – click “lotus notes client access” – http://intranet .8am/8pm.7-8am (night  AM shift). but don’t order EVERYTHING on the panel blindly ‐ Can customize results trending by creating your own list y 94 .” ‐ Many options are not in use – don’t get confused – e.com. KTPH and NNI R es id en c ‐ All intervention radiology orders start with “IR. st ‐ Administer 1 dose > eIMR > parenteral medicine (one of the tabs near the top) > administer order (near the bottom) > check appropriate buttons (it is still the Drs’ responsibility. Learn how to actually do it – rule of thumb dissolve Abx with water for injection as some may ppt w/ N/S) al M ed ic i ne By NHG IM Residents . 2-3pm (AM  PM shift). paracetamol prn (instead of qds prn) and put “Up to Q6H” special instructions. 9-10pm (PM  night shift) UpToDate – can access from home! Login to intouch.g. skin scrape [IDS]. usually means DND and the nurses will need the case notes . qds 8am/12pm/4pm/8pm (vs Q6H – 8am/2pm/8pm/2am). it is a bonus.N H G “Passing report” times – sacred timings for the nurses before they can go home after a long shift. Treatment PCN ‐ Can order multiple relevant tests fast by clicking on Order template (drop down just above area for ordering.2010 batch with contribution from TTSH.g.bottom right hand corner – UpToDate Online In te rn eIMR – ‐ Help nurses obtain prn meds for patients when the patient asks for it.nhg.OM . Don’t get nasty over it. tds – 8am/2pm/8pm (vs Q8H – 12pm/8pm/12mn). (EMOS) diet DM 1500k. to the right).order e. Otherwise they can only serve those meds during specific times ‐ Drug serving times . if the nurses help you.8am.

72 Level 8 – Wards 82 al M ed ic i ne Tower B Level 1 (learning centre) – Lecture rooms (for modular specialty teaching sessions) Level 2 – Diagnostic Radiology (note: MRI operates after office hours at the diagnostic radiology. carrom. KTPH and NNI R es id en c 95 KTPH Important locations Tower A Level 1 – A&E department Level 2 – Endoscopy centre and board room (for IM modular teaching sessions) Level 4 – staff lounge (there is pool table. library and comfy seats) y .86 (Surgical and medical overflow wards) Level 9 – Wards 95.52 Level 6 – Wards 61.96 (Orthopaedic and medical overflow) Level 10 – Ward 105 (medical ward) N H G In te rn Wards Tower A (A1/A2/B1 class) Level 5 – Wards 51.56 (Geriatric and medical overflow wards) Level 6 – Wards 65. Ward 46 (isolation ward) Level 5 – Wards 55.Tower B (ICU/B2/C class) Level 2 – Wards 26 (MICU) Level 3 – Wards 36 (SICU) Level 4 – Ward 45 (renal centre). 66 (medical wards) Level 7 – Wards 75.2010 batch with contribution from TTSH. CT scan/XR operate both here and at the A&E) By NHG IM Residents . fuss ball.62 Level 7 – Wards 71.76 (medical wards) Level 8 – Wards 85.

75. fish and co. toast and mee rubus.76. Mr Bean. Sells drinks. mee siam. the medical registrar buys dinner. coffee shop near to northpoint.86.2010 batch with contribution from TTSH. ‐ Higher end: Eatzi (Jack's place) at Safra Yishun IT system By NHG IM Residents . ‐ Level 1: subway.ayam penyet. 1 covers general ward and blue letters) ‐ Most of the time.. kampong fried rice ‐ Outside: northpoint. wards 66. level 1): recommended food. desaturation or typical chest pain Food options ‐ Tower B B1 level: kopi kaki. coffeeshop opp safra yishun (nice chicken rice and zi char!).95. edo sushi ‐ Food fare food court (Tower C..*note: in case of max bed occupancy rate --> new cases will be lodged in Virtual Ward (Ward 71 in A&E dept) --> check with your MOs if you are covering this ward! Calls ‐ Collect call key from security office at level 1 on day of call ‐ Return key the next day ($50 penalty if return >1day later) ‐ Request for either Tower A or B on-call room for general medicine (depending on your call coverage areas) there will always be spare rooms on level 10.e. a couple don't! ‐ Always keep your MOs informed of any sick passive case i. but ask around. 85) ‐ 2 registrars on call each night (1 covers ICU and A&E.96) and 1 follows MO4 (covering Tower A. KTPH and NNI N H G In te rn al M ed ic i ne R es id en c y 96 . 65.1 follows MO2 (covering wards 56.105) ‐ MO3 will tag on MO1 (covering wards 55. ‐ 2 HOs on call each night . wanton mee.

a classical ring that you will soon learn to hate. ne By NHG IM Residents .To assess the ward occupancy rate and the details of a booking from ED. KTPH and NNI R es id en c y 97 .Phlebotomist service comes 3 times a day. will sound throughout all N H G In te rn al M ed ic i . You need a manual form. Latest blood taking timing range from 7 to 8 plus. . they do not do blood cultures or ABG or GXM. . Traditional PCT/ platelets and FFP require GXM. altogether 4 signatures. . (it will come out as a blank page) .Vitals: located in the flowsheet tab or in the patient summary tab if u want to see graphical view .Discharging patients: need to ensure the primary diagnosis is filled up right at the bottom option of summary “completed” or not.Albumin does not require GXM. you can use BMS-live mozifire webpage.Everytime there is a new booking from ED.You are required to annotate all results by pressing down on the middle scrolling button. For eg: ward b66 ID would be wardb66 and password would be wardb66. Password and ID is common to the wards. of which the timing depends on which ward you are in. 2 stickers on the top and the ordering dr blank. Need to sign on the tube. patient’s summary copy of the discharge will not be printed out. If these 2 fields are not completed.GXM/antibodies screening cannot be ordered in the system.2010 batch with contribution from TTSH. Another staff needs to counter sign on the form before u can despatch. .KTPH uses sunrise clinical manager .Daily Work flow: Morning after rounds .Investigations ordered on arrival will be printed out together with the patient’s copy of discharge summary. .

Remember to look at the top left hand corner where medications that has been stopped during admission are written. CT brain/MRI brain when ordered. and consider if these need to be restarted.- - - - - - N H G - In te rn al M ed ic i ne By NHG IM Residents . pass the file and all to the staff nurse incharge of the y 98 . derm. Services like hematology will need to call TTSH. HOs can sign consent (unlike in TTSH) Scans done during office hrs till abt 9-10pm will be charged at normal rates. some call and fax. so that the nurses can send off the IMR to the pharmacy in the morning. even if it has been clerked by the virtual ward team in ED already. Give your signature to sign off. After doing all the necessary documents for discharge. can try calling the CT/MRI dept staff first. some faxing only. No need to call radiologists. will usually be done on the same day. Scans outside these hours will be more expensive. so decide if they are warranted or urgent. the IMR can be ticked during the rounds. There is a copy of the workflow in each work. All patients coming up from the ED must be reviewed.2010 batch with contribution from TTSH. Certain services like RAI. If urgent. Transfers from other wards (esp A tower lodgers) should be reviewed as appropriately. find out where it is! Some services need calling. All scans with contrast and MRI (with or without contrast) need consent. The booking will then appear on BMSlive webpage. PSYCH referrals have to be made before 11am sharp and must call the on-call. or else it you will get a scolding and patient will not be seen on that day. There is fixed blue letter referral workflow. KTPH and NNI R es id en c - the ward phones. When discharging patients. neurology have fixed blue letter days (not every day). so replies may not be as prompt (because its reviewed by visiting consultants).

Friday’s Prof raja’s teaching will be at 1pm in ward 65’s Location may change so keep a look out for weekly schedule sent out by secretary every week) tutorial room.30am: Mortality rounds alternate with combined teaching N H G In te rn al M ed ic i ne By NHG IM Residents .2010 batch with contribution from TTSH. KTPH and NNI R es id en c y 99 . Must be punctual! . Venue either at boardroom (tower A level 2 office) or at tower B level 1 main office.Tuesday’s IM modular teaching at 730am will be videoconferencing with TTSH.Departmental meeting on Friday mornings 7.Monday and Tuesday 7.Thursday lunch time teachng at 1pm is at Kaizen room 1 at the learning centre. .patient. PSAs here do not do discharges.30am emergency and core acute st tutorials will be for the 1 3 months . Afternoon after changes Teachings . .

Joel Lee.List of Impt Numbers in KTPH KTPH prefix = 6602 + ____ (see below) Lab main 2322 MicroB 2335 Biochem 2322/2325 Hemato 2338 Blood bank 2321 MSW 2588/2599 MOT 2760/2770 MRO 2466/2464 ITD helpdesk 1800 587 4478 Ms Xin Yee (BMU) 91142116 – Impt! For transfers of lodgers from Tower A back to Tower B Radiology On call radiographer 91371751 Counter (appt) 2700/01/2698 CT rm 2699 Angio rm 2706 US rm 2693/94/95 MRI rm 2709 Snr SN (Carol) Angio . Quek Zhi Han w/ special thanks to Eugene Chua al M ed ic i ne By NHG IM Residents . KTPH and NNI R es id en c y 100 .2669 Inpt Pharm 2632/33/34 On call Pharm 98550620 Drug Info 2629 N H G In te rn From Kenny Tan.2010 batch with contribution from TTSH.

KTPH and NNI R es id en c 101 y . EES 800mg 12h PO Gentamicin 80mg 8h or120-240mg om IV infus [chk lvls] Imipenem 500mg 6h IV Metronidazole (Flagyl) 400mg 8-12h PO. Bactrim (Co-trimox) 2 tab (960mg) bd PO [CI: CRF] Cefazolin 1-2g 8-12h IV (2g on call to OT) bolus Cefepime 1-2g 12h IV Ceftazidime (Fortum) 1-2g 8-12h IV infusion [pseudomonas] Ceftriaxone 1-2g om IV bolus (1g)/infuse (2g). 500mg 6-8h IV infusion Piperacillin-Tazo (Tazocin) 4. [5mU per vial] Doxycycline 100mg bd PO Erythromycin 500mg-1g 6h PO/IV.5-1g om-12h IV [chk lvls] Others:Acyclovir 800mg 5x/day x 7-10/7 PO (zoster).2g 8h/12h IV bolus/slow inf. PO] Cephalexin 250-500mg 6h PO Ciprofloxacin 500mg 12h PO.25–0.Drugs doses Antibiotics/Antimicrobials Amoxicillin 250mg–1g 8h PO Ampicillin 0.2010 batch with contribution from TTSH. 150-200 mg/kg/day IV Amikacin 7.5g 6-8h IV [pseudomonas] Vancomycin 0. 1.5g 6h PO.5-2g 4-6h IV bolus/infusion. 400mg 12h IV infusion (8h if Pseudomonas) Clarithromycin (Klacid) 500mg bd PO Cloxacillin 0.5mg/kg 12h/15mg/kg 24h (CrCl >90) Augmentin 625mg 8h/12h PO. 2g bd [meningitis] nd Cefuroxime (Zinnat) 500mg 12h PO [2 gen cephalosporin. 250-500mg 6h PO Crystalline Penicillin 4mU 4h IV infusion.250750mg 8h IV Chloroquine 600mg base (4 tab) x1 then 300mg [chk G6PD] om PO Quinine: Load (wt x20) in 1 pint D5% IV over 4h then (wt x N H G In te rn al M ed ic i ne By NHG IM Residents .

30.2010 batch with contribution from TTSH.5-15mg/day maint Promethazine (Phenergan) 25-50mg PO/ IM/ IV Synacthen test IV 250 g at 0 min (check 0.1ml) ID) (occ. 250mg ON Relievers: Atrovent (20g) (Ipatropium MDI) 2/2 bd Ventolin (Salbutamol) 4/4 qds/prn MDI.5-10mg/day PO Chlorpheniramine (Piriton) 4mg 6-8h PO Hydroxyzine (Atarax) 10-25mg tds [itch] Loratidine (Clarityne) 10mg om PO Fludrocortisone (Mineralocorticoid) 50-200mcg OM PO Hydrocortisone 100mg 6-8h IV. KTPH and NNI N H G In te rn al M Allergy/Anti-inflamm/Anti-histamines/Steroids Dexamethasone 4-8mg 6-8h i/v.Asthma Aminophylline: Load IV 6mg/kg/20min (not on Theopylline) then 25mg/h. 1:2:1 Q4-6h (COPD) PO Prednisolone 30mg OM x 5/7 Theophylline (Nuelin SR) PO 125mg ON/bd. 60 min) ed ic i ne R es id en c 10) in ½ pint D5 over 4-8h bd-tds [Falciparum malaria] TB: Mantoux (10U (0. 0.5g om x 2/12 [liver] th Ethambutol 600mg (15mg/kg) (1=100mg) om x 2/12 [if 4 required] TripleRx: Clarithromycin 500mg bd PO + Amoxycillin 1g bd PO x 2/52 + Omeprazole 20mg bd PO x 6/52 y . PO 4mg tds/prn Preventers: Becotide (50g) (Beclomethasone MDI) 2/2 bdtds 102 By NHG IM Residents . 10mm wheal = +ve Rifampicin 450mg (600mg if > 50kg) om PO x 6/12 [liver] Isoniazide 300mg om PO x 6/12[liver] + Pyridoxine 10mg om Pyrazinamide 1. 5-20mg OM/5-10mg ON PO Prednisolone 10-30mg om PO then 2. Theophy lvl 10-20mg/L) IV Hydrocortisone 100mg 6-8h Neb Ventolin: Atrovent: N/S 1:(0):3 (asthma). 1U). (25mg/ml in D5%.

Patch (Nitrodisc) 5-10mg/24h Heparin (refer to heparin infusion protocol on pharmacy bulletin) ISDN 5-20mg bd-tds po [angina.5. total) In te rn al M ed ic i ne By NHG IM Residents .Flixotide (250g) (Fluticasone MDI) 1/1-2/2 bd Pulmicort (200g) (Budesonide turbohlaer) 2/2 bd Calcium: Calcium: [(40-Alb) x 0. total) (CI: liver dz) Simvastatin (Zocor) 10-80mg ON (LDL. LVF] ISMN (Imdex 30-60mg om) (Ismo 20mg bd-tds) PO [angina. CCF] Ticlopidine (Ticlid) 250mg bd PO Warfarin: Load 5.5-250mcg om po [lvls] Dopamine 3-20mcg/kg/min IV [200mg in 0. Ca et vit D 1/1 OM/bd PO. INR.2010 batch with contribution from TTSH.5ml/h] GTN (0.3 mg OM then check PT. (2) IV N/S 1L/hour or 4L/24h (3) Pamidronate (bisphosphonate) 30-90mg in 500ml N/S over 4 hour + N H G Cardio-Vascular Aspirin 100mg om PO + famotidine 40mg bd Clopidogrel 75mg om PO Clexane 1mg/kg SC om (prophy) /bd (tx) [LMW Hep] Digoxin 62.02] + Ca (1) Stop thiazides.6g bd (Triglycerides) Fenofibrate 100-300mg on Lovastatin 10-60mg ON (LDL.3-0. [counselling] Cholesterol/Lipids Gemfibrozil 0.1L NS at 27. KTPH and NNI R es id en c 103 y .3g) 1/1 S/L max x3. Calcichew 625-1250mg OM/bd + High: Calcium: [(40-Alb) x 0.02] + Ca Low: Ca gluconate 10% 10ml over 10min then 40mls/24h.

Pravastatin 10-40mg ON Atorvastatin 10-80mg ON Rosuvastatin 5-40mg ON Ezetimibe 10mg ON Constipation Fybogel 1/1 om [bulk] Lactulose 10mls tds. PO dulcolax 2 tab BD or 4 tab once. acidosis] (1 line in 104 By NHG IM Residents . hemoptysis) ed ic i ne R es id en c y .2010 batch with contribution from TTSH. KIV fleet enema N H G Diabetes/Hypoglycemia Acarbose (Glucobay) 25-100mg tds Glibencamide (Daonil) 2.4 g/day) (expectorant) Procordin 10mls tds (red) (suppressant. KTPH and NNI In Diarrhoea Lomotil 1/1 tds-qds [Antimotility] Loperamide (Imodium) 2-4mg tds-qds [Antimotility] Lacteolforte 1 sachet BD Activated charcoal 2 tab TDS te rn al M Cough Bromhexine (Bisolvon) 8mg or 1/1 tds (expectorant) Dequalium or Difflam lozenges 1/1 tds/prn (sore throat) Dextromethorphan 10mls tds (black) (suppressant) Diphenhydramine 10mls tds (black) (expectorant) Guaifenesin 200-400 mg Q4H (max 2.5mg-10mg om/bd [2 gen SU] st Metformin 250mg-1g om-tds [CI: ESRF. 2 gen] nd Glipizide (Minidiab) 2.5-15mg om [long act SU][CI >60yrs] nd Gliclazide (Diamicron) 40-80mg om/bd [short act SU. 30mls in hep encephalopathy [osmotic] Senna 11/11 ON [stimulant] Dulcolax (Bisacodyl) PO 5-15 mg (up to 30 mg) PR 10 mg Bowel prep: PEG 2L.

Mg. Actrapid [yellow bottle.P. Mixtard usu 30/70 (R:N) Epilepsy/Fits: h/c.2010 batch with contribution from TTSH. drug levels Carbamazepine 200mg OM/ BD PO Diazepam (Valium) 5-10mg IV / rectal over 2 min [acute fit] Gout Allopurinol 100-300mg om [CI: acute attack] Diclofenac sodium SR 75mg BD Colchicine 0.25-1g om/ bd [short act 1 gen SU] Insulin: R=SI.25mg/h infusion (Varices). clear][short] N=Insulatard [green. PO 140 mg/kg. Mebeverine 135 mg tds (IBS) Fluimucil (Acetylcysteine) 60mg BD x 2/7 (b4 CT scan).fat pt) Metformin (Glucophage) Retard 850mg bd st Tolbutamide 0. ABG.25mg IV stat then 0.cloudy][intermediate]. KTPH and NNI R es id en c 105 y .5mg tds Prednisolone 30mg om x 5/7 N H G In Gastritis/Bleeding GIT/PUD Antacid 2 tab bd-tds PO Famotidine 20-40mg bd PO [with NSAIDs] Mist carminative 10mls tds/prn PO [wind] Magnesium Trisilicate (MMT) 10mls tds/qds/prn PO Omeprazole (Losec)/Pantoprazole 20-40mg om/bd Esomeprazole IV 40mg om-bd Esomeprazole infusion 8mg/h (80mg in 1 pint N/S @ 50mls/h) Somatostatin 0. U/E/Ca. IV 150 mg/kg over 60 minutes te rn al M ed ic i ne By NHG IM Residents .

Act. Vomitting. 12. 1-5mg IV BDZ antag: Flumazenil IV 0.Neuro-psych meds Diazepam (Valium) 2-10mg PO. Giddiness Metoclopramide (Maxolon) 10mg tds/prn PO/ IM/ IV Ondansetron (Zofran) 4mg IV/ 8mg bd PO Prochlorperazine (Stemetil) 5-10mg bd/tds PO. Aim 160/100 slowly Amlodipine 5-10mg om PO +/.2010 batch with contribution from TTSH.4-0. 5mg stat-tds IM/IV Midazolam (Dormicum) 7. CCF: Ace+Diur.5-10mg om PO [Ca ] Atenolol 25-100mg om PO [B] Captopril 6.5-5mg bd-tds or on PO.5mg Overdose [drug tox = LiH (green tube).25mg-50mg tds PO [ACE] Enalapril 2. B: Asthma.5-50mg om PO [Thiaz D](elderly)[+ K+] Metolazone: 2.5-20 mg OD (edema) or 2. charcoal 50g 4-6h [<4h] N H G In te rn Nausea.5-15mg PO. 5-10mg IV/IM Fluoxetine (Prozac) 10-40mg om-bd PO Haloperidol 0. levels=plain] Lavage [<2h.5-10mg om-bd Nifedipine 10mg PO Q8H +/.Atenolol ne By NHG IM Residents .5-50mg om-bd PO [K sparing D] Hypt Emergency/Urgency (>230/130). KTPH and NNI R es id en c y 106 . DM: Ace C/I: Ace: Cr>300. C: dyslipid 2+ Amlodipine (Norvasc) 2.send tox]. 1mg over 1 min max 5mg IV [B] + Spironolactone 12.5-5 mg OD (BP) 2+ Nifedipine LA 30-60mg om-bd PO [Ca ] Propanolol 10-40 mg bd-tds PO.enalapril 2.5mg IM Cinnarizine (Stugeron) 25mg tds/prn PO al M ed ic i Hypertension Comorb: Angina/AMI: Ace/Beta/Ca.5-10mg om-bd PO [ACE] Frusemide (Lasix) 20-80mg om-bd PO/IV bolus [loop D][+ K+] Hydrochlorthiazide 12. dyslipid. heart-blk.

5-1g tds-qds/prn po.Paracetamol: N-acetylcysteine (200mg/ml): 150mg/kg in 200mls D5 over 30min (usu from A&E) then 50mg/kg in 1 pint D5 over 4h then 50mg/kg 1 pint D5 over 8h. 20mg (1ml) IM Topical: Fastum/Voltaren gel N H G Piles Daflon 2 tab (900mg) tds x 4/7 then 2 tab bd x 4/7 then 1 tab bd Fybogel 1/1 bd + Lactulose 10ml tds Lignocaine gel prn for pain 107 By NHG IM Residents .5-1mg/kg IV + Maxolon Tramadol 25-100mg tds prn PO + Lactulose Hyoscine butylbromide (Buscopan) 10-20mg tds po.2010 batch with contribution from TTSH. Pain Paracetamol 0. KTPH and NNI In te rn al M ed ic i ne R es id en c y .5-2mg/h IV or 2-5mg/h SC (AMI: 2-4mg/5min) Pethidine 25-75mg tds/prn IM or 0. give 10mcg/ 2 min Mist Morphine 5-15mg 4-6h PO + laxative & Maxolon Morphine 0.4mg in 10ml (give 1ml/ time up to 2 mg) Codeine phosphate 15-30mg TDS PO+ laxative (max 60mg Q4H) Durogesic (Fentanyl) patch 6-50 mcg/h over 72h [CD] IV 1-3 mcg/kg to 10 mcg/ml. supp 25mg Indomethacin 25-50mg tds PO + PPI [gout] Mefenamic acid (Ponstan) 250-500mg tds/prn PO + PPI Naproxen (Synflex) 550mg bd/prn po (EC 375mg BD) Opioids: With Laxative (Senna/Lactulose) + Maxolon 10mg Opioid: Naloxone 0. 325mg supp (kid 125mg) Anarex (Paracetamol+Orphendarine) 2 tab tds/prn NSAIDS: With famotidine 20mg bd / omeprazole 20mg bd Diclofenac (Voltaren) 25-50mg tds. 75mg IM max bd.

108 By NHG IM Residents . nasal spray (200U) 1/1 each nostril OM [sitting up.1ml S/C) x 5/7.Sodium True Na+ = Na+ + gluc/4 Low: max  by 10mM/24h Not dry. renal fxn good or SIADH: Fluid restrict. 1 hour before breakfast] ++ Ca : Ca et vit D 1-2 tab om PO. <2. KTPH and NNI In te rn al M Renal Calcium acetate 625mg tds w/ meals PO Ferrous fumarate 200-400mg om-bd PO Renalmin 1/1 om PO Recormon (Erythropoeitin) 2000-4000u 1-3x/wk SC/IV ed ic i ne R es id en c Potassium Low: Inverted T.6-1. PR elevation.2g om/bd PO (also give with diuretics) High: >6 ECG: Tall T. glucose. Frusemide + Dry: 0. U wave.5: K 7.45% 10mls in 100ml N/S IV over 1hr max 20mmol/h. do not flush Mist KCL 10-15mls tds PO Span K 0.9% N/S 0. max 20mmol/pint. See also Calcium.2010 batch with contribution from TTSH.6 x wt x [125-Na ]/154 litres /24h + <120/Fitting: Na 3% + Lasix [3%=514/L instead of 154] NaCl 600mg (10mmol @) PO N H G Vitamins/Food IV albumin 20% 100ml over 2hr Calcitonin 100u om-bd IM (test dose 0.wide QRS. ST depression Stop diuretics. small P Resonium 15-30g 8h PO/ 30g fleet Glucose 50% 40mls (dilute w/ N/S) + insulin 10IV (check h/c stat + hrly h/c) Calcium gluconate 10% 10mls over 10min IV (cardioprotect) with continuous ECG monitoring y .

394 in = 0.23 Cr(mol/ml) (x 0.geraldtan.0328 ft Temperature: Celsius=5 x (Farenheit-32) / 9 Weight: 1 kg = 2. Always check if in doubt.com.70716 updated 16/7/2007 Edit history: Gerald Tan. Grace Chang This is an informal list only. KTPH and NNI R es id en c Fe: Ferrous fumarate 100-400mg om/bd PO +/. 100mg OM PO/IV (alcoholic) IM Vit B12 1mg OM x 3/7 then PO Princi-B forte 1 tab om y 109 . Updates/corrections: http://www.laxative. Glucose: mmol/L = mg/dl x 0.N H G Edited from: HO Drug list ver 4. IV Venofer 100200mg in 200ml N/S over 1 hour (check Fe after 48h) 23x/week Folate 5-10mg om PO (check for B12 def before replacement) Neurobion 1-2 tab om Vit B Co 1-2 tab OM Vit C: 100-500mg om PO. Sangobion/ Neogobion 1-2 tab om/bd PO.2 lb ed ic i ne By NHG IM Residents . For renal failure. 100-500mg/ml IM/IV Vit K: 10mg OM IV x 3/7 for raised PT Thiamine (Vit B1) 10-30mg PO. use MDRD.2010 batch with contribution from TTSH. Lim Baoying.055 Length: 1 cm = 0.85 for female) Online at nephron.com/school In te rn al M Common calculations Cr Clear (ml/min) = (140-Age) x Wt x 1.

e. press “0” or 63571000 if using workphone te rn Ward numbers = 2(XX)(Y) – where XX is ward level and Y is ward letter (A=1 or 5.g. Ward 12C = 2123/7 al M ed ic i 8131 8157/3 8142/3 8145 8163/4 7053 7056 7070 ne By NHG IM Residents . KTPH and NNI R es id en c 1492 1485 1478 8484/5 110 8938/9 8955 8968/9 8976 8464 9186 4133 2016 6357 xxxx 0 1800 4834 357 y . B=2 or 6 etc) . Ward 5A = 2051/5.Important phone numbers Lab Biochem Haemato MicroB Histo Immuno Imaging Duty Radio Interven.2010 batch with contribution from TTSH. Radio CT Room US Room MRI NNI (MRI) NNI (CT brain) EMG / EEG Miscellaneous BTS MO Drug Info TTSH prefix Operator ITD Help desk Surgical Main OT EOT OT Fax Endo centre N H G In When in doubt.

Zeng Shanyong In te rn al M ed ic i ne By NHG IM Residents . Dr Nigel Tan. Ho Quan Yao. Prof Chia Chung King. Dr Chia Yew Woon.Ms Selvia Kosim. Mr Winson Low And many others who have come together to make this book possible With contributions by: N H G R1s 2010/11 – Jacqueline Foo. KTPH and NNI R es id en c y 111 . Dr Chen Shiling. Joel Lim. Dr Ranjana. Dr Seow Cherng Jye Our Program coordinators (i. Brenda Lim. Kenny Tan. Goh Wen Yang. Daniel Yap. baby-sitters) .Acknowledgements Special thanks to: Our mentors .2010 batch with contribution from TTSH. Ivy Ng. Dr Charles Vu. Ms Melody Kuan. Dr Phoa Lee Lan. Dr Faith Chia. Mogilan. Lin Huiyu. Dr Lieu Ping Kong. Raphael Lee.for helping to edit this book (in order of appearance) – Prof Koh Nien Yue. Tan Seng Kiong. Mok Kwang How. Dr Quan Wai Leong. Raymond Liang. Prof Suresh. Dr Daniel Chew. Quek Zhihan. Dr Goh Kian Peng Our chief residents – Dr Endean Tan. Yeo Chong Ming. Joel Lee. Mahaboob Shariff.e. Dr Adrian Liew. Dr Changa. Andrew Leong. Dr Stephen Tsao. Valliammai. Dr Wu Huei Yaw. Dr Ong Kiat Hoe. Dr Lee Sze Haur. Violet Hoon. Emily Tan.

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