Authors:

Dr. Atmadeep Banerjee

Dr. Ishan Sen

Dr. Rittika Biswas

Special thanks to:

Dr. Arijit Biswas

Dr. Nitish Akhuli

Disclaimer:

The opinions in this document are those of the authors and do not reflect
local hospital guidelines and protocols. This document therefore is bereft of
any legal standing.

All credits and copyrights to links used here belong to the original makers of
the videos.
Dear interns,

Now that you have earned your prefix, a long and exciting journey awaits. We know how
overwhelming the initial weeks of your internship can be, but trust us as we say that despite
its ups and downs, you’re going to love every bit of it.

Four and a half years of medical school have taught you what to do as a doctor, but it is this
year that, you will find, will teach you what not to do as a doctor. As you move from one
posting to another, we hope this book eases your transition and familiarises you with the
peculiarities of the respective postings.

This book, however, does not substitute your senior or their experience and knowledge.
Whenever in doubt, always consult your senior first if possible. In fact, you will learn more on
the job than you ever will from this book. The primary purpose of this is to orient you towards
the responsibilities of the intern life and to make you a safe doctor.

Remember, Murphy’s Law is your most reliable friend during internship. Anything that can go
wrong will go wrong; so it’s always better to err on the side of caution. Nothing in medicine is
constant, so please hold the urge of acting on assumptions unless a senior is involved.

This book aims to guide you through the first few critical minutes of patient management,
particularly in the case of emergencies. It is neither complete, nor comprehensive, but has
just enough to buy you time till your senior can be called and further management can be
initiated.

Through this book, we want to ensure that you can confidently approach a patient, assess
them and determine a course of action without losing much time. As new interns, we had
often struggled with emergency and (so-called) difficult cases, but we hope this book
leaves you with enough self-confidence to thrive as a doctor even when you are alone.

In addition to some commonly encountered situations, we have also provided samples of

documents that an intern needs to fill up on a regular basis. Towards the end, there are links
to YouTube videos for procedures commonly performed in the ward.

As you embark on your internship journey, we wish you the very best.

Although all attempts have been made to prevent errors in this book, we apologize if any are
present, and would love to hear from you so that they can be rectified and improved upon in
the future versions. Please feel free to reach out to us if you have any suggestions or
feedback regarding this.

Dr. Atmadeep Banerjee

Dr. Ishan Sen
Dr. Rittika Biswas
 Index

The ABCDE approach ........................................................................... 01

The unconscious patient ...................................................................... 04

The convulsing patient ......................................................................... 05

The patient with chest pain ................................................................... 06

The breathless patient .......................................................................... 07

The breathless child ............................................................................. 08

The patient with anaphylaxis................................................................. 09

The patient with reduced urine output .................................................. 10

The patient with abdominal pain ........................................................... 11

The constipated patient ........................................................................ 12

The patient with earache ...................................................................... 13

The patient with nasal problems ........................................................... 14

The patient with throat problems .......................................................... 15

The Ophthalmology patient................................................................... 16

History taking in Ophthalmology emergency ......................................... 17

Pediatric dose calculation .................................................................... 18

Paperwork samples .............................................................................. 19

Tips for sending blood investigations .................................................... 24

Video guides for commonly performed procedures ............................... 25

 The ABCDE Approach
What and Why?
• It is a structured approach for initial assessment and management of a critically-ill or
worsening patient.

• It ensures that the issues which have the greatest risk of causing death are identified and dealt
with first, before moving on to less serious issues.

• The aim is to keep the patient alive and provide some clinical improvement, thus buying time
for definitive diagnosis and management.

• Remember that each component should ideally be assessed and managed, before moving on
to the next component. However, in real life since there are multiple health-care personnel
involved in a resuscitation approach, multiple components are actually managed
simultaneously by different members of the team.

• Therefore, the first step is to always call for help and support.

We have provided a brief overview of each component of the ABCDE approach below.
For a more detailed guide, visit:
https://www.resus.org.uk/library/2015-resuscitation-guidelines/abcde-approach

For a video demonstration of the ABCDE approach in practice, visit:

https://www.youtube.com/watch?v=KNqoXboSVUI

Airway
• Identify airway obstruction:

 Complete: Paradoxical chest and abdominal movements, absent breath sounds

at the mouth and nose, central cyanosis

 Partial: Stridor, snoring, choking, drooling

 If the patient is speaking clearly, that usually indicates that the airway is clear.

• Manage airway obstruction:

 Most patients require simple maneuvers such as repositioning, airway suction,

or head tilt and chin lift.

 Certain patients may require further management such as tracheal intubation.

Make sure to always seek senior support if in doubt.

• Oxygen:

 Start high flow Oxygen in critically-ill patients unless contraindicated.

 Make sure to monitor saturations using pulse oximetry to help guide decisions
regarding Oxygen requirement.

01
 Breathing
• Identify problems with breathing:

 General: Sweating, use of accessory muscles, central cyanosis, SpO2

 Quick respiratory examination to help recognize and rule out important

differentials, e.g. trachea (shifting?), JVP (raised?), inspection (pattern of
breathing?), palpation (rib fracture? Surgical emphysema?), percussion (fluid?
blood? pneumothorax?), auscultation (wheeze? crepts? absent breath sounds?)

• Management:

 Oxygen: Use pulse oximetry as a guide

 Definitive management: As needed. May include nebulization, needle aspiration

or other drugs/procedures. See the section on The Breathless Patient for more.
Seek senior support if in doubt.

Circulation
• Identify volume status and risk of shock:

 General: Color and temperature of peripheries, CRT

 Pulse rate: Remember that patient with acute significant hemorrhage may not
immediately develop pallor, but are always tachycardic.

 Blood pressure

 Auscultation of the heart

 Urine output in last 6 hours

 Signs of external or internal bleeding

• Management of shock:

 Insert 1 or more wide-bore IV cannulas.

Take bloods for investigations as per unit protocol.
Give a bolus of 500ml Normal Saline over 15 mins.
(Consult seniors before initiating fluid resuscitation in patients with Heart
Failure)

 Inform seniors immediately.

02
 Disability
• Examine the pupils

• Calculate the GCS

• Measure the CBG

 Management of patients with abnormal CBG results is given in the chapter on

The Unconscious Patient.
• Check if the deterioration could be the result of any drugs or poisoning.

Exposure
• Full exposure of the patient may be needed to identify important findings. Make sure
to respect the dignity of the patient. Following are just some of the important possible
findings:

 Rash

 Wound

 Snake bite

 Sources of infection e.g. indwelling catheters

Post-resuscitation tasks:
• These will depend on the findings and outcome of the initial resuscitation. In general,
the following are some of the important tasks to keep in mind:

 Full clinical history and a review of the patient’s notes and investigations.

 Documenting findings and actions performed.

 Informing seniors. They will arrange admission or referral if necessary.

 Initiating definitive management and requesting further investigations as

necessary. Seek senior advice wherever needed.

 Communicating with the patient’s family.

03
 The Unconscious Patient
First Steps:
• ABCDE and manage.
Simultaneously take history from relatives/ if present.

• Inform seniors as soon as possible.

• Important to note the following under D (Disability):

 GCS

 Pupils

 Reflexes, including Plantar

 CBG

Checking the CBG is very important in unconscious patients, especially for those
who are known diabetics. Following is a general guidance of how the CBG
measurement can help guide management if diagnosis is still unclear.
Remember that each patient must be dealt with depending on their individual
circumstances, and therefore the any history that can be gathered is invaluable.

CBG

Low High
Normal
(< 70 mg/dl) (> 250 mg/dl)

• IV 25% Dextrose • Consider ABG, CT Brain • Consider DKA or HHS

- 100 ml stat • Consider ABG
• Consider other diagnoses
• Recheck CBG every 15 • If DKA or HHS suspected
• Inform senior ASAP
minutes
 Insert 2 wide-bore IV
• Repeat IV 25% Dextrose if cannulas and rehydrate
needed using IV Fluids (Normal
• As soon as patient Saline)
recovers, give oral  Do not give Insulin
Carbohydrate load before starting IVF first
• Inform senior ASAP  Inform senior ASAP

04
 The Convulsing Patient
First Steps:
• Call for help

• Secure Airway

• Give 100% Oxygen

If CBG is low (< 70mg/dl),
• Secure IV access + Check CBG
manage accordingly.

• Inj Lorazepam (4mg) IV stat

[may repeat after 10-20 mins]

• If the patient is already on

treatment with Anti-epileptic
drugs, then make sure
maintenance doses are given.

• IV Fluids if dehydrated

Seizure stopped?

Yes No

Inform seniors • Inj Levetiracetam (1g) IV stat

for admission.
• If the above is unavailable, consider
Infusion Phenytoin (15-18mg/Kg) in
500ml NS @ 50mg/min

Monitor BP and ECG.

Yes Avoid Phenytoin in patients with low BP, low
HR or Heart block.

Seizure stopped?

No

Call seniors immediately.

05
The Patient with Chest Pain
First Steps:
Exclude potentially life-threatening
causes, including but not limited to
ACS, PE, Pneumothorax.
Be guided by history and
examination findings. Including vitals.

If suspected Cardiac chest pain, give:

• Tab Aspirin 300 mg stat

• Tab Isosorbide Dinitrate 5 mg

stat (sublingual)

• Call seniors immediately

Investigations that may be considered in

patients with chest pain:

• ECG

• Troponin T

• CXR

Call seniors immediately if any

doubt, or if patient is unstable or
worsening.

06
 The Breathless Patient
First Steps:
• ABCDE and manage.
Simultaneously take history from patients/relatives if present.

• Inform seniors as soon as possible.

• Important to note under A (Airway):

 Stridor, choking, drooling etc can be indications of upper airway obstruction

and can be fatal unless steps are taken to relieve the obstruction promptly.

 If SpO2 < 94%, give high flow Oxygen (aim for 94—98%)

 If known COPD, be cautious with Oxygen (aim for 88—92%). Use a Venturi
mask if available.

• Important to note the following under B (Breathing):

 If wheeze/ronchi on auscultation, nebulise with Duolin and Budecort (1

respule of each). May need to repeat multiple times if SoB not relieved.

 If crepitations on auscultation, consider the possibility of fluid overload states

such as Heart Failure or CKD. Consider IV Furosemide (40mg or 1 ampoule)
stat.

Other important differentials to consider:

1. Anaphylaxis - Must be recognised and treated promptly.
Suspect in patients with acute onset SoB, possibly with stridor, hypotension +/-
itching/rash. There might be history of known allergy.
If suspected, give IM Adrenaline (1:1000) - 0.5ml stat. Inform seniors immediately.
2. Pneumothorax - Suspect when lung sounds appear to be completely absent on any
part of the chest.
3. Pumonary Embolism - Suspect particularly in cases where there is co-existent DVT
(unilateral tender calf swelling), or patients have a known malignancy/post-op.
4. LRTI/ Pneumonia/ Covid-19
5. Acute Coronary Syndrome
6. Anxiety Attack
Keep in mind that these are just some of the more common causes, and this list is not
exhaustive.

Tips from your seniors:

• Patients with respiratory distress can deteriorate very Be careful when considering
rapidly, and may require respiratory support in Critical Oxygen or Sedatives for
Care Units. patients with anxiety attacks.

• Call seniors immediately if you recognize any red flags,

Gentle counseling is often the
are unsure of the patient’s condition, or feel like the
best course of action.
patient is worsening despite management.

07
 The Breathless Child
First Steps:

• ABCDE and manage.

Simultaneously take history from relatives/parents if present.
Always rule out foreign body obstruction.
• Inform seniors as soon as possible.

• Call seniors immediately if there are any danger signs, or if you are unsure of management.

Further management:

• In all breathless patients, initially start Oxygen through face mask or nasal cannula, while
completing further assessment. Checking SpO2 is an important step.

• In patients with wheeze, consider nebulization (driven by Oxygen) with:

 3% NaCl in children < 3 months old.

 Duolin - 1/2 respule in children 3 - 6 months old.

 Duolin - 1 respule in children > 6 months old.

• Following nebulization, reassess the child and check for signs of improvement.
Nebulization may need to be repeated.

• In patients with stuffy/blocked nose, consider Saline Nasal drops.

• Inform seniors immediately if there is a lack of improvement or if you have any concerns.

08
 The Patient with Anaphylaxis
Is it Anaphylaxis?
Anaphylaxis is likely when all 3 of the following are present:
1. Sudden onset and rapid progression of symptoms
2. Life-threatening Airway and/or Breathing and/or Circulation problems
3. Skin and/or mucosal changes
Supportive evidence:

• Exposure to a known allergen

Patients who do not meet these criteria and present simply with mild itching and/or
urticaria are likely to be having a simple allergic reaction. However, it is important to
confirm with seniors whenever there is any doubt.

Management of a patient with Anaphylaxis:

• Call for help.

• ABCDE to assess the situation.

• Inj Adrenaline (1:1000) - 0.5mg IM stat (dose for adults) in the Antero-lateral aspect
of mid-thigh.
This is the most important step in the management of Anaphylaxis, and there should
be no undue delay in administering Adrenaline. Keep in mind that the IM route is
preferred over IV.

• Consider the following:

 Secure Airway if compromised

 High flow Oxygen

 IV Fluid Challenge (500ml NS)

 IV Hydrocortisone (200mg for adults)

 IV Chlorpheniramine (10mg for adults)

 The trigger (e.g. bee-sting) should be removed if possible.

• Anaphylaxis is life-threatening. Seniors must be informed at the earliest opportunity.

Management of a patient with simple allergic reaction:

If you are absolutely certain that there is no risk of anaphylaxis, then consider the following:
1. Inj Phenargan (Promethazine) - 1 ampoule IM stat
2. Tab Levocetirizine (5mg) - 1 tab ODHS for 3 days
3. Counsel the patient for allergen avoidance and advice review at OPD/ER SOS.

For more info:

https://www.resus.org.uk/sites/default/files/2020-06/EmergencyTreatmentOfAnaphylacticReactions%20%281%29.pdf

09
 The Patient with Reduced Urine Output

First Steps:

• ABCDE and manage.

• Must distinguish between kidney failure and urinary obstruction. A detailed history
and examination can help:

 Known case of CKD/AKI/Urinary stones/BPH/neurogenic bladder?

 Is the patient dehydrated (vomiting/diarrhoea/poor oral intake)?

 Any history of surgery/trauma?

 Signs of sepsis/UTI?

 Examination: Palpable bladder +/- tenderness indicates obstruction.

What should you do?

• Catheterize the patient.

• If already catheterized, change it or consider a bladder wash if there is a blocked

urethral catheter.

Large volume of urine

Not relieved
may be drained

Patient dehydrated Fluid overloaded

Consider Fluid challenge Consider IV Furosemide

with 500 ml Normal Saline (40mg or 1 ampoule) IV

Caution: Be aware of Urea,

Creatinine and Electrolyte
values before this.
• Do not attempt catheterization if H/O Urethral trauma,
Pelvic trauma, Bladder neck obstruction, Malignancy of
urinary outflow tract.
• If catheterization is difficult, or if you are unsure
regarding its appropriateness, speak with seniors. Some
patients may need suprapubic cystostomy.

10
The Patient with Abdominal Pain
First Steps:

• ABCDE and manage.

• A detailed history is essential.

For female patients, always remember to confirm the LMP and take history for associated
gynaecological complaints such as PV discharge or bleeding.
Consider referral to Gynae ER if appropriate.

• A thorough abdominal examination is important. Some of the important findings to look out
for include:

 Abdominal distension

 Raised local temperature

 Local/diffuse tenderness

 Rebound tenderness

 Cardboard rigidity

 Absent IPS

• If any of these signs are present, or you are unsure of what to do, inform seniors ASAP.

• Initiate initial management as appropriate. This may include:

 IV Fluids

 Appropriate medications to relieve pain

 Antiemetics

 Some patients may require Nasogastric tube insertion and/or Urethral catheterization.

• A Straight X-Ray Abdomen in AP view, showing both domes of diaphragm is often a

useful investigation in this situation.

Tips from your seniors:

• Avoid NSAIDs in patients with epigastric pain.

Consider PPI (Inj Pantoprazole 40mg IV) +/- Gastroprotective agents instead,
especially if there is history of dyspepsia.
• Rule out constipation as a differential. If present, consider treatment with Syrup
Lactulose and/or Phosphate enema.
• Renal colic: Consider Inj Diclofenac 75mg IM
• Biliary colic: Consider Inj Drotaverine 40mg IM
• Pain of acute pancreatitis is unlikely to be relieved by anything less than opioid
analgesics. Consider Inj Tramadol 50mg IV. Remember to always give antiemetics
with Tramadol.

11
 The Constipated Patient
First Steps:

• ABCDE and manage.

• A detailed history of the nature and duration of constipation is essential.

• Specifically enquire regarding:

 Vomiting: Has the patient been vomiting? Contents? Episodes? Duration?

 Obstipation: When has the patient last passed stool or flatus?

• A thorough abdominal examination is important. Some of the important findings to

look out for include:

 Abdominal distension

 Local/diffuse tenderness

 Absent IPS or High-pitched IPS

If Obstipation and/or Vomiting present, If no danger signs:

or if you are unsure of what to do:
• Initiate initial management.
• Inform seniors asap Consider:
• Initiate initial management.  Appropriate pain medication
Consider:
 Syrup Lactulose
 IV Fluids
 Phosphate enema
 Appropriate pain medication
• A Straight X-Ray Abdomen in AP
 Antiemetics view can be a useful investigation
in some cases.
 NG Tube
• Once constipation is relieved,
 Urethral catheterization
advice patients to take a diet high
• A Straight X-Ray Abdomen in AP in fiber, and explain warning signs
view can be a useful investigation of bowel obstruction and
to help detect dilated bowel loops, dehydration.
air-fluid levels, stool shadows, etc.
• Request senior review as
and help guide further
appropriate.
management.

12
 The Patient with Earache

First steps:
First, examine the ears.
Likely diagnoses for common findings are given below:

• Blackish/Brownish material - Wax

• White spores - Otomycosis
• Discharge - COM

If any doubts, call the first on-call.

Management of common conditions:

Suggested conservative management for some common conditions are given below. Speak
with seniors if there are any doubts.

• Wax - E/D Otorex/ Drep WX/ Soliwax

• Otomycosis - E/D Otodac-CL/ Nuflucon/ Candibiotic
• Discharge - E/D Candibiotic-AB/ Otodac-DX/ Drep
For patients with ear discharge, also give
N/D Xylometazoline/ Xylomist-P (Paediatric)

All Ear Drops are commonly prescribed as 2 drops TDS for 7 days.
Xylometazoline Nasal Drops should not be given for more than 5 days.

Advice all patients to attend the OPD.

Make sure to rule out warning signs in all patients, and inform seniors accordingly.

Here is a useful video demonstrating the procedure for an ear examination and Otoscopy:
https://www.youtube.com/watch?v=FE0sot4OoAE

13
The Patient with Nasal Problems

First steps:
Common complaints regarding the nose include congestion and epistaxis.
In either case, first, examine the nose.
If any doubts, call the first on-call.

Management of common conditions:

Suggested management for some common conditions are given below. Speak with
seniors if there are any doubts.

• Congestion - N/D Xylometazoline - 2 drops TDS x 5 days

• Inflamed turbinates - N/S Fluticon-FT - 2 puffs BD x 3 days
• Epistaxis - Check for active bleeding.
If active bleeding present, call the first on-call.
• Epistaxis without h/o trauma - Check BP (especially in the middle-
aged and elderly)

Advice all patients to attend the OPD.

Make sure to rule out warning signs in all patients, and inform seniors accordingly.

14
The Patient with Throat Problems

Something stuck in the throat:

• ABCDE and manage.

• Take a brief history. Try to find out what has been swallowed and when.

• Examine the throat and try to visualize the foreign body.

In any case, call the first on-call.

Hoarseness:
• Take a brief history and examine the patient.

• Rule out any warning signs.

• Hoarseness by itself is not an emergency. If there are no other problems, consider

conservative management with Paracetamol and/or saline gargle, and advice the patient to
attend the OPD.

If any doubts call the first on-call.

Stridor:

Call all seniors immediately.

15
 The Ophthalmology Patient

Foreign body sensation in eye:

• Take a brief history and perform local examination.

• Apply one drop of topical anesthetic in the affected eye.
• Perform saline wash of the affected eye.
• Check visual acuity, pupillary reflexes. Look out for corneal abrasion. If all
findings are within normal limits, consider discharging the patient with
carboxymethylcellulose eye drops and topical antibiotics with a note for
reviewing at Eye OPD the following day.
• Call seniors immediately if you need assistance at any point, or are unsure of
the management..

Injury to eye:

• ABCDE and manage.

• Take a detailed history and perform local examination.
• Perform initial symptomatic management with analgesics and topical drops.
• Call seniors for further management.

16
History taking in Ophthalmology Emergency

C/O: Chief Complaints

In case of trauma, mention date of injury (DOI), mechanism of injury (MOI), site of injury
(SOI). Mention if there is any history of vomiting, convulsions or loss of consciousness.
On Examination:

R/E:
Visual acuity
L/E:

R/E:
Eyelids
L/E:

R/E:
Conjunctiva
L/E:

R/E:
Cornea
L/E:

R/E:
Anterior chamber
L/E:

R/E:
Pupils
L/E:

R/E:
Digital IOP
L/E:

R/E:
Range of movements
L/E:

17
 Pediatric dose calculation

1. Syrup Paracetamol (125/5): BW x 0.6 ml per dose TDS/QDS/SOS

BW
2. Syrup Ondansetron (2/5): /2 ml per dose x TDS
BW
3. Syrup Drotin DS (20/5): /2 ml per dose x TDS
BW
4. Syrup Metronidazole (100/5): /2 ml per dose x TDS
BW
5. Syrup Amoxyclav (225.5/5): /3 ml per dose x TDS/BD
BW
6. Syrup Azithromycin (200/5): /4 ml per dose x OD
BW
7. Syrup Cough mix: /4 ml per dose x TDS
BW
8. Syrup Salbutamol: /4 ml per dose x TDS
BW
9. Syrup Atarax (10/5): /4 ml per dose x QDS
BW
10. Syrup Pedicloryl (500/5): /2 ml per dose x 3 times
(Triclofos) Repeat after 20 minutes.
BW
11. Syrup Ranitidine (15/5): /5 ml per dose x BD
12. Syrup Albendazole (200/5): 10 ml once → Repeat after 14 days.
13. Syrup Zinc (20/5)
If < 6 months old: 2.5 ml OD x 14 days
If > 6 months old: 5 ml OD x 14 days
14. Syrup Lactulose: 1 ml/Kg x ODHS

18
 Paperwork samples
Pathology requisition form:

19
 Paperwork samples
Biochemistry requisition form:

20
 Paperwork samples
Radiology/ECG/Echo requisition form:

21
 Paperwork samples
Ultrasound requisition form:

22
 Paperwork samples
Blood requisition form:

23
Tips for sending Blood Investigations
Sample blood vial:

Where do you send blood investigations?

Time
Before 2 pm After 2 pm
Place

College Building CBC, ESR, LFT, Lipid profile, Urea, Creatinine -

Central Laboratory Na, K, Serology (HbsAg, anti-HCV, HIV I &II) RE, Na, K, Urea, Creatinine, Serology

Which blood investigations go in which vials?

Purple (EDTA) vial RE, CBC, ESR

Red (clot) vial Na, K, Urea, Creatinine, LFT, Lipid profile, Serology

Light-blue vial* PT, aPTT, INR, D-dimer

Grey vial FBS, PPBS, RBS

*Make sure to fill the light-blue vial

exactly up to the mark on the side. No more, no less!
Otherwise, the sample will be refused.

24
Video guides for commonly performed procedures

1. Blood sampling:
www.youtube.com/watch?v=7NSEFVbzTAU

2. IV Cannulation:
https://www.youtube.com/watch?v=EY-_2L08ETs

3. Arterial Puncture (ABG):

https://www.youtube.com/watch?v=m0yFpcqKAm4

4. Urethral catheterization:
Male: https://www.youtube.com/watch?v=vd8wMa3wfmU
Female: https://www.youtube.com/watch?v=uQbHLq9md8Q

5. Nasogastric Tube insertion:

https://www.youtube.com/watch?v=1OakmxZDa5c

25