Contents

Abdominal pain.....................................................................................................................................2
Differentials.......................................................................................................................................2
Investigations....................................................................................................................................2
Abdominal pain management...........................................................................................................2
Anemia..................................................................................................................................................5
Chest pain/SOB......................................................................................................................................6
Differentials.......................................................................................................................................6
Investigations....................................................................................................................................6
Cardiac management.........................................................................................................................6
Respiratory management..................................................................................................................7
Collapse.................................................................................................................................................8
Differentials.......................................................................................................................................8
Investigations....................................................................................................................................8
Collapse management.......................................................................................................................8
Diabetic emergencies..........................................................................................................................11
Diabetic ketoacidosis.......................................................................................................................11
Hyperosmolar hyperglycemic syndrome.........................................................................................11
Hypoglycemia..................................................................................................................................11
Headache.............................................................................................................................................12
Differentials.....................................................................................................................................12
Headache investigations..................................................................................................................12
Headache management...................................................................................................................12
Hyperkalemia......................................................................................................................................15
Management...................................................................................................................................15
Hyponatremia......................................................................................................................................16
Approach.........................................................................................................................................16
Investigations..................................................................................................................................16
Abdominal pain
Differentials
Peritonitis, ruptured
Generalised AAA, obstruction,
mesenteric ischaemia

RUQ Gallstones

Epigastric Pancreatitis, gastritis

Abdo pain
Appendicitis, renal
RLQ colic, tubovarian
disease

Suprapubic Cystitis

Diverticulitis, renal
LLQ colic, tubovarian
disease

Investigations
B: FBC/U&E/LFT, lipase, lactate, BGL
O: Urine dip, hCG
X: AXR, USS, CT
E: ECG

Abdominal pain management

Acute pancreatitis
S: Epigastric pain radiating to back associated with vomiting relieved by sitting forward
O: Epigastric tenderness, Cullen/Grey-Turner signs
A: Deranged LFTs, raised lipase, CT, raised Glasgow score
P: IV fluids

Acute mesenteric ischaemia

S: Severe abdo pain on b/g hypercoagulable state
O: Pain out of proportion to exam
A: Raised lactate, CT
P: NGT, IVF, antibiotics, surgery

Appendicitis
S: Periumbilical to RIF pain associated with anorexia and fever
O: McBurney’s sign, Rosving’s sign, psoas sign, local peritonism
A: Elevated AIR score
P: Surgery

Bowel obstruction
S: Colicky abdo pain, constipation, distension, vomiting
O: Distended, tender abdomen, high pitched bowel sounds
A: AXR, CT
P: NGT, IVF +/- surgery

Diverticulitis
S: LIF pain, fever
O: LIF tenderness, local peritonism
A: Raised inflammatory markers, CT
P: Clear fluid diet, antibiotics

Gallstones
Gallstones can cause biliary colic, cholecystitis, CBD stone, and cholangitis
A: Obstructive LFTs, raised inflammatory markers, USS, CT, MRCP

Biliary colic is pain due to stones in CBD

S: RUQ/epigastric pain exacerbated by fatty food
P: Analgesia, low-fat diet, outpatient cholecystectomy

Cholecystitis is inflammation of the gallbladder due to CBD obstruction

S: Continuous RUQ/epigastric pain
O: RUQ tenderness/guarding, Murphy’s positive
P: Antibiotics, +/- ERCP, cholecystectomy

CBD stones cause RUQ and jaundice

P: ERCP

Cholangitis is inflammation of CBD due to obstruction

Causes RUQ, fevers, jaundice
P: Antibiotics, ERCP

Gastritis
S: Epigastric pain
O: Epigastric tenderness
A: OGD if recurrent
P: PPI +/- H pylori eradication

Peritonitis
S: Severe generalised abdo pain
O: Firm, guarding, peritonitic
A: Subdiaphragmatic air on CXR, CT abdo
P: Surgery

Renal colic
S: Spasms of loin-groin pain, vomiting, writhing
O: Renal angle tenderness
A: Haematuria on dip, CT KUB
P: Diclofenac +/- tamsulosin/surgery

Tubovarian disease
DDx = ectopic, ovarian cyst, ovarian torsion, PID

Ectopic characterised by 6-8 weeks amenorrhoa followed by unilateral pelvic pain and spotting
A: raised hCG, USS
P: methotrexate +/- surgery

Ovarian cyst rupture and torsion are characterised by sudden severe unilateral pelvic pain
A: negative hCG, USS
P: Surgery if torsion

PID is characterised by bilateral pelvic pain associated with discharge

A: Raised inflammatory markers, positive swabs
P: Antibiotics
Anemia
Iron deficiency, chronic
inflammation,
Microcytic
haemoglobinopathy e.g.
thalassemia

Recent haemorrhage,
renal failure, thyroid
Normocytic
abnormality, chronic
inflammation
Anaemia
B12/folate deficiency,
EtOH, thyroid
Macrocytic
deficiency, bone
marrow Ca

Haemolysis, acute
With reticulocytosis
blood loss
Chest pain/SOB
Differentials
Pericardial Pericarditis

ACS,
Cardiac Myocardial decompensated
HF, myocarditis

Vascular Aortic dissection

URTI, foreign
Upper airway
body, anaphylaxis

LRTI,
Chest pain/SOB Lower airway
COPD/asthma
Respiratory

Pleura Pneumothorax

Vascular PE

Other Anxiety

Investigations
B: FBC/U&E/CRP, Tn, D-dimer, BNP, ABG
O: Sputum culture
X: CXR, CTPA
E: ECG

Cardiac management
Acute coronary syndrome
S: Crushing chest pain radiating to neck/L arm associated with nausea/SOB/diaphoresis
O: -
A: ST elevation, new LBBB, T wave inversion, Q waves
P: MONAC

MONAC = Morphine 10mg, metoclopramide 10mg, oxygen, GTN, aspirin 300mg, clopidogrel 300-
600mg

Aortic dissection
S: Sudden tearing chest pain radiating to back
O: Unequal arm BPs
A: ECG inferior MI, CXR wide mediastinum, CT angio
P: Surgery

Decompensated heart failure

S: SOB/orthopnoea/PND, pink frothy sputum, leg swelling
O: Raised JVP, peripheral oedema, bibasal crackles, S3 gallop
A: ECG to exclude MI, raised BNP, CXR, ECHO
P: PODMAN
PODMAN = Position sitting, Oxygen, Diuretic (20 mg IV frusemide), morphine 10mg, anti-emetic
(metoclopramide 10mg), GTN

Myocarditis
S: Cardiac symptoms associated with fever
O: Signs of HF associated with fever
A: Diffuse ST/T wave changes and raised Tn associated with raised inflammatory markers
P: Supportive management and treat cause

Pericarditis
S: Retrosternal pain radiating to traps relieved by sitting forward after viral prodrome
O: Pericardial rub
A: Widespread PR depression and saddle-shaped ST elevation; globular heart on CXR, echo
P: NSAIDs

Respiratory management
Anaphylaxis
S: Rash/SOB/hypotension/GI symptoms post exposure to drugs/food/latex
P: 0.5mg IM adrenaline, non-rebreather, fluid bolus, 200mg IV hydrocortisone, 10mg IV
chlorpheniramine

IM adrenaline can be given Q5min

If still deteriorating, give 0.5mg/h IV adrenaline

Asthma/COPD exacerbation
S: SOB and wheeze
O: Respiratory distress, reduced air entry, wheeze
A: ABG, CXR
P: O SHIT ME

O SHIT ME = Oxygen, 5mg salbutamol neb, 100mg IV hydrocortisone, ipratropium 0.5mg neb +/-
theophylline, 10mmol magnesium, and epinephrine 0.5mg IM

Lower respiratory tract infection

S: Productive cough associated with fever and pleuritic chest pain
O: Coarse crackles
A: Raised inflammatory markers, positive sputum culture, consolidation on CXR
P: Antibiotics

Pneumothorax
S: Sudden pleuritic chest pain
O: Absent breath sounds +/- tracheal deviation, JVP elevation, hypotension
A: CXR showing air in pleural space
P: Consider aspiration or chest drain

Pulmonary embolism
S: SOB and pleuritic chest pain associated with hemoptysis
O: Elevated Well’s score
A: Sinus tachy, raised D-dimer, CTPA
P: 1.5mg/kg Clexane per day for 5 days then transfer to anticoagulant
Collapse
Differentials

Postural hypotension,
Cardiogenic aortic stenosis,
arrhythia

Stroke, seizure,
Collapse Neurogenic vasovagal, situational,
Parkinson's

Intoxication,
Other
mechanical fall

Investigations
B: FBC, U&E, CRP, BGL
X: CT head, echo, carotid dopplers
E: ECG, telemetry
S: L/S BPs, EEG

Collapse management
Aortic stenosis
S: SAD
O: Ejection systolic murmur
A: Echo
P: Surgery/TAVI

SAD = syncope, angina, dyspnoea

Arrhythmias
S: LOC associated with palpitations/exercise/lying supine
A: ECG, telemetry, echo
P: Depends on type of arrhythmia

Arrhythmia management:
 Sinus: Tx cause

SVT: 1. Vagal manoeuvre

Narrow complex 2. 6-12mg adenosine 3.
50mg tartrate

AF: 50mg tartrate or

Tachycardic
60mg diltiazem

Broad complex Call for help/shock

Arrhythmia

Narrow complex except

0.6mg atropine
complete block

Bradycardic

Broad complex or
Call for help/pace
complete block

Parkinson’s disease
O: TRAPS
P: Sinemet

TRAPS = Tremor at rest, cogwheel Rigidity, Akinesia, Postural instability, Shuffling gait

Postural hypotension
S: Dizziness/LOC when from standing to sitting due to dehydration/anaemia/infection/autonomic
neuropathy
O: Postural drop >20mmHg or BP increase >20 BPM
A: FBC, U&E, CRP, BGL
P: Treat cause

Seizure
A: Electrolytes, BGL, drug levels, CT head
P: 5mg IV midazolam; 10mg IM if no IV access; long-term anti-epileptics if >2 episodes

Situational syncope
S: Transient LOC due to coughing/toileting

Stroke
S: Sudden-onset neurological symptoms
O: ROSIER 1+
A: ECG, CT, coag screen, carotid dopplers
P: Acute = thrombolysis/aspirin + clopidogrel; long-term = clopidogrel + statin

ROSIER = Asymmetric facial weakness, asymmetric arm weakness, asymmetric leg weakness, speech
defect, visual field defect
Vasovagal
S: Transient LOC preceded by nausea/sweating/closing visual fields in response to
pain/emotion/prolonged standing
Diabetic emergencies
Diabetic ketoacidosis
Defined by BGL > 11, pH < 7.3, and ketosis
Managed with IVF and insulin
Need to keep K+ >5.5 and BG: >14
Monitor Q2H until stable

IVF regime:
1. 1L stat
2. 2L + KCl over 4 hours
3. 2L + KCl over 8 hours
4. 2L + KCl over 12 hours

Add 20mmol KCl if K <5.5 and 40mmol if K <4.5

Add 10% IV glucose at 125ml/h and reduce saline by same amount if BGL <14

Insulin regime:
Prescribe Novorapid sliding scale

Hyperosmolar hyperglycemic syndrome

Defined by BGL > 30, serum osmolality > 320, and hypovolaemia
Manage as per DKA

Hypoglycemia
If conscious give glucose gel and recheck in 10 minutes

If unconscious give 150ml 10% IV glucose stat and repeat as necessary

If no IV access give 1mg IM glucagon
Headache
Differentials

Tension, cluster,
Primary migraine, trigeminal
neuralgia

Headache Meningitis, raised ICP,

temporal arteritis,
Intracranial
venous sinus
thrombosis, SAH, ICH
Secondary
Acute glaucoma,
sinusitis, HTN,
Extracranial
carotid/vertebral
dissection

Headache investigations
B: FBC, U&E, CRP +/- ESR and cultures
X: CT head
S: LP

Headache management
Acute closed-angle glaucoma
S: Pain, swelling, and blurring affecting one eye
O: mid-dilated and irregular pupil; cloudy cornea
A: Tonometry
P: Acetazolamide/alpha agonist/beta blocker/laser

Carotid/vertebral artery dissection

S: Occipital headache associated with neck and facial pain after neck trauma
A: CT or MR angiography
P: Surgery

Cluster headache
S: Painful attacks around one eye
O: Lacrimation, eyelid swelling, Horner’s syndrome
P: 100% O2 + triptan; Verapamil for prevention

Hypertensive encephalopathy
S: Headache, visual blurring, and vomiting associated with HTN
A: CT to exclude hemorrhage; urine dip for hematuria
P: IV labetalol

Intracranial hemorrhage
S: Stroke symptoms associated with headache
A: CT
P: BP control

Meningitis
S: Headache associated with fever, rash, photophobia, and neck stiffness
O: Kernig’s and Brudzinski’s signs
A: Blood and LP cultures
P: Ceftriaxone, vancomycin, and dexamethasone

Kernig’s sign = Inability to straighten knee when hip is flexed to 90 degrees

Brudzinski’s sign = Hips and knees flex when neck is flexed

Migraine
S: Unilateral pulsating pain associated with aura and photophobia
P: Abort with NSAIDs/triptan; prevent with propranolol/amitriptyline

Raised ICP
S: Pain worse in morning or with straining and associated with vomiting
O: Papilledema, CN VI palsy, Cushing’s sign
A: CT head
P: Mannitol; Tx cause

Sinusitis
S: Facial pain exacerbated by straining associated with nasal congestion and rhinorrhea
O: Sinus tenderness
P: Saline rinse +/- antibiotics

Subarachnoid hemorrhage
S: Sudden severe headache associated with meningism
O: Meningism
A: CT head; LP if CT negative
P: coiling/clipping of aneurysm; CCB to prevent vasospasm leading to ischaemia

Temporal arteritis
S: Unilateral throbbing pain associated with scalp tenderness and jaw claudication
O: Temporal tenderness
A: Raised ESR, temporal artery biopsy
P: High dose steroids

Tension headache
S: Bilateral band sensation associated with stress
O: Tension and tenderness in neck and scalp
P: Simple analgesia

Trigeminal neuralgia
S: Unilateral stabbing pain in trigeminal nerve distribution
A: MRI to find cause
P: Anticonvulsants
Venous sinus thrombosis
S: Pain associated with abnormal neurology on b/g hypercoagulable state
A: CT; MR venography
P: Clexane
Hyperkalemia
Causes
Increased intake: Supplements, fluids, blood transfusions
Decreased excretion: Renal failure, aldosterone deficiency
Intracellular to extracellular shift: Hemolysis, tissue breakdown, acidosis

Symptoms
Nausea/vomiting
Muscle pain/weakness
Palpitations

ECG changes
Tall Ts, PR widening, QRS widening, P loss

Management
5-6.4
Low potassium diet
Review medications

6.5+ or symptoms or ECG changes

10ml 10% calcium gluconate to stabilize cardiac membrane
50ml 50% glucose + 10 units novorapid to shift K into cells
Hyponatremia
Approach

Hypervolaemic Heart/liver/renal failure

Euvolaemic Drugs, SIADH, adrenal

insufficiency, overhydration,
(Urine Na >20) hypothyroidism

Hyponatraemia

Hypovolaemic Reduced intake,

diarrhoea/vomiting/diuresis,
(Urine Na <20) pancreatitis

Elevated lipids, protein, or

False hyponatraemia
glucose

Investigations
FBC
Serum osmolality
Morning cortisol
BGL
Lipids
Urine sodium and osmolality

Drugs that cause hyponatremia

ACE inhibitors
ARBs
Thiazide diuretics

Syndrome of inappropriate ADH

Defined as euvolemic + urine osmolality >100 + normal renal/adrenal/thyroid function

Caused by:
Drugs e.g. antidepressants and antipsychotics
CNS pathology
Lung pathology
Malignancy
Post-op pain
Idiopathic