Common treatment orders 2020
A. Urgent !
1. De-sat
2. BP drop
3. Decrease /No urine output
4. Raise BP ~ First reminder ~ (pg.5)
5. Haemoptysis 1. Attend the patient
6. GI bleed / coffee ground vomit 2. Find the cause
3. Treat before deteriorate
B. Lab results
7. Hb
8. Plt
9. Raised INR ~ 2nd reminder ~ (pg.8)
10. Hypo K Recheck after Mx
11. Hyper K
12. Hyper Na
13. Hypo Na
14. Hyper Ca2+
15. Hypo Mg
16. pH < 7.1 ?
C. Cardiac
17. Fast AF
18. Tachycardia
19. bradycardia
20. Chest discomfort (ACS)
21. DVT
D. Endo
22. DKI drip (fasting of DM patients)
23. Hypoglycaemia (H'stix <3.5)
24. Increased H'stix / Sliding scale of Actrapid HM
25. DKA
26. Thyrotoxicosis
27. SST
1
E. GI
28. Constipation
29. Dyspepsia
30. Abdominal pain (anti-spasmotics)
31. Diarrhoea
32. Haemorrhoid
33. H pylori Med
F. Neuro
34. Stroke / CVA
35. Epilepsy
36. Seizure attack
37. CNS tumour / haemorrhage with mass effect
G. Resp
38. Cough medications
39. Chest infection / pneumonia
40. Intubation
41. Ventilator basics
42. COAD drugs & Mx
43. Anti-TB drugs
44. SOB in terminal illness / Sputum sound
45. Induce sputum by hypertonic saline
46. pleurodesis
H. Unclassified ward complaints
47. Pain
48. Headache
49. Fever
50. Nasal allergy
51. Drug allergy
52. Sore throat
53. Skin rash
54. Nocturnal leg cramp
55. Insomnia
56. Dizziness / Nausea / Vomit
2
57. Abnormal behaviour
58. Violent patients
59. Pruritus (+ suspected scabies)
60. Red eye / eye discomfort
61. Drug withdrawal symptoms
62. Nocturnal irritability
63. Oral ulcer
64. Palpitation
65. Hiccups
I. Miscellaneous
66. Contrast allergy
67. Drug overdose
68. Thyroxine replacement
69. Gout
70. Cellulitis
71. DVT warfarin titration
72. Menorrhagia
73. AROU
74. haematuria
75. Unit conversion
76. Creatinine clearance
77. Abnormal lab results / alert
78. Cert 人
3
A. Urgent !
Means: “pop yourself up”
1. de-sat
- consider causes:
- Cardiac: CHF, AMI, arrhythmia, etc ECG 心
- Chest: pneumothorax, pneumonia, pulmonary embolism, mucus, COAD, APO etcCXR
- P/E: vitals, JVP, oedema, listen to chest, heart sound
- Mx: CXR (U&P) / ABG / RLFT; +/- cardiac enzymes/ECG (if cardiac causes)
- Give O2 1-6L via NC or 35/50/100% via face mask (not to exceed N/C 4L/min in COAD)
- Suction for sputum
- Intubation ?/ Ambu bag
- +/- Ventolin 2 puff Q4H PRN (for asthma)
- ***Treat underlying causes (Laxis? / Abx? / BiPAP?)
** Pulse oximetry can be deceiving. Assess RR/ pulse (increased pulse often imply
genuine problem). Try warm up peripheries. Check ABG if in doubt.
2. BP drop (esp: SBP<90 ) -> shock
- set large bore IV (green / pink cap)
- Shock ( cardiogenic vs non-cardiogenic) , and further identify the underlying cause;
- Withhold anti-HT drugs (diuretics and nitrates can also decrease BP)
- P/E: hydration status, signs of sepsis, JVP (CHF?), heart sound, wheeze, urticarial rash
- Mx order: BP/P/ Temp/ SaO2 Q1h
- Fluid resuscitation (very cautious in CRF or CHF)
-NS 500ml FR x1 or Hartmann sol 500ml FR x1 What is Hartmann solution ?
Inotropes ? (seek local preparations in wards)
1.) Dopamine : 1gram in 500ml NS (200mg in 100ml NS): give 5-20ml/hr
(**It would be safe to seek help from senior if Dopamine fails)
2.) Norepinephrine (NE): 8mg in 100ml D5: give 8 – 20ml /hr (useful in septic shock)
3.) Dolbutamine : 250mg in 50ml D5, 5mg/ml, 1ml/hr
4.) Adrenaline drip via CVP ( we would give dopamine first)
- 30mg in 500ml NS: give 5-20ml/hr or 6mg in 100ml NS 1-20ml/hr
( Ward : 3mg in 47ml NS, give 5 ml/hr )
Day1: Do eat 4
3. Decreased or no urine output (if 4hr < 50ml or 1hr<20ml for 6 hours)
- Check BP/P, I/O, temperature, CVP & drain outputs (if any)
- drug chart for nephrotoxic drugs (aminoglycoside, sulphonamide, NSAID)
- Differentiate between causes of
Post-renal : (? BPH / UTI / block foley) ~ First reminder ~
- feel for bladder +/- bedside bladder scan, check Foley patency 1. Attend the patient
Renal: 2. Find the cause
- creatinine level 3. Treat before deteriorate
Pre-renal:
- P/E: feel peripheries, check hydration status, JVP, basal crep, oedema
- PR exam (if PR bleed / tarry stool),
- CXR (if indicated)
For pre-renal causes
- if non-cardiogenic, treat with fluid challenge, e.g. NS 500ml FR or Q1H or Q2H x1
- Hartmann 500ml FR or Q1H x1
- if cardiogenic, according to BP
- consider inotropes (e.g. dopamine) / lasix (e.g.lasix 20 or 40mg iv stat x1)
- Set up CVP
** CVP may not be available in usual situations.
** Take time to attend patient to assess volume status (oedema, basal creps over chest, JVP)
if 1-2 attempts of fluid challenge failed. Patient may be drowned by CHF if several bottles
of fluids were flushed by phone order without assessment.
4. Raised BP (if SBP >180 or DBP >90)
- Common triggering factors: pain, choking, anxiety, confusion, bowel / urinary urgency
(esp. in bedbound / restrained patients)
- Look for chest pain (?MI), SOB (?CHF), headache (?stroke), blurred vision, fundi changes
(↑ICP).
- Norvasc 2.5mg or 5mg x 1 or daily
- Captopril 6.25mg po x 1 or TDS (Avoid in poor renal function)
- Metoprolol (Betaloc) 25mg BD (Avoid in heart failure / HR =/<60 / asthma / PVD)
- Methyldopa (Aldomet) 250mg x 1 or TDS
If eating not allowed, check why
- If swallowing problem, insert Ryle’s Tube and give anti-HT through it
5
Day2: Do sleep
- If pre-op / OGD, check try labetalol 5mg IV stat (better ask your MO)
** In practice, the anti-HT dosage and frequency are variable. Those listed are small
dosages which should help during midnights. Usually stat x 1 would be fine.
** don’t give Adalat sublingual, it can cause sudden drop of BP -> CVA
5. Haemoptysis ( CA lung, tuberculosis & bronchiectasis )
- ABC ! ; SpO2 monitoring
- Bld x ABG
- Sputum x AFB x3, cytology, C/ST, R/M
- Transamin 500mg IV stat then Q6H or QID PO
- MT-2 test / T-spot if TB suspected (may be next morning)
- if known bronchiectasis, consider x-ray for bronchial artery embolization (BAE)?
Three airborne transmitted dis: TB, measles, varicella zoster
6. GI bleed / Coffee ground vomiting
- set large bore IV angio-cath
- Check abdo exam + PR
- Stop aspirin or warfarin or NOAC (dabigatran / rivaroxaban ) or brillinta
- Special alert if Hx of cirrhosis (? bleeding esophageal varices):
--> urgent consult surgical
- NPO ( except med ), give IV fluid,
- BP/P, U/O Q1h x 4 then Q4h if stable
- CXR (look for free gas under diaphragm)
- R/T to BSB, aspirate Q1H x4 then Q4H
- Foley insertion (if in shock)
- Blood x CBC (urgent) + T&S
(For newly admitted UGIB, need to workup for underlying cause,
e.g. by Bld x CBP, L/RFT, clotting, hepatitis status, AFP, Type and Screen)
- Pantaloc 80mg stat then 40mg Q12h IV
Or infusion : Pantoloc 40mg in 100ml NS , give 8mg /hr (20ml/hr)
- Nexium 80mg IV bolus then 40mg Q24h
- Anti-encephalopathy (if cirrhosis): lactulose 20ml QID (? Consider R/T insertion)
- Consult surgical x OGD. ( + Prepare consent form )
6
Day3: When you feel alone, pray to God
You chop means:
B. LABORATORY RESULTS
You are responsible for it
7. Hb
- Check vitals BP / P (tachycardia means problem)
Look for underlying cause: (GIB, menorrhagia, NSAID, recent Surgery)
- PR exam
- Bld x T&S , iron profile (+/- CBP, PBS, INR, Hb pattern, B12/folate, LDH, retic?)
- Stool x occult blood x 3 ( if no obvious PR bleeding, Sensitive? Specific ?)
- Transfuse if Hb < 7; aim at raising Hb to above 7 after transfusion
(Each unit of packed cells raise Hb for about 1g/dl)
- Can consider giving lasix 20mg iv after each pint of transfusion (PC is good vol expander)
- Check post transfusion Hb (+/- RFT)
- If massive transfusion ( > 4 unit of pack cell), consider to give 1 (PC) + 1 (Plt) + 1 (FFP)
- For MDS anaemia / terminal malignanc: treat only if symptomatic (transfusion has risk !)
If any problems related to blood transfusion e.g. Patient with Group A Rh –ve , only Group A
Rh +ve blood a/v , consult haematologist
8. Decreased platelet count (plus fulfill indication for transfusion)
- any sign of sepsis? bruises / active bleeding ? risk of fall -> ICH ? planning procedure /
surgery ?
- 4 or 6 units platelet conc FR x 1 (watch out for fluid overload)
9. Raised INR (read Houseman handbook GM7 when you are free...)
- Transfuse 4 units FFP FR x 1, then re-check INR
Platelet > 70 & INR < 1.3 can tolerate procedures. e.g. TACE, ERCP, Abscess drainage,
PTBD insertion & PCN
Note: FFP cannot stay long in the circulation, only give it within an hour before any
procedure. If not, just waste FFP
10 . Hypokalaemia K
- Look for common causes, e.g. diuretics, vomiting, etc
If cause not obvious, or persistent hypoK, or severe hypoK (K<2.5):
- check spot serum K and osm, urine K and osmol (TTKG?), baseline ECG
Day4: When you’re not sure, ask your senior 7
- Syrup KCl 2gram PO (1gram = 13.4 mmol) Q2H x 2-3 doses
- Or slow K (8mmol K/600mg tabs) tab 1 daily/BD/TDS PO
- Intravenous K supplement if severe or NPO (K<= 2.5mmol/l) ~ 2nd reminder ~
- Give 40-120mmol/d: Don’t exceed 10mmol/hr, use large vein Recheck (blood / x-ray )
- Monitor K, ECG, urine output, +/- consult ICU after you alter management
- Avoid dextrose (lead to further drop in serum K level)
- Give separately or add to original IVF, e.g.:
10mmol KCl in 100ml NS, Q2H x 1
NS 500ml Q8H/pint + 20 mmol KCl/pint (i.e. 60mmol KCl/day) for 3 days
- Usually will re-check Bld x K after supplement if original K<3.0
- Consider hypoMg for persistent hypoK
*** Ward preparation: NS 500ml + 10 mmol KCl or NS 500 ml + 20 mmol KCL
11. Hyperkalaemia (could be life threatening!!!)
K not very high (<6)
- Review drug chart, ECG, cardiac monitoring
- Resonium C 15gm Q6H x 2 PO/PR
- Resonium A (if low Na, watch-out Na and H2O overload) 15gm Q6H x 2 PO/PR
- Recheck Bld x RFT afterwards
K >6
- do the above then
- 10 ml 10% calcium gluconate slow IV stat with cardiac monitor (over 3 min) (by you !)
- DI drip: 50ml D50 + 10u Actrapid HM IV over 30 min
- Repeat ECG in 5 min (if original ECG showed hyper K changes)
- H’stix q1h x 4 then Q4h (may prolong hypo-gly after DI drip)
- repeat RFT
12. Hypernatraemia
- hydration status? , clinical sign (palpitation)
- 500ml D5 over 4 hr 沖淡 (Don’t be too aggressive. Too rapid correction can kill.)
- Recheck blood x RFT
13. Hyponatraemia
- hydration status ? (hypo- / eu- / hyper-volaemia?)
Day5: even if they are extremely busy (and irritable) 8
- Check serum osmol, cortisol, TSH, urine osmal, Na ( always remember adrenal
insufficiency if sBP <100) (NPC with radiotherapy is common in HK)
- Check drug (lasix)
- Treat according to underlying causes ( Refer Houseman Handbook when you are free...)
Hypo-volaemic -> IV NS 500ml Q6h /pint
Eu-volaemic -> fluid restriction , high salt diet
Hyper-volaemic -> Lasix 20mg (IV / PO) + NaCl 900mg TDS PO
14. Hypercalcaemia:
- corrected Ca2+ : (40 – alb ) x 0.02 + serum Ca2+
- off supplements : CaCO3 , vit D
- Bld x RFT, CaPO4, ESR, ALP, Mg, Ig pattern, SPE, +/- PTH
- urine x BJP / SPE
- NS Q6h/pint for rehydration then +/- Lasix
- Pamidronate 60 – 90 mg in 500 mL NS over 4 hrs (weak)
- Zometa 4mg in 100ml NS over 15 min (strong)
- calcitonin / hydrocortisone ?
15. hypo Mg
IV 5 mmol 49.3 % MgSO4 + 100ml NS over 1 hour
PO Mgtri 10ml TDS -> monitor K / Mg / ECG
16. pH < 7.1 (? Cause)
- check ventilator / BiPAP setting if any
- see hydration status/ Hstix (if suspect HONK / DKA , refer to section 25. DKA)
- 100ml 8.4% NaHCO3 over 1 hour (seldom indicated)
- Re-check Bld x ABG afterwards
** See pCO2, beware of hypoventilation / paradoxical cerebral acidosis. Patient may
develop apnea / respiratory arrest.
9
Day6: 又要愛人如己
C. CARDIAC
17. Fast AF (Cause ? ACS ? infection ? pain ?)
- Cardiac monitoring, ECG 12 leads ( note the rhythm- sinus tachycardia )
- Amiodarone drip ( ok for WPW, beware of sign of hyperthyroidism)
- Loading: 150mg in 100ml D5 (No NS!!) over 30 min
- Maintenance: 600mg in 500ml D5 (No NS!!): 20ml/hr
- Digoxin (omit if AR <60)
- Loading dose: 0.25mg in 10ml NS infusion stat, then Q8H x3
- Maintenance: 0.125 mg daily po (0.0625mg for elderly)
- Herbesser 2mg IV and see response (usually very fast)
- Urgent / routine consult medical ? (depends on haemodynamic status)
-
18. Narrow complex tachycardia :
Confirm it is the case with ECG
1. Vagal manuevers contraindicated in patient with carotid bruit
2. ATP 10mg rapid IV push (look at cardiac monitor and prepare crash cart) wait for at least
2 minutes before next dose ATP 20mg rapid IV push warn patient of transient flushing
& chest discomfort
3. Verapamil (isoptin) 2.5mg IV if tachycardia persists & BP stable , can repeat 5mg IV
after 15 min if BP still okay
4. If BP not stable, then synchronized DC cardioversion
19. Bradyacardia:
1. Really bradyacardia ? Assess the rhythm yourself
2. Clinically stable? Conscious state, BP, SOB congestive heart failureneed of atropine,
TCP or inotrope as stated in houseman handbook
3. Causes of bradyacardia 12 leads - ECG
a. drugs- beta-blocker / Digoxin review drug chart
b. Physiological: hypothermia
c. Pathological: rhythm sick sinus syndrome & Atrioventricular block 3 degrees,
hypothyroidism, ACS / MI, HyperK, ……
20. Chest discomfort (ACS)
- Blood x CK, LDH Q8H x3 - ECG stat, then Q8H x3, TnI / TnT stat
- Inform MO +/- urgent consult medical (if likely ACS, e.g. raised TnI)
Day7: Remember, you’re a doctor 10
- Aspirin 160mg chewed stat
- Nitrates: TNG tab 1 SL prn
If chest pain at rest regardless of TNG:
- Isoket infusion 50mg in 100ml NS, start with 4ml/hr (max 20ml/hr)
- Nitrocine 25mg in 100ml NS, start with 4ml/hr (Other dosage: 1mg / 1ml NS, 1ml / hr)
** Avoid nitrates if baseline BP already on low side. If in doubt, ask senior
If chest pain subsided
- Isordil 10mg tds po
- Nitroderm 10mg LA QD
- Cartia 100mg (or Aspirin 80 or 160mg) daily PO
- LMW heparin (if pain not controlled or high risk features present)
- Enoxaparin 0.4ml SC Q12H (40kg person)
- Innohep 0.3/0.4/0.5/0.6 daily SC
If CHF?
- Acertil 2mg daily (max 8mg daily)
- Zestril 2.5mg daily (max 20mg daily)
21. DVT :
A. Really DVT ? ( ? Well’s score)
Clinically unilateral leg swelling, warmth, redness, dilated veins (symptoms)
Homan’s sign , any SOB, BP/Pulse (sign)
Risk factors: old age , malignancy, OT esp. pelvic surgery, OC pills
Urgent US Doppler to confirm
B After confirmation
1. Complete bed rest
2. ECGlook for tachycardia, RV strain, S1Q3T3
3. CXR: any linear atalectasis
4. Monitor BP/P/SaO2 Q1H x 4 , if stable then Q4H
5. Enoxaparin 0.4ml SC Q12 H ( for BW < 40kg, 0.5ml for 50kg , 0.6 ml for 60 kg)
6. Consult medical for warfarin dosage (refer item 71) or NOAC
11
Day8: Be nice to nurse, they can help you (occasionally)
D. ENDOCRINE
22. DKI drip (for fasting of DM patient)
- D10 500ml Q8H, plus the followings:
H’stix Actrapid HM KCL
4-7 0 0
7-11 5 5
11-17 10 10
17-22 15 15
>22 20 20
(e.g. D10 500ml + 10u Actrapid HM + 10mmol KCl Q8H/pint)
23. Hypoglycaemia (H’stix <3.5) –sweating , dizziness, feel weak
- Cause? Sepsis? Drugs? Intake ?
- 50ml D50 iv stat x1 (better to give either 40ml or 60ml as the package limitation)
- then D10 Q8h /pint
- H’stix / neuro-obs Q1H x 4 then Q4H
Oral form dextrose even better as the sugar would not overshot and then dropped quickly
24. Increased H’stix
- 15-20: Actrapid HM 4U SC x1
- 20-24: Actrapid HM 6U SC x1
- >24: Actrapid HM 8U SC x1 / better inform (See vitals / hydration. If dry, for fluid support)
Sliding scale of Actrapid HM
Always look out for any infection , not only giving insulin !
- Check H’stix Q4H , then Actrapid HM according to the following scales:
H’stix Actrapid HM
<8 0
8-12 2
12-16 4
16-20 6
>20 8 + inform
- Or just order single strength according to H’stix reading, e.g.
- Actrapid HM 4 unit sc tds prn if H’stix >16 (or omit if H’stix <10)
12
Day9: Do eat
Hyperglycemia (poor DM control)
- Check HbA1c, glucose, ABG if DKA suspected
- Urine for ketone, sugar, albumin
25. DKA
- NPO Why suddenly DKA?
- O2
- BP/P/SaO2 Q1h
- Strict IO chart
- Foley if RU >250ml (or for urine monitoring)
- Sputum C/ST
- Urine multistix, C/ST
- Bld x CBC, R/LFT, chloride, osmo, CK/LDH/TnI, Glu, ABG, C/ST
- CXR (urgent)
- Fluid supplement, eg. 1-2L over 1st hour (check any dept protocol)
- Insulin pump (1/2 dose in hyperosmolar non-ketotic coma)
- Recheck Hstix Q1h initially
- Recheck RFT, ABG ~Q6h
- +/- empirical Abx
26. Thyrotoxicosis
- Inderal 10mg TDS PO (beware of asthma!)
- Propylthiouracil 100mg TDS PO (check allergic history) or
- Carbimazole 10mg TDS PO
27 SST
Add 250 mcg tetra-cosactide to 500ml NS
Low dose: 2ml NS -> 1 mcg
Check blood : 0 / 30 / 60 min
13
Day10: Do ask anything you’re not sure
E. GASTROINTESTINAL
28. Constipation
- R/O IO, ileus, dehydration (Hx: usual bowel habit)
- review drug chart (Al/ Ca, antacid, CCB, opiate)
- P/E: Abd palpation +/- PR
- Senokot 7.5 or 15mg Nocte po prn
- Lactulose 10ml bd/tds po prn
- Softon 100mg BD PO
- Dulcolax 1 tab PR x1 stat, or Fleet enema 1 tube PR x 1 stat
- Metamucil 10ml BD/TDS PO (orange powder)
** PR agents are often enough, if fail, repeat. Manual evacuation sometimes very helpful.
29. Dyspepsia (?Cause)
- MgTri 10ml tds po, or Triact tab 1 tds po
- Gasteel tab 1 tds po / Mylanta 10ml tds / Gaviscon 10mg tds po
30. Abdominal pain (anti-spasmotics)
- Holopon tab 1 tds po prn
- Buscopan tab 1 tds po prn or Buscopan 20 or 30 or 40mg IM/SC Q6H prn
Don’t use it in I.O., myasthenia gravis, urinary retention due to prostate hypertrophy
If newly admit abdo pain:
Mx NPO
Urine multistix x 1 / urine culture
Bld x CBC, clotting, L/RFT, CaPO4, amylase, T&S, TnI (+/- CRP / ESR)
ECG (if AF , check ABG -> acidosis may point to ischaemic bowel)
CXR, AXR (E/S)
Only ABG can tell pH !
VBG pH has no meaning !!!
31. Diarrhoea
- Chart I/O, +/- IVF supplement
- Look for underlying causes, prescribe the followings only if indicated:
- Lomotil tab 1 qid po prn ( to overcome the side effect of neotigmine in MG)
- Imodium tab 1 qid po prn
- Kaopectate 10ml qid po prn
14
Day11: 愛是恆久忍耐
32. Haemorrhoid (? Cause : constipation / cirrhosis )
- Faktu supp tab 1 BD or ointment LA tds
- Xylocaine jelly LA tds prn
- Anusol 1 tab Daily PR
- laxatives
33 H pylori treatment
Pantoloc 40mg BD + Klacid 500mg bd + amoxicillin 1g bd for 7 days
(substitute amoxicillin with metronidazole 500mg bd in case of penicillin allergy)
15
Day12: Treat your patient nicely (even if they make you feel sick)
F. NERVOUS SYSTEM
34. Stroke / CVA
- NPO except med, IVF (Use NS first. Avoid dextrose-containing IVF)
- BP/P/SaO2 Q4H
- Neuro Obs Q1H x 1/7 (GCS)
- Bld x CBC, L/RFT, clotting, fasting lipid, fasting glucose (Risk factor modification)
- CXR, ECG
- Urgent CT brain (plain)
- Urgent consult medical x assessment
- Off anti-HT drugs; treat only if really high, e.g. BP>200/100
- Off aspirin / warfarin, ( resume after hemorrhagic stroke excluded by CT brain)
- PT x Limb and chest physio ; OT x ADL assess
- speech therapist x swallowing assessment
35. Epilepsy
- ABC, O2, H’stix,
- blood for CBC, LRFT, CaPO4, glucose
- Give D50 50ml iv, thiamine 100mg iv
- Phenytoin (Dilantin) 600mg (10 - 15mg / kg) IV over 30min, then 300mg po/IV
- PR diazepam (valium) 5 mg Q12h PRN (if convulsion > 10 min)
- Consult anaesthetist, ICU (if intubation)
- Monitor BP/P, RR, ECG, temp ; convulsion chart
- Look for infection, poisoning, anti-convulsant withdrawal
36. Seizure attacks
- Convulsion chart, +/- neuro-obs
- If not spontaneously subside in 10min, can consider:
- Valium 5mg iv/PR stat x 1 (up to 5mg Q12h )
37. CNS tumour or haemorrhage with mass effect
- Dexamethasone 8 mg IV x 1 then 8mg Q8H IV
- Dilantin 600mg IV x 1 or 600mg in 100ml NS over 30min x 1; then 100mg Q8H IV
- Pantoloc 40mg IV Q24h / Zantac 50mg iv Q8H
- 20% Mannitol 250ml iv over 20min, then Q8H (if severe cerebral swelling)
- Transamin 1g IV x 1 then 500mg Q6H IV (if sign of bleeding)
16
Day13: Take a break
G. RESPIRATORY
38. Cough medications
- Mucolytics: fluimucil 200mg tds ( more expensive) , 橙樹化痰素
- bisolvon 8mg tds ( cheaper) 氣舒痰
- Expectorants: MES 10ml tds 馬尿
- Cough suppressants: phensedyl 10ml tds, promethazine compound 10ml bd, pholcodine
- Others: Elixir Benadryl, Cocillana 10ml QID PO
39. Chest infection / pneumonia (cough / sputum / dyspnoea)
- Bld x CBC/DC, L/RFT, C/ST
- Sputum x C/ST, AFB smear + C/ST
- CXR
Antibiotics:
- Augmentin 375mg tds (or 1gram BD) po or Augmentin 1.2g iv Q8H
- Unasyn 375mg BD po or Unasyn 750mg iv Q8H
- Klacid 250mg or 500mg BD po ( Clarithromycin)
- Sulperazon 1g iv Q12H + vit K 10mg daily (Suspect HAP)
- Tazocin 4.5g IV Q8H
- Levofloxacin (Cravit) 500mg daily PO - check sputum x AFB first to avoid partially treated
TB
For aspiration pneumonia:
- Remember to ask choking / vomiting Hx
- Speech therapist x swallowing assessment
- IV Augmentin 1.2gram Q8h (may need Sulperazon/ Tazocin if suspect HAP)
For Flu
- NPA x flu A/B
- Tamiflu 75mg BD PO x 5 days (treatment for confirmed case) (dose reduction if elderly
or renal impairment)
40. Intubation ( 2 drugs would be given?) (Don’t give muscle relaxant w/o supervision!)
- make sure suction ready
- Suxamethonium 50mg iv (see K)
- rocuronium 25mg IV (for RSI, use only in very experienced hand !!)
- etomidate (if ICU / anesth setting)
- size 7.5 Endotracheal tube , marking at 22-24cm with cricoid pressure
17
Day14: You’re beautiful
- Air Entry( Rt = Lt ) 5 points auscultation , See chest expansion
- O2 100%
- Check CXR post-intubation, for tube position / exclude any pneumothorax
41. Ventilator settings
Initial settings:
- CMV mode (for resp muscle paralysed)
- Tidal volume (TV): 500mL (500ml/50kg)
- Pressure support: 12
- FiO2: 100%
- RR: 14 /min (if raised ICP / sepsis, need hyperventilation; RR: 18-20/min)
- PEEP (positive end expiratory pressure): 6 cmH2O
- Tinsp: 1.2 sec
- IE ratio: 1 : 2 (may not need to set in some types of machine)
- Recheck ABG 15min after change of setting
- Changed to SIMV mode (if spontaneous breathing) another day when improved
Sedation for ventilator (if patient is very awake / Fight機)
- Consider stat dose of morphine 1mg or dormicum 1mg then infusion
- Morphine 1mg / ml NS @ 2ml/hr (infusion)
- Dormicum 45mg in 45ml 0.9% NS @ 1ml/hr (infusion)
- (ICU setting ) fentanyl 1000mcg in 20ml Premix @ 1 ml /hr
If the followings occurred while on ventilator:
Decreased SaO2
- Check whether pneumothorax
- Increase FiO2 (keep max <60%)
- Increase PEEP (increase recruit alveoli, decrease dead space)
Increased CO2
- Increase RR
- Increase tidal volume (wash out CO2)
- Sedation (more synchronized breathing)
Alarm (high pressure; small TV)
- Pneumothorax / pleural effusion -> chest drain ?
- Block tube => suction / change ET tube
- Fighting vs machine => sedate (last thing to consider)
18
Day15: Learn to form Discharge plan
Alarm (high TV; low pressure)
- Leaking air => check
- BP low
- Must check whether pneumothorax
42. COAD drugs & Mx (steroid + bronchial dilator + antibiotics) (please read GOLD)
- Ventolin 2 or 4 puff Q4h or QID (see puff technique if newly use)
- Atrovent 2 puff QID (long term: consider LAMA)
- Bisolvon 1 tab TDS PO or Fluimucil 200mg TDS PO
- MES 10 ml TDS PO
- Hydrocortisone 100mg IV Q8H then Prednisolone 30mg daily PO (when stable)
- Chest physio & PFR BD
43. Anti-TB drug (check Houseman handbook and consult medical)
- Isoniazid 300mg ; Rifampicin 450mg ; Pyrazinamide 1.5g ; Ethambutol 900mg
- Vit B6 10mg daily
(check HbsAg, anti-HCV, anti-HIV, visual acuity as baseline)
44. Dyspnoea in terminal ill
- consult specialist for advise
- SC Buscopan 20mg q8h if many secretion
- Consult specialist for strong opioid (e.g. morphine) if RR>24
Sputum sound 煲水聲
- Suction / chest physio / treat chest infection
- can try atropine 0.1% 0.3mg SC Q6h or buscopan 20mg SC Q8h
45. induce sputum by hypertonic saline
- 1.5 ml 5.85% hypertonic saline + 2.5 ml 0.9% normal saline nebulized daily PRN
46. Pleurodesis
- minocycline 300mg in 50ml NS for intrapleural cavity
- oxytetracycline 250mg in 50ml NS for intrapleural cavity
- talc 2gram in 50ml NS + lidnocaine
19
H. UNCLASSIFIED WARD COMPLAINTS
47. Pain 痛
- Panadol 500mg QID prn PO/PR (max: 4 gram / day; 2 gram/d if cirrhosis)
- Naprosyn 250mg TDS PO (for MSK pain)
- Diclofenac (Voltaren) 75-150mg daily PO / Voltaren SR 100mg daily
- Tramadol 50/75mg IMI Q6H prn ( beware of resp distress & nausea, avoid in head injury,
can cause serotonin syndrome if on SSRI)
** Add PPI (Pantoloc 40mg daily) for NSAID use.
Local application
- Analgesic balm LA tds prn
- Voltaren gel LA tds good for post-traumatic inflammation
- Hirudoid LA tds prn good for drip site wound 喜療妥
Osteoporotic bone pain:
- Calcitonin nasal spray 400U BD x 7 days
48. Headache
- Document GCS, brief Hx and P/E to r/o sinister causes
- Hx: aura, vomit, blurred vision, ocular pain, HI, ?most severe headache ever
- P/E: BP/P, facial tenderness, fever, neck rigidity, rash
- Ix: Bld x ESR (if suspect GCA), CRP,
- sinus x-ray, CT brain, ?LP
- Panadol 500mg QID PO prn. (Other analgesics choices as above.)
49. Fever
Common causes:
- post-op causes, resp (pneumonia, URTI), UTI, drip sites, wounds, gynae (in female), GI,
ENT, drug-induced, tumour, etc…
Review medications (? on Abx), lab results (e.g. on Abx already & WCC on decreasing
trend?)
Mx order:
- Septic workup if not done:
- Bld x CBC/DC, LRFT, CaPO4, clotting, ESR/CRP, Blood x C/ST
- Sputum x C/ST
20
- MSU x C/ST
- +/- CT brain then LP (if neck rigidity / skin rash / confusion)
- PUO: viral titre / monospot / Widal / cold agglutinin / malaria / ANA / RF
- CXR
- If indicated, start empirical antibiotics
- Panadol 500mg Q4h PO prn if temp >=38 degrees
- if NPO: panadol 500mg Q4h PR prn or Indocid 1 tab Q12h PR prn if fever
(For neutropenic fever WBC<1, ANC<0.5: Tazocin 4.5 gram Q8h IV or Fortum 1-2 gram IV
Q8h)
Post-op fever:
- Within 48 hours: usually atelectasis
- chest physio , incentive spirometry, encourage deep breathing
- 48 hours to 5 days: chest infection, UTI, drip sites, etc…
- After 5 days: wound infection, intra-abdominal abscess, DVT
For tumour fever:
- touch baseline, swinging, not septic looking, all c/st -ve
- Naprosyn 250mg TDS PO + pantoloc 40mg daily (avoid NSAID if renal impair)
50. Nasal allergy -relief of symptoms of allergic rhinitis
- Piriton 1 tab (4mg) TDS PO
- cetirizine (zyrtec) 1 tab daily PO / Clarityne (loraditine)1 tab daily PO 佳力天
- Phenergan (promethazine) 25mg TDS PO (** can be very sedating, avoid in Geri)
51. Drug allergy (Must see SaO2, if desat or angiooedema -> inform MO)
- Hydrocortisone 100mg IV Q8h ; Piriton 10mg IV Q8h
- if anaphylaxis: + 100% O2, adrenaline 10ml in 1:10000 solution IV / 1ml 1:1000 IM
52. Sore throat
- Cepacol/Dequadin/Strepsils tab 1 QID PO prn 得果定/ 使立消
- 0.2% Chlorhexidine MW 10ml LA TDS
- Thymol gargle MW 10ml LA TDS
53. Skin rash
- Exclude allergic reactions
21
- Synalar Cr 0.005/0.025/0.05% LA TDS
- hydrocortisone cream 1% LA TDS
Grey Nail (Fungal ?)
- Bactroban cream LA TDS
- Trosyd LA TDS
Burn wound : Actovegin LA TDS
TKI induced hand-foot syndrome
- Silver sulphadiazine cream 1% LA TDS
- Hydrocortison cream 1% LA TDS
54. Nocturnal leg cramp
- Baclofen 5mg tds PO (muscle relaxant)
55. Insomnia
- Piriton tab 1 po x 1
- Ativan 0.5-1.0mg Nocte PO x 1
- Imovane 3.75mg Nocte PO x 1 ( zopiclone 1 tab = 7.5 mg)
56. Dizziness 暈
If sudden onset and severe
- Hx and P/E to exclude sinister causes (e.g. stroke) check tone & power both sides
- Non specific ? Vertigo ( Hallpike’s maneuver )
- H’stix stat, postural BP (= erect and supine)
- +/- CT brain (? SOL / haemorrhage / infarct )
- ECG
-Bld x CBC, LRFT, CaPO4, clotting
- Stemetil 1 tab / 5-10mg tds prn, Stemetil 11.25mg IMI q6h prn
- Ser C (Merislon) 1 tab (6mg) tds po prn
Vomiting/ Nausea 嘔
- Look for underlying cause (e.g. S/E of medications)
- ? IO , peritonism , increase ICP, MI, VBG if AF ? metabollic acidosis (? Ischaemic bowel)
- Maxolon 10mg tds po / Maxolon 10mg IM/IV Q6h prn (avoid if suspect IO / MBO)
- Kytril 1mg IV / Zofran 8 gm IV (expensive, seen in chemo / oncology units mainly)
22
57. Abnormal behaviour
- For those with psychi history, watch out for drug overdose / drug interaction
- Haloperidol 1 mg Q6H IMI/SC;
half dose for elderly (try Haldol drops 0.1mg x1 if frail)
58. Violent patients (? Cause)
- Haloperidol 1mg IMI x 1
- Ativan 0.5 mg – 1mg PO x 1
- Quetiapine 12.5 mg PO x 1
- Pulse oximetry, cardiac monitor, BP/P Q1H x 4
59. Pruritis 癢
- After excluding allergic reactions / scabies in OAH elders
- Aqueous cream LA tds prn
- Eurax cream LA tds prn 優力斯
- Piriton 1 tab tds po prn
- Atarax 1 tab (25 mg) tds po prn
If suspect scabies:
- Skin scrapping for scabies (check worst skin lesion: finger web, axilla, groin, knee)
- 5% permethrin cream LA, to whole body except face once (+/- repeat after 1 week), or
- Benzyl benzoate lotion LA, to whole body except face once daily at night for 2 doses
- Follow by eurax the day after if persistent itchy rashes
60. Red eye or eye discomfort
- Do exclude sinister causes first! (e.g. ciliary flush / eye pain / corneal ulcer/ halos)
- Hypromellose 2 drops LA Both eyes tds
- Methylcellulose eyedrop 2 drops LA BD BE
61 Drug withdrawal symptoms (Drug addicts)
- Physeptone (methadone) 5 or 10 or 15mg BD po prn (ask detox clinic to fax the usual dose)
62. Nocturnal irritability
- Quetiapine 25mg nocte PRN (see baseline ECG for any QT prolongation)
- Haldol 1mg nocte PO (Haldol drops 0.1 mg nocte PRN for geri, start low)
63. Oral ulcer
- Bonjela LA TDS
- Solcoseryl dental paste LA TDS
- Acyclovir Cr LA TDS (herpes ?)
23
- Thymol Gargle 10ml LA DS
- Diflucan syr 50 mg daily PO (fungal ?)
- Aspirin Gargle 300mg MW QID
64. Palpitation
- Inderal 10mg TDS PO prn ( propranolol)
(only for symptomatic Rx; always look for underlying cause, e.g. arrhythmia, AMI..)
65. Hiccup
1. Paper bag for self re-breathing (布袋法)
2. Stemetil 5-10mg TDS PO PRN
3. largactil 25mg TDS PO PRN (not much ppl use this?)
24
8. MISCELLANEOUS
66. Contrast allergy / pre-medication (Some x-ray dept NO need pre-med)
- (urgent) Hydrocortisone 200mg IV on call to radiology department then q4h till 12hour after
CT scan or
- Prednisolone 40mg BD PO + Pepcidine 20mg BD PO 1 day before exam
** Always refer to the protocol of radiology department. It differs in different hospitals.
67. Drug overdose (refer to houseman handbook for specific treatments)
- usually more than 1 drug !
- Suicidal precaution
- NPO, give IVF
- BP/P/SaO2 Q4H; Neuro-obs Q1H for 1/7; Cardiac monitor
- Urgent bld x CBP/DC, clotting, ABG, L/RFT, glucose, CaPO4, amylase, toxicology
(paracetamol, salicylate, benzodiazepam, ethanol)
- Urine for toxicology
- Gastric lavage for toxicology (seldom use now)
- consult toxicology ! (HKPIC) – 27722211 or 26351111
68. Thyroxine replacement
- Start at 25microgram daily; check TFT to monitor the dose (at least 4 weeks interval)
69. Gout
- Colchicine 0.5mg TDS until pain subside /diarrhea (consider 0.25 mg if elderly, better tolerated)
- Naprosyn 250mg BD PO / regular panadol 500mg QID PO
- low purine diet
- withhold diuretics ? / improve hydration
70. Cellulitis
- On exam, note any fluctuation (which indicate underlying abscess),
if +ve, bedside needle aspiration to look for pus aspirates (usually done by MO)
- (DM?) Hstix TDS
- bld x CBP, L/RFT, ESR/CRP, Blood x C/ST;
- wound swab x C/ST
- X-ray of the affected part: to exclude underlying osteomyelitis / septic arthritis
- ampicillin and cloxacillin 500mg iv Q6H
- If mild, ampicillin and cloxacillin 500mg QID PO x 1/52
** Mark margin of erythema with marker if suspect NF. Review yourself / ask nursing staff to
inform in margin grows rapidly.
25
71. DVT Warfarin titration
- clexane 0.4 mg SC Q12h x 3 days then start
- Warfarin 3mg daily PO (loading) x 3 days then 1mg daily PO
- if elderly > 70 yrs old or malnutrition or BW < 60 kg, omit loading
- daily INR till stable
(Consider NOAC ?)
72. Menorrhagia
- BP / P Q4h
- CBC, clotting , T&S
- Transamine 500mg QID PO
73. AROU:
- Feel for bladder -> bladder scan
- Bld x CBC, L/RFT, Ca PO4, glucose
- CSU x C/ST
- KUB
- foley to BSB if RU > 400ml
- senna 15mg nocte / lactulose 10ml BD PO (to ensure good bowel open)
** Do not check PSA during ROU episodes. Look for UTI / constipation, esp. in females
74. Haematuria :
- DAT, Encourage fluid intake
- CBP, L/RFT, CaPO4, Glu, INR/APTT
- Save urine x inspection
- MSU x C/ST
- EMU x AFB x 3
- Urine x cytology x 3
- KUB
- Pyridium 1 tab tds x 1/52 (warn patient for orange urine)
- Nitrofurantoin 50mg QID x 1 /52 if febrile (or other Abx acc to prev C/ST)
- consult uro x cystoscopy +/- IVU
75. Unit conversion
- mmHg x 0.13332 = kPa
76. Creatinine clearance (by C-G)
(140-age) x BW(in kg) x 60 ( x 0.85 if female) / serum Cr x 49
Or CrCl = (24 hr Cr / serum Cr) x 0.7
26
77. Abnormal lab results
- With alert : inform MO if not sure
- **Abnormal pathology report/ tumour: trace folder + inform case MO (don’t just chop!)
78. Cert 人
No detectable blood pressure / pulse
No spontaneous breathing
Pupils fixed and dilated
No oculocephalic reflex
ECG asystole Is ECG a must for certified death ?
Patient certified death at time, date
Cat 1 body
27
th
(Table below from IMPACT 5 edition)
28
29
30
31
Please take good care of yourself, physically and spiritually.
This note is intended for personal use.
Please do not copy any part of it without exercising your own judgement.
This is not a textbook, please don’t quote it.
Please keep yourself update to international and local guidelines.
Please throw this little booklet after your internship, things get changed!
Update on 14/5/2020
32
