Samuel Quek 21/4/15 00:19

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Samuel Quek 21/4/15 00:19

A S u r v iv a l
Formatted: Font:(Default) Times New
Roman, 12 pt
Samuel Quek 21/4/15 00:19
Formatted: Normal, Left

G u id e t o S G H :
For Junior Doctors

Brought to you by
The Junior Doctors Committee, SGH
Learning and Career Development Department, SGH
Medical Manpower Department, Singapore Health Services

First Edition: August 2009.

-0-
 Contents:

1. Getting around SGH – layout map and telephone

numbers
2. Preparing for work in SGH
3. First day at work/orientation in wards
4. Learning to use Sunrise Acute Care/OTM
5. Ward rounds
6. Doing changes
a. Blue letter referrals / referrals to step-down
facilities
b. Obtaining investigations / angiographic
procedures
c. Arranging for surgery / endoscopy (aka PFO)
d. Discharge summary and prescriptions
e. Others
7. Night calls
8. List of commonly used drugs

DISCLAIMER: Information correct as of 1st August 2009

-1-
Getting around SGH

Level 1

-2-
Level 2

-3-
Important Telephone Numbers
Area Ext Area Ext
Operator! J 0 IPS (blk 6 lvl 2) 5135
OT reception 4364 Radiologist 5460
EOT 4365 Radiology (blk 4225
2 lvl 2)
Day surgery 4121 Trace XR 4232
reports
Endo Centre 3986 Interventional 3955/3941
Radiology (blk
2 lvl 2)
Blood Bank 3666/4852 CT 3960
BTS MO 91864133 Trace CT 5672
reports
Biochemistry 4653 2D Echo 5577
lab
Hematology lab 4628/4629 NHC 2DE 64367867
Report
Histology lab 4930/1 Vascular Lab 5614
Microbiology 4908 Nuclear 4203
lab Medicine
Virology 4941 SICU 4222
Cytology 4954 CCU 4440
Client Services 4950 MICU 4450
(Path)
TB Laboratory 62221391 NICU 5333
Peritoneal 81251394 Drug 4112
Dialysis Nurse Information
MRO 4333 Pharmacist On 97733301
Call
NHC MRO 94367640 Palliative 81232711
Medicine
NHC 64367800 Medical 65574796
Manpower
NCC 8083
-4-
Preparing for work in SGH
■ Attend the orientation lectures
■ Know which department and team you will be joining
■ Speak to seniors or current HOs in the department
■ Find out who the consultants are, what the department
schedule is like, where and when ward rounds start and
any other dept-specific jobs that you are expected to do
(e.g. running SDA)

First day at work

■ Arrive early J
■ Introduce yourself to the ward staff and to the ward
Sisters
■ Familiarise yourself with the ward. Find out where
case sheets, charts & IMRs are kept, where the
preparation room is and (very importantly!) where
equipment like the resus trolley and pulse oximeters are
stored
■ Prepare for ward rounds
■ Make and print a list of your team’s patients (see
Learning to Use Sunrise/OTM)
■ Check up on all the latest investigation results and
note them down on your list
■ Plan your route if you have many patients in different
wards all over the hospital
■ Get the case files, IMRs and clinical charts ready

-5-
How to use Sunrise Acute Care
1. To create a list of patients
o Click on “File” > “Maintain list”> “New”
o To create list according to location, click on
“Location” > “Include patients at selected locations
only” > “SGH” > “Inpatient locations” > Desired
block and ward number > “Add” > “Ok”
o To create list according to consultant, click on
“Click on “Providers” > (key in and select required
name) > “Add” > “OK”
o Name your list

TIP: Only choosing “provider” will create a list that

includes all patients who are also registered in the clinics,
etc. Therefore, use the “provider” option in conjunction
with the “location” option (Add “inpatient locations” to
selected locations)

2. To search for a specific patient

o Click on “File” > “Find patient” > Fill in patient
particulars/IC number, then select desired visit to
hospital

-6-
 o The patient will be added to a “Temporary list”
(which will not be saved if you log off).
o To save patients into a new list, highlight their
names then click on “Save selected patients” and
either add them into an existing list or create a
new list

3. To view patient’s results

o Select the patient by highlighting patient’s name
on your list
o Click on “Results’ and view desired investigation
results (may be viewed as a summary page, trend
view or single reports)

4. To print out patient’s results

o Select desired results to be printed
o Click on the printer icon then choose either “Trend
result” or “Single report” (remember to highlight
only the result that you want to print from
“Summary”, otherwise ALL results from current
admission will be inadvertently printed out)

-7-
To create a list of patients:

Click on “File” >

“Maintain List” > “New”

By location:

Click on “Location”>
“Include patients at
selected locations
only” > “SGH” >
“Inpatient locations”
> Desired block and
ward number >
“Add” > “Ok”

By consultant:

Click on
“Providers” > (key
in and select
required name) >
“Add” > “OK”

And you now have your list:

-8-
 TIP: Add “HIDS” and “IMS” to
your toolbar by going to
“Preferences” > “Toolbar”.

Otherwise you can also

access HIDS or IMS by
going to “Tools”

Printing results
Click on the printer icon, then
Results of investigations choose either “Trend result” or
“Single report” (remember to
highlight only the result that you
want to print from “Summary”,
otherwise ALL results from
current admission will be
inadvertently printed out)

Choose to
view
results in
different
formats

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 Making a Prescription

Tick in the
box for
drugs that Ensure correct
you would dose, route,
like to frequency,
repeat duration before
submitting orders

Type in
name of Submit order
drug and when done
select
from list
shown

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Ward rounds
Armed with your list, you can now start seeing patients
before the consultants and registrars arrive
Documentation in Case Sheets
1. Ensure that the date, time and name of most senior Alyssa Chiew 2/10/13 06:04
Formatted: Indent: Left: 0.63 cm,
doctor doing the ward round is written down on the Numbered + Level: 1 + Numbering Style:
1, 2, 3, ... + Start at: 1 + Alignment: Left +
Aligned at: 1.59 cm + Tab after: 2.22 cm
left hand margin of the page + Indent at: 2.22 cm, Tabs: 1.27 cm, List
tab + Not at 2.22 cm

2. Write legibly in the case sheets using the SOAP

format
• S (subjective) – Ask patient how he is doing, any
complaints, etc

• O (objective) – Write down patient’s parameters Alyssa Chiew 2/10/13 06:04

Formatted: Indent: Left: 1.27 cm,
(e.g. temperature, blood pressure, heart rate, Bulleted + Level: 1 + Aligned at: 1.59 cm
+ Tab after: 2.25 cm + Indent at: 2.25
cm, Tabs: 1.93 cm, List tab + Not at 2.25
intake and output, relevant investigation results). cm

Also include relevant physical findings (e.g.

neurological examination for a patient with recent
CVA or abdominal findings in a surgical patient)

• A (assessment) – Also known as ‘Impression’. List Alyssa Chiew 2/10/13 06:04

Formatted: Indent: Left: 1.27 cm,
the patient’s current issues in order of importance Bulleted + Level: 1 + Aligned at: 1.59 cm
+ Tab after: 2.25 cm + Indent at: 2.25
cm, Tabs: 1.93 cm, List tab + Not at 2.25
cm

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 • P (plan) – Plans for patients should be written out Alyssa Chiew 2/10/13 06:04
Formatted: Indent: Left: 1.27 cm,
clearly. Plans which are also instructions for Bulleted + Level: 1 + Aligned at: 1.59 cm
+ Tab after: 2.25 cm + Indent at: 2.25
cm, Tabs: 1.93 cm, List tab + Not at 2.25
nurses to carry out (e.g. nursing procedures, cm

discharge plans, investigations to be done) should

be written into the left hand column
3. Sign and stamp your name at the end of each entry

Writing into the IMRs

1. Ensure that you date and time every entry Alyssa Chiew 2/10/13 06:04
Formatted: Indent: Left: 0.63 cm,
2. Use generic names as far as possible Numbered + Level: 1 + Numbering Style:
1, 2, 3, ... + Start at: 1 + Alignment: Left +
Aligned at: 1.59 cm + Tab after: 2.22 cm
3. Write names, dosages and units clearly! + Indent at: 2.22 cm, Tabs: 1.27 cm, List
tab + Not at 2.22 cm

4. Sign off EVERY entry in the IMR

5. Do not forget to fill up the page for the patient’s diet
6. Instructions for blood glucose monitoring should be
written on the back page of the IMR

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After Ward Rounds: Doing Changes
Bloods
WARINING: MAKE SURE THE STICKER BELONGS TO THE
RIGHT PATIENT. MAKE SURE YOU WALK TO THE RIGHT
PATIENT AND IDENTIFY THE PATIENT BY NAME AND IC
AND CHECK THE WRIST TAG.

1. Type of tubes to use:

• Purple - FBC; Alyssa Chiew 2/10/13 06:04
Formatted: Indent: Left: 1.6 cm, Hanging:
0.66 cm, Bulleted + Level: 1 + Aligned at:
• Yellow - UECr/LFT/Cardiac enzymes; 1.59 cm + Tab after: 2.25 cm + Indent at:
2.25 cm

• Blue - PT/PTT;
• Pink - GXM
• Green- Toxicology
• TB quantiferon: 3 special tubes, ask the nurses to
order these in advance
• Uncommon investigations: Check with client
services (x4950)
2. For GXM: Sign 7 stickers for the tube, the GXM form
accompanying the tube & the GXM form for the
nurses to collect blood with (i.e sign two forms)
3. Taking blood when setting IV plugs: Attach blue
connector & vacutainer holder to the IV plug & watch
those tubes (culture bottles included) fill effortlessly
away

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4. Taking blood from lines: Similar to a blood C/S (i.e.
needs to be sterile)
What you need: dressing set, sterile gloves, 2x20ml
syringes, hep saline flush, yellow caps
Clean the area, draw out 5-10ml & discard, draw the
blood you need, flush liberally, close with new yellow
cap
5. Adding on blood: Call up the relevant lab (as long as
the blood has been taken within the same day)
6. Urgent ABG or blood transfusion
• Urgent ABGs can be done in the lab at block 6 Alyssa Chiew 2/10/13 06:04
level 5 Formatted: Indent: Left: 1.6 cm, Hanging:
0.66 cm, Bulleted + Level: 1 + Aligned at:
1.59 cm + Tab after: 2.25 cm + Indent at:
2.25 cm
• Urgent blood can be collected from the blood
bank, also at block 6 level 5
• Bring along your GXM form and stickers
• Enter via the block 7 entrance if you don’t have
the access card
7. Needlestick injuries
• Rinse under running water STAT Alyssa Chiew 2/10/13 06:04
Formatted: Indent: Left: 1.6 cm, Hanging:
0.66 cm, Bulleted + Level: 1 + Aligned at:
• Always report! (RMS) 1.59 cm + Tab after: 2.25 cm + Indent at:
2.25 cm

• Take or ask someone to help take the patient’s

blood (if it gets chopped with the “SGH
needlestick project’ chop, the patient won’t be
charged)

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 • Keep the patient’s sticker so you can trace the
results
• Go to the Staff Clinic or A&E to get your blood
taken

Blue letter referrals

1. Generally means a referral letter to a different
department seeking advice or assistance in the
management of a patient
2. Know what the indication for the referral is!
3. Writing a blue letter. Give a brief summary of the
patient’s relevant medical history, current issues,
investigations & treatment, and how the referred
specialist is to help in the management (e.g. referral
to ID for antibiotic stewardship, referral to CVM to
rule out AMI)
4. Sending off a blue letter
• During office hours
a. Non urgent blue letters should be dispatched
by 4pm to ensure that the patient is seen on
the same or next day
b. Contact the on-call Registrar for urgent
referrals – Remember to tell them the

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 patient’s location! These blue letter may then
be clipped in front of the patient’s case sheet
and need not be dispatched
c. For urgent CVM blue letters during office
hours, call CCU at 4440 to find out which
Registrar to contact
• After office hours (including weekends)
a. Non-urgent blue letters will not be dispatched
till the next working day
b. If you need patients to be seen urgently,
contact the on-call Registrar, and similarly, do
not dispatch the blue letter
5. Review of patient by another specialty
1. Before sending off a blue letter, check that the
patient is not under active follow up with that
particular discipline (prevents delayed reviews
from your blue letter bouncing back). You can
check this by asking the patient, reviewing old
notes or checking visit history on Sunrise Acute
Care.
2. Check which consultant the patient has been
seeing & call that consultant

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Referring to Integrated Care System (ICS), mainly for
voluntary nursing homes
1. ICS applications for nursing homes are done
online
2. The MSW in charge will create an application for
the patient, after which you and the PT/OT
involved will fill in the relevant sections
3. Either ask the nurse manager of the ward to log on
for you, or (because sisters are usually pretty
busy) create your own account at
https://www.ics.com.sg/ereg

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Obtaining investigations
- For non-urgent investigations, fill up relevant forms
and fax them to the relevant departments
- For urgent investigations
o Regular X-rays – fill up X-ray form, write
URGENT and fax form to radiology department
o US/CT/MRI scans – fill up X-ray form and
additional “Urgent Investigation” form, and fax
both down to radiology department
o Check renal function before ordering CT scans
with contrast: IV hydration +/- N-AcetylCysteine
may help reduce risk of renal failure.
o Patients with history of multiple allergies or
asthma will need preloading with steroids
(usually IV hydrocortisone 100mg STAT)
o Angiography / interventional procedures – fill up
form, go personally to the interventional
radiology department and speak to the
radiologists there; get a protocol from the
department and prepare patient as necessary
(eg FBC, PT/PTT within 3 days of procedure,
consent, etc). Inform ward staff of date and time
of procedure.

- 18 -
 o Other investigations – Speak to relevant labs
- For investigations to be done after office
hours/weekends
o Speak to radiologist on call and if approved, fax
down X-ray form to radiology department (5133)

Listing patients for surgery

- Different departments have different protocols,
therefore always check with your consultant
regarding the need for pre-procedural investigations

- 19 -
Elective List
- Important things to remember when planning
patients for surgery:
o Check the patient’s FBC, U/E/Cr, GXM +/-
PT/PTT
o For patients above 50 or with indications (e.g.
chronic smoker), do ECG and CXR
o Ask if the patient needs any pre-operative
assessment for risk stratification (e.g. referral to
CVM for history of IHD with previous CCF KIV
for further investigation of cardiac status prior to
op, or referral to respiratory medicine for chronic
smoker who has symptoms of significant
dyspnea). If so, refer them to the relevant
specialties early.
o Confirm if there is a need to stop
antiplatelets/anticoagulants prior to invasive
procedures
o Ensure patient is NBM from 12 MN onwards the
day before operation (may take clear feeds till
about 6am)
o Put up an OT chit (see “Learning to use the
OTM”)

- 20 -
 o Check if patient requires blood on standby
during the operation (see “Learning to use OTM”
and “Arranging for blood products”)
o Check with team which priority patient is to be
listed for in cases of emergency procedures
o For urgent cases, may need to speak to the
anaesthetist on call to inform them of case
(usually done by the MOs, but occasionally the
responsibility may fall to you)

- When patient has not yet been listed for an operation

(listing can be done up to 11am the day before
operation day)
o If operation date is a few days away, fill in listing
form and fax to listing room
o Call listing room to confirm receipt of listing form
o For last minute listings (after 11am the day
before operation) aka “manual listing”, go to the
major OT reception counter to handwrite the
particulars of patient and operation (ask the OT
reception nurses for help if you are lost). Bring
along 8-10 patient sticky labels and ask for
carbon paper, as there will be multiple copies of
the OT list to fill in.

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Emergency List
- For operations to be done in the emergency theatres
(EOT),
o Ensure that patient has valid blood
investigations and has been fasted appropriately
o For major operations, ensure valid group and
cross match with blood on standby
o Ensure consent has been taken
o Send OT chit (see “Learning to use OTM”) and
call EOT at 4365 to check for receipt of EOT
Chit
o Remember to fill up the pt’s comorbidites under
“past medical history” as this is important for
anaesthetist

Listing patients for endoscopic procedures

o Ensure FBC, U/E/Cr, GXM +/- PT/PTT done
o ECG and CXR if indicated
o Keep NBM from 12 midnight onwards the day
before procedure
o Prescribe 2 litres of PEG from 6pm onwards the
day before a colonoscopy
o Put up an OT chit (see “Learning to use OTM”)

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o For urgent cases, inform staff at endoscopy
centre of case
o If General Surgery saw your pt as a blue letter &
requests for a scope the next day without
specifying any particular surgeon, do the
following: Monday = “Team 1 Reg On Call” (ß
choose this option from the list of doctors in
OTM), Tues = T2 Reg On call… and so on,
except for Fri = Team 6 and Sat = Team 5.

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Learning to use OTM

1. Log on to OTM using your userid and password

2. Submitting an OT chit
o To submit an emergency OT Chit, click on “OT Alyssa Chiew 2/10/13 06:04
Formatted: Indent: Left: 1.27 cm,
Chit” > “Emergency OT Chit” Bulleted + Level: 1 + Aligned at: 0.63 cm
+ Tab after: 1.27 cm + Indent at: 1.27
cm, Tabs: 1.9 cm, List tab + Not at 1.27
o To submit an electively listed OT Chit, click “OT cm

Chit from Worklist” > select theatre number >

“search” > select patient’s name > “create chit”
o Alternatively, click on “Emergency OT Chit” >
“Elective” > and when prompted, click yes to add
on chit
o Fill in patient’s MRN and the correct account
number
o Fill in all relevant details (all blue boxes are
compulsory boxes)
o Remember to include all relevant medical history.
This helps the anaesthetist in deciding the urgency
of procedure, or whether further blood
tests/investigations need to be done before
sending patient for the operation.

- 24 -
3. To look up listed patients
o If you are in a surgical department, you will have
to look out for patients who have been listed for
operations and may be admitted the day before
the operation. To obtain the list of patients listed in
a certain operating theatre, click on “Schedule” >
“Online Listing Enquiries” > then choose “OT
listing by OT” > “OT number”

4. To check for availability of blood on standby

o Click on “Blood” > “Homologous Blood
Information” and key in necessary information

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Learning to use OTM

Log on to OTM

To submit an
emergency OT chit,
click “OT Chit” >
“Emergency OT Chit”
Emergency OT Chit
To submit an elective
listed OT Chit, click
“OT Chit from Worklist”
Alternatively, click on
“Emergency OT Chit”
> “Elective” > and
when prompted, click
yes to add on chit

All blue items are

compulsory

* tip: fill in relevant

medical history to
assist anaesthetist in
deciding whether
further inx may be
necessary prior to op
- 26 -
Elective OT Chit (listed)

For cases pre-listed in

system, just click on patient’s
name and click “create chit”

To check patient’s listed for a specific date

Click “Schedule”>
“Online Listing
Enquiries” > then
choose “OT listing by
OT” > “OT number”

- 27 -
To check if blood for standby is approved,

Click on “Blood” >

“Homologous Blood
Information” and key
in necessary
information

- 28 -
Discharging a patient
- When team has decided that a patient is for
discharge, certain documents need to be prepared.
These include the discharge summary, MC,
prescription and relevant memos
o Important points:
§ Try to provide a detailed history in HIDS for
ease of future reference
§ Include relevant investigations (do not
include ALL investigations done in the past
month!)
§ Manually include cardiac investigation
results e.g. ECG, 2D Echo, cardiac
catheterization reports and vascular
investigations if any (as these are currently
not available on Sunrise)
§ Include impressions/assessments by other
specialties if blue letter referral was
previously made, also include which
specialist consultant is involved
§ Include any complications/problems during
stay

- 29 -
 - Prepare prescriptions early to prevent delay in
discharging patients
o Controlled drug prescriptions (e.g. for morphine)
need to be handwritten in a particular format.
There is a sample copy to follow in most wards.
Otherwise, ask pharmacy to fax over
o Also include controlled meds in your electronic
prescription so that they’ll be in the patient’s
medication record.

- Do not give the detailed discharge summary to

patients/relatives unless approved by team
consultant, instead, inform patients/next of kin to
request for a copy of discharge summary/medical
report from business centre

Others
1. Arranging blood products
o
WARNING: CHECK THE WRIST TAG AND
MAKE SURE YOU CHECK PATIENTS
IDENTITY WITH NAME AND IC NO. DO
NOT CHECK BLOOD AT THE NURSES
COUNTER!

- 30 -
 Call blood bank at 3666
o Ensure valid group and cross match (GXM) done
o In SGH, a GXM sample is valid for 3 days
(inclusive of day sample was taken)
o If there is a valid GXM, ask for patient’s blood
group
o Platelets, CSP and FFP require approval from
BTS (blood transfusion service) MO. If blood bank
is unable to approve PCT, will also require prior
approval from BTS MO
o Call BTS MO at 91864133 to obtain approval for
required blood products. Ensure you have
patient’s particulars (name and IC number), blood
group and indications for transfusion prior to
speaking to BTS MO
o Inform ward nurse of approval by BTS MO and
they will collect products from blood bank
o Of particular importance if you’re calling for
haem/onc patients, check if the blood needs to be
irradiated and/or filtered (usually for pts planned
for or post-transplant)
2. ESRF patients
§ Haemodialysis

- 31 -
 o Things to ask (Some patients carry a card
with these details): Which dialysis centre,
usual dialysis days, when the patient had his
last dialysis & whether it was successfully
completed & which renal consultant he follows
up with
o If patient is likely to be due for dialysis during
his stay, call up dialysis centre and ask for:
Dry weight, flow rate, usual dialysis duration,
HIV / HepB / HepC status
o Next call the renal MO under the patient’s
consultant to ask them to help with the
dialysis prescription (a form on which they
write instructions for dialysis)
o Ask the nurses to place the dialysis
prescription form in the patient’s IMR for the
renal MO to fill in
§ Peritoneal dialysis
o Call the PD nurse (8125 1394, 24 hours) for
help with setting up the bags
o Hypocount monitoring is done with a different
glucometer when patients are on PD! Remind

- 32 -
 the nurses to obtain this machine to prevent
spuriously high readings

§ Taking blood/transfusions: Try to arrange for

bloods to be taken pre-dialysis (to spare the
patient from multiple phebotomies) & for
transfusion to be done across dialysis to reduce
the risk of fluid overload

3. Pacemakers
§ Will usually need a CVM review for advice
§ For pacemaker calibration, call Medtronics
technician - 91199955

- 33 -
New cases
1. Useful framework for listing your plan:
§ Diet
§ Activity: fall precautions, CRIB
§ Vitals: parameters, hypocount, I/O
§ Investigations: bloods, urine, stool, radiological
§ Drugs: fluids & medications
§ Trace old notes

2. Elective admissions for operation

§ Pre-clerk
§ Check the op list before hand & pre clerk the
patients
§ Also pre-clerk those planned for op on Mondays,
so your on-call friend doesn’t get overwhelmed on
Sunday

3. Consent & Marking

§ Make sure the consent form, relevant addenda &
any necessary research consent forms are signed!
§ No abbreviations
§ List of addenda available on SGH intranet

- 34 -
§ Pink consent form for patients unable to give their
own consent
§ If no relatives available to sign the pink form, 2
consultants can instead sign in the case notes to
approve the procedure
§ Use a waterproof marker to mark the correct site
of surgery (check with pt to make sure that you are
indeed marking the correct site)

- 35 -
Common Ward Issues (list not meant to be
exhaustive) – call for HELP early!

1. Unconscious patient Alyssa Chiew 2/10/13 06:04

Formatted: Indent: Left: 0 cm, Bulleted +
§ Attend to patient immediately! Level: 2 + Aligned at: 2.54 cm + Tab
after: 3.17 cm + Indent at: 3.17 cm, Tabs:
0.63 cm, List tab + Not at 2.54 cm + 3.17
§ Ensure Airway, Breathing, Circulation cm

§ Call for help

§ Ensure monitors in place for BP, HR, SpO2
§ Assess ECG monitor rhythm
§ Manage as per BCLS/ACLS protocols
§ Consider stat hypocount

2. Breathlessness Alyssa Chiew 2/10/13 06:04

Formatted: Indent: Left: 0 cm, Bulleted +
§ If a nurse calls you to inform you that a patient is Level: 2 + Aligned at: 2.54 cm + Tab
after: 3.17 cm + Indent at: 3.17 cm, Tabs:
0.63 cm, List tab + Not at 2.54 cm + 3.17
acutely breathless, alarm bells should ring! Attend to cm

the patient immediately!

§ Give supplemental oxygen as necessary
§ Find out quickly why patient is admitted, any reasons
for patient to be breathless?
§ Ensure parameters are normal, especially oxygen
saturation, heart rate and blood pressure
§ Assess patient – ensure ABC adequate, call for help
if necessary
§ Take a short history if possible

- 36 -
 § Examine patient, looking out for common causes,
e.g. pneumothorax, acute asthma/COPD
exacerbation, acute pulmonary edema, acute
pulmonary embolism, AMI
§ Arrange for investigations to be done urgently, eg
FBC, UECr, cardiac enzymes, ABG, CXR, ECG

3. Chest pain Alyssa Chiew 2/10/13 06:04

Formatted: Indent: Left: 0 cm, Bulleted +
§ Attend to patient immediately, call for help as Level: 2 + Aligned at: 2.54 cm + Tab
after: 3.17 cm + Indent at: 3.17 cm, Tabs:
0.63 cm, List tab + Not at 2.54 cm + 3.17
necessary cm

§ Give supplemental oxygen

§ Ensure ABCs adequate, keep SpO2 >95%
§ Take a history and examine patient
§ FBC, UECr, cardiac enzymes, ECG, CXR urgently
§ Consider AMI, pneumothorax, pulmonary embolism

4. Confused patient Alyssa Chiew 2/10/13 06:04

Formatted: Indent: Left: 0 cm, Bulleted +
§ Ensure ABCs and vital signs adequate Level: 2 + Aligned at: 2.54 cm + Tab
after: 3.17 cm + Indent at: 3.17 cm, Tabs:
0.63 cm, List tab + Not at 2.54 cm + 3.17
§ Is it acute? Conscious level? (May have to consider cm

intubation if GCS <8)

§ May be due to multiple differentials eg MI, sepsis,
electrolyte imbalances, hypoxemia, hypercapnia,

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 uraemia, liver failure OR intracranial event (stroke,
bleed)
§ Perform a neurological examination
§ CT Head if there is a focal neurologic deficit
§ FBC, UECr, stat hypocount, cardiac enzymes, ECG,
ABG, CXR, blood cultures

5. “Vomited blood” Alyssa Chiew 2/10/13 06:04

Formatted: Indent: Left: 0 cm, Bulleted +
§ Is it truly haematemesis/upper BGIT? Level: 2 + Aligned at: 2.54 cm + Tab
after: 3.17 cm + Indent at: 3.17 cm, Tabs:
0.63 cm, List tab + Not at 2.54 cm + 3.17
§ Ensure ABCs cm

§ Two large bore IV cannulas to cubital fossa

§ Run crystalloids fast
§ Insert NGT and urinary catheter
§ Send off FBC, PT/PTT, GXM, UECr, cardiac
enzymes, ECG, urgently
§ Consider transfusion of blood products as necessary
§ Signs of acute abdomen?
§ Call for help

6. Abdominal pain Alyssa Chiew 2/10/13 06:04

Formatted: Indent: Left: 0 cm, Bulleted +
§ Ensure ABCs adequate Level: 2 + Aligned at: 2.54 cm + Tab
after: 3.17 cm + Indent at: 3.17 cm, Tabs:
0.63 cm, List tab + Not at 2.54 cm + 3.17
§ Take a history and examine patient cm

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 § Look out for any signs of acute abdomen, if present
will require surgical consult KIV further investigations
eg CT Abdomen/Pelvis
§ Consider serial abdominal examination and
symptomatic treatment if no signs of acute abdomen
§ Keep NBM / Iv Drip

7. “Patient spiked a temperature” Alyssa Chiew 2/10/13 06:04

Formatted: Indent: Left: 0 cm, Bulleted +
§ Check case sheets and parameter charts Level: 2 + Aligned at: 2.54 cm + Tab
after: 3.17 cm + Indent at: 3.17 cm, Tabs:
0.63 cm, List tab + Not at 2.54 cm + 3.17
§ Examine patient for localization of symptoms/signs cm

§ Do a full septic workup; FBC, blood cultures (2 sets,

aerobic and anaerobic from different sites), urine
FEME and culture, CXR. If there is a vascular device
in-situ e.g. Hickmann line, send off retrograde
cultures from each port as well.
§ KIV start or change antibiotics

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Medications for Common Patient Complaints

Important Points:
- Always check patient’s identity with name AND
IC
- Make sure you order in the correct patient’s
IMR
- Check for drug allergies
- Check wrist tag for ID (also beware RED tag)
- Think about possible contraindications & drug
interaction
- When giving first dose, make sure that you’re
giving it to the right person, at the right dose,
via the correct route & at the correct speed
- Please dose adjust for renal impairment
- Handy drug guides
o ePharmacopoeia on SGH intranet
o Drug Info (4112) or pharmacist on call
o Sanford Guide for antibiotics

Alyssa Chiew 2/10/13 06:04

Formatted: Indent: Left: 0 cm, Numbered
+ Level: 1 + Numbering Style: 1, 2, 3, ... +
Start at: 1 + Alignment: Left + Aligned at:
1.27 cm + Tab after: 1.9 cm + Indent at:
1.9 cm, Tabs: 0.63 cm, List tab + Not at
1.27 cm + 1.9 cm

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1. Antibiotics
§ Augmentin PO 625mg BD, IV 1.2g q8h
§ Ceftriaxone (Rocephin) IV 1-2g OM
§ Ciprofloxacin PO 500mg BD, IV 200 to 400mg q12h
§ Cloxacillin PO 500mg Q6h or IV 500 to 1000mg q6h
§ Crystalline Penicillin IV 2-4MU Q6H
§ Metronidazole (Flagyl) PO 400mg TDS, IV 500mg
Q8h
2. Abdominal Bloating or “Wind” Alyssa Chiew 2/10/13 06:04
Formatted: Indent: Left: 0 cm, Numbered
§ Mist carminative 10mls TDS/PRN + Level: 1 + Numbering Style: 1, 2, 3, ... +
Start at: 1 + Alignment: Left + Aligned at:
1.27 cm + Tab after: 1.9 cm + Indent at:
1.9 cm, Tabs: -0.63 cm, List tab + Not at
1.27 cm + 1.9 cm

3. Constipation Alyssa Chiew 2/10/13 06:04

Formatted: Indent: Left: 0 cm, Numbered
§ Lactulose 10mls TDS, Senna 11/11 ON, Dulcolax + Level: 1 + Numbering Style: 1, 2, 3, ... +
Start at: 1 + Alignment: Left + Aligned at:
1.27 cm + Tab after: 1.9 cm + Indent at:
PO 5mg or PR 1/1, Fleet enema 1.9 cm, Tabs: -0.63 cm, List tab + Not at
1.27 cm + 1.9 cm

4. Allergic reaction Alyssa Chiew 2/10/13 06:04

Formatted: Indent: Left: 0 cm, Numbered
§ Discontinue or remove offending agent + Level: 1 + Numbering Style: 1, 2, 3, ... +
Start at: 1 + Alignment: Left + Aligned at:
1.27 cm + Tab after: 1.9 cm + Indent at:
§ Anti-histamines: Chlorpheniramine (Piriton) PO 4mg 1.9 cm, Tabs: -0.63 cm, List tab + Not at
1.27 cm + 1.9 cm

TDS, Promethazine (Phenergan) PO 25-50mg TDS

§ KIV Hydrocortisone IV 100mg q6h, Prednisolone
PO 10-30mg OM

- 41 -
5. Angina Alyssa Chiew 2/10/13 06:04
Formatted: Indent: Left: 0 cm, Numbered
§ Sublingual GTN 1/1 + Level: 1 + Numbering Style: 1, 2, 3, ... +
Start at: 1 + Alignment: Left + Aligned at:
1.27 cm + Tab after: 1.9 cm + Indent at:
1.9 cm, Tabs: -0.63 cm, List tab + Not at
1.27 cm + 1.9 cm

6. Breathlessness/Wheeze Alyssa Chiew 2/10/13 06:04

Formatted: Indent: Left: 0 cm, Numbered
§ Ventolin MDI 2puffs PRN + Level: 1 + Numbering Style: 1, 2, 3, ... +
Start at: 1 + Alignment: Left + Aligned at:
1.27 cm + Tab after: 1.9 cm + Indent at:
§ Nebs Ventolin: N/S (1:3) Q4-6H 1.9 cm, Tabs: -0.63 cm, List tab + Not at
1.27 cm + 1.9 cm

§ KIV Hydrocortisone IV 100mg Q6h

§ IV Frusemide 40mg STAT if suspect pulmonary
oedema
7. Dizziness: Alyssa Chiew 2/10/13 06:04
Formatted: Indent: Left: 0 cm, Numbered
§ Prochlorperazine (Stemetil) PO 10mg TDS OR IM + Level: 1 + Numbering Style: 1, 2, 3, ... +
Start at: 1 + Alignment: Left + Aligned at:
1.27 cm + Tab after: 1.9 cm + Indent at:
12.5mg STAT 1.9 cm, Tabs: -0.63 cm, List tab + Not at
1.27 cm + 1.9 cm

8. Electrolyte Abnormalities (common) Alyssa Chiew 2/10/13 06:04

Formatted: Indent: Left: 0 cm, Numbered
§ Hypokalaemia + Level: 1 + Numbering Style: 1, 2, 3, ... +
Start at: 1 + Alignment: Left + Aligned at:
1.27 cm + Tab after: 1.9 cm + Indent at:
§ Oral: Mist KCl 10ml TDS, Span K 0.6 – 1.2 g OM 1.9 cm, Tabs: -0.63 cm, List tab + Not at
1.27 cm + 1.9 cm

§ Intravenous replacement is recommended if K+ is

less than 3.0 mmol/L or patient has symptoms
(cramps, cardiac arrhythmias, muscular
weakness). IV 7.45% KCl 10mmol in in 100ml N/S
over 1hr

- 42 -
 § Hyperkalaemia: Alyssa Chiew 2/10/13 06:04
Formatted: Indent: Left: 0.63 cm,
§ IV Glucose 50% 40ml with IV insulin 10 IU (draw Bulleted + Level: 1 + Aligned at: 1.27 cm
+ Tab after: 1.9 cm + Indent at: 1.9 cm,
Tabs: 1.27 cm, List tab + Not at 1.9 cm
with INSULIN syringe)

10U = 0.1ml

§ Resonium PO 15g or PR 30g

§ IV Calcium gluconate 10% 20ml if there are ECG
changes or cardiac arrhythmias.
§ Hypoglycemia
§ IV D50% 20-40ml (dilute with N/S or H20), then
consider setting up maintenance D5-10% drip

9. Dyspepsia Alyssa Chiew 2/10/13 06:04

Formatted: Indent: Left: 0 cm, Numbered
§ Magnesium Trisilicate (MMT) 10mls TDS, + Level: 1 + Numbering Style: 1, 2, 3, ... +
Start at: 1 + Alignment: Left + Aligned at:
1.27 cm + Tab after: 1.9 cm + Indent at:
Famotidine 20mg BD 1.9 cm, Tabs: -0.63 cm, List tab + Not at
1.27 cm + 1.9 cm

10. Nausea/Vomiting Alyssa Chiew 2/10/13 06:04

Formatted: Indent: Left: 0 cm, Numbered
§ Metoclopramide (Maxolon) PO/IV/IM 10mg + Level: 1 + Numbering Style: 1, 2, 3, ... +
Start at: 1 + Alignment: Left + Aligned at:
1.27 cm + Tab after: 1.9 cm + Indent at:
TDS/PRN 1.9 cm, Tabs: -0.63 cm, List tab + Not at
1.27 cm + 1.9 cm

Alyssa Chiew 2/10/13 06:04

Formatted: Indent: Left: 0 cm, Numbered
+ Level: 1 + Numbering Style: 1, 2, 3, ... +
Start at: 1 + Alignment: Left + Aligned at:
1.27 cm + Tab after: 1.9 cm + Indent at:
1.9 cm, Tabs: -0.63 cm, List tab + Not at
1.27 cm + 1.9 cm

- 43 -
11. Pain
§ Paracetamol 1g TDS/PRN, Anarex 2 tab TDS/PRN
§ NSAIDs; Diclofenac (Voltaren) 25-50mg TDS/PRN,
Mefenamic acid (Ponstan) 500mg BD/PRN,
Naproxen (Synflex) 550mg BD
§ Opioids (give with laxatives & maxolon): Pethidine
IM 25-75mg TDS/PRN, Tramadol PO 50-100mg
TDS

12. Seizures Alyssa Chiew 2/10/13 06:04

Formatted: Indent: Left: 0 cm, Numbered
§ Diazepam IV 10mg IV over 2 min + Level: 1 + Numbering Style: 1, 2, 3, ... +
Start at: 1 + Alignment: Left + Aligned at:
1.27 cm + Tab after: 1.9 cm + Indent at:
1.9 cm, Tabs: -0.63 cm, List tab + Not at
1.27 cm + 1.9 cm

- 44 -
Main contributors
1. Dr. Liaw Chen Mei, Department of Anaesthesia and
Surgical Intensive Care
2. Dr. Yang Liying, Department of Obstetrics and
Gynaecology

Editor
Dr. Kenneth Chan, Department of Respiratory and
Critical Care Medicine

- 45 -