Ortho HO must know

 Clerking key points:

- age/ race/gender

- chief complain

- presenting history (how it happens-where they fall, how, why; pain-what kind of pain-location, intensity, relieving factors) 

- other related signs and symptoms: LOC(loss of consciousness), headache, N&V(nausea and vomiting)

- treated by any other hospital?

- past medical history: underlying disease? DM/HPT? well controlled?

- Social hostory: ADL, who he is staying with?

- P/E- relevant and related: Observe, palpate, motor: Range of movement of limbs, sensitivity, neurological

- report any X-ray or CT scan done

Review pt in the morning. 

- the header is S/B Dr. XXX or <AM review> 

format:

- age/race/gender

- Post operation Day/ Day admission, what kind of surgery, 

- pt condition: oral and toiletry, SOB, fever, cough/flu, pain(pain score), 

- vital signs: BP, Pulse, T

- P/E: dressing, wound/condition

- Plan: continue previous meds, change dressing, physio referral, feeding, pain medication

Must know: (for ortho)

- how to read the spine X-ray/ any xray

    - check alignment

    - body: vertabral body, spinous process, antevertebral body, 4 lines of X-ray, 

    - any burst /compression fracture

    - to determine via TLCIS if the person with thoracolumbar injury needs surgery or not. 

- physical examination

    - motor, sensory and neurological: any abnormalities, know what is it testing for 

- differences between Upper Motor neuron and Lower Motor Neuron, 

    - Cauda Equina 

    - end of UMN is L2

COMMON TO DO LIST

• TO do ABG, use the blue needle and syringe to extrct the blood
• to do line, use pink needle, find the vein on pt hand, feel and put it in. 
• to do slap, need a friend to help with releasing the water from the back slap(10 layers)
• to do skin traction: prepare the cover and weight(10% of pt body weight)
• to be prepared always for mo who is coming for pt. 

UGIB Q&A

 Q1. What is the anatomical level to ddx upper and lower GI bleed?

• at the duodenal-jejunal junction at the ligament of treitz
• UGIB are bleeding proximal to ligament of trietz
• LGIB can also cause from bleeding of small bowel, 
• those bleeding distal to the ligament of treitz can consider as lower GI bleed

Q2. What are your aims in assessment for a patient with UGIB?

• to assess if patient is stable
• if they are in active bleeding
• is it variceal or non variceal bleed

Q2. How to access the stability of the patient?

• vital signs
• mental status
• urine output. 

all these could help chart the grade of shock clinically - especially Heart Rate !

- if you notice from the table below. 

• the heart rate could already classify the type of shock into class I and class II and it also shows us "THERE is BLEEDING" 
• BP came 2nd as when we realise BP drop, shock is already grade 3. 
• and blood loss has already reached at least 1.5L
• if grade 2 systolic pressure is still normal and diastolic is low : 

Q3.  How do we access if they are still actively bleeding?

• colour of hemetemesis
• fresh blood
• coffee ground colour

• amount of hemetemesis
• large?

** anemic Sx is not enough to diagnose if they are still having active bleed. as acute bleed will cause collapse first even before they have the symptoms. 

Q3a. If patient has history of melena, is it usually active bleed or already stopped?

• Yes, usually it is active and has maroon colour, also called fresh melena 

• Blood is irritative to gut, they either comes out from the mouth or the anus. 
• opposite to fresh melena is old melena or stale melena
• Old melena: black is colour, and towards formed stool. 

Q4. Some of the black stool presentation still could be active bleed, what type of presentation we can see in this type of patient?

• large amount of black stool and watery
• also called watery melenic stool 
•  patient family/ Staff nurse can have complain of patient changing diapers multiple times however soaked. although it is not red, still considered active bleed. 
• can happen in both UGIB and LGIB

Rule out UGIB first as 80% of PR bleed is from upper GI, 20% from LGIB

•  Despite resuscitation, patient still has persistent tachycardia

Q5. How to access the source of bleeding, variceal vs non variceal?

• Patient's History
• variceal bleed: large amount of fresh hematemesis, has copious blood
• usually described as bowls of blood or cups of blood. 
• massive bleeding usually came from varices
• however it is usually PAINLESS
• causes:
• any history of liver disease: jaundice, stigmata of liver disease, portal hypertension secondary to chronic liver disease, hep B
• high risk behaviour
• non variceal bleed: cause is usually peptic ulcer disease (PUD)
• pain 
• have hx of epigastric pain
• cause: 
• long standing NSAIDS usage/ steroids usage
• hx of hyperuraemia (CKD)

Why do we need to differentiate variceal and non variceal bleed?

• variceal bleed: need urgent OGDS (no active bleed)
• non variceal still can wait and scope within 24 hours 

Q1: if patient is suspected with variceal bleed, he has active bleeding and continuously vomit blood. 
his vitals are not stable. Outline your acute management

• ABC
• A: If airway compromise to intubate , to secure airway
• insert 2 large bore IV cannula
• blood taking(FBC+coag) + GXM + safe O blood (preferably cross match blood)
• fluid resus with crystalloid then add colloid while waiting for blood and blood products
• can refer to the fluid and electrolyte QnA link here
• to arrest and stop the bleeding
• inserting sengstaken tube

• vital signs monitoring

THEN SEND pt to ICU once he is stable

since patient having active bleed, he is not fit for OGDS, as we couldnt view the source of bleeding clearly. the active bleed will obscure the lens of OGDS

** differences between UGIB 2 to PUD , pt who has variceal bleed, you will need urgent OGDS as long as they have no active bleed. those with UGIB 2 to PUD we still can wait and scope within 24 hours. 

Q1a: what do we do next once patient in ICU- medical therapy?

• start IVI octreotide
• on pt with and without active bleed. 
• replace blood loss and correct coagulopathy
•  FFP
• start antifibrinolytic agent eg: IV tranxenemic acid 500mg TDS
• transfused if needed
• start PPI infusion
• reduces mortality in variceal bleed
• due to reduce in acid in stomach, it also lower down incidence of rebleeding 
• start antibiotic
• as pt usually immunocompromised due to hepatic failure
• in various study shows abx may reduce mortality rate in bleeding pt
• 
  
• beta blocker
• usually given after patient recover
• as might cause low systemic blood pressure in acute setting

Q2: how does octreotide help with the bleeding?

• it inhibits release of glucagon 
• glucagon is splanchnic vasodilator
• when splanchnic circulation is reduced it will cause reduce in portal pressure

Q3: how long can we place the sengstaken tube?

• 48hours
• longest: 72 hours/3days
• as it is just a temporary solution to the problem. 
• however have to deflate the esophageal balloon intermittently every 2 hours
• important to reinfate to prevent hypoxia and necrosis of compressed tissue
• and esophageal perforation is fatal cause it is in the thoracic cavity if perforated. 

Q4: what is the PPI infusion that is given

• IVI pantoprazole 80mg stat then 8mg/hr
• GOLD STANDARD to give the regime stated above. 
• if no pantoprazole, omeprazole is also accepted

Q4b: why PPI is important and superior as medical treatment?

• proton pump inhibitor, blocks the H+/K+ ATPase
• inhibition is irreversible. 
• therefore causes profound and prolonged reduction of acid production

CPG malaysia for UGIB mx

do review back the summary done last time and come test yourself here!'https://yu4med.blogspot.com/2021/04/ugib.html

Referral template to paeds - from OBGYN HO prespective

HUSM obgyn paeds referral template:just a note for me to remember when needed to be used. 

This template is also being passed down by seniors, grateful to those who started this. 

It is too common that we are being scolded for not presenting detail enough while referring case to MO paeds. This will be especially useful for those who are like me, went to OBGYN posting first before paeds, and have no idea what to do. 

Good luck guys!

It is part malay and english, so those who dont understand malay it's time to pick up a new language. 

**especially those who graduated oversea. 

Paeds referral

Summary:

Dr, saya HO(houseman) xxx, from LR(labor room)/ward xx nak refer baby of 

(example of problems)

i. M(maternal) GDM on insulin/metformin

ii. M PROM > ? hrs

iii. M GBS positive

iv. Macrosomic baby (> 4.5kg)

v. Low birth weight baby (<2.5kg)

(Example notes to write in record)

This is baby of ___.

Baby boy/girl, currently _ hours of life. 

Born via SVD at _weeks __days POA(period of amenorrhea)/POG(period of gestation) 

with BW(birth weight) _kg & Apgar score __ at 1 min 

Antenatally mother have

1.

2.

3.

4. 

On examination of baby

- Baby pink, active on handling

- Anterior fontanelle normotensive

- Good sucking

- Lungs clear, RR?, no grunting, no nasal flaring

- CVS S1 S2 heard, HR?

- PA soft, 2A1V

- Male/female genitalia normal. Bilateral testes descended (if male), anus patent

- No DDH, good palmar grasp

- Spine Normal

- Moro complete. 

Some details to take note for each case:

1. Low birth weight(LBW) baby

• LBW<2.5kg
• VLBW <1.5 (V: very)
• ELBW <1kg (E: extreme)

*Not all LBW are SGA (Small Gestational Age)

*It can be AGA (Appropriate for Gestational Age)

So plot growth chart if has LBW baby

SGA : wt <10th centile

Symmetrical SGA : all components <10th centile

Asymmetrical SGA : wt (weight) <10th centile, COH (circumference of head) and length almost achieve centile for the gestational age 

2. Infant diabetic mother

Screen for diabetic embryopathy

1. mention types of medication used

- are they on Insulin? 

• type of insulin? actrapid / insulatard
• what is the total dose per day
• when they start?
• is their BSP (blood sugar profile) optimised?

2. Please mention Hba1c: indicates control 

• (if possible mention early pregnancy HbA1c and late pregnancy values)

3. BSL (Blood Sugar Level) of baby at 1 hr

• If refer at 4 hours of life, at least have 2 BSL. If hypoglycemic after feeding refer immediately to MO paeds. 

3. Infant of hyperthyroid mother

• Please know latest TSH, T4 and Medications of mother
• Heart rate of child 

4. Infant risk of sepsis

(PROM, PPROM, UTI(urinary tract infection)) 

UTI

1. If UTI please mention when they got UTI

• inform the UFEME results
• inform urine C+S if available

2.  Any Antibiotic coverage?

• types of antibiotic
• dosage
• given how many times
• since when
• any temperature spike or signs of sepsis in mother

PROM/PPROM

(premature rupture of membrane). preterm premature rupture of membrane

• Please know duration of leaking

• >12hrs? / >24hrs?

• Doses of antibiotics?

            - last dose bila , how many of hour before delivery

            - any chorioamnionitis signs?

            - liquor?

• post delivery baby mcm mana?

• Mother

• FBC: Hb, WBC, PLT

• HVS C+S (high vaginal swap culture and sensitivity)

reference:

1. https://myhow.files.wordpress.com/2013/11/hoguidepeds1.pdf

HO medical - EMERGENCY management

Some of the notes seniors passed down which is very useful. I edited and add in some points i get during my posting as well. 

Big thumbs up to them who prepared the list and Thank You💕💖

1. Hypokalemia
2. Hyperkalemia
3. Hypoglycemia
4. Hyperglycemia
5. Chest Pain
6. Hypotension
7. Asystole
8. VT
9. Atrial Flutter
10. SVT
11. Fit
12. GCS drops
13. Aggressive behavior
14. Nausea/ vomiting
15. Diarrhea
16. Hematemesis
17. Shortness of Breath
18. Other electrolytes
19. UGIB
20. Anaphylaxis
21. Dengue

1. Hypokalemia (K+ <2.5)

- ECG STAT to look for hypokalaemic changes, check whether patient symptomatic.

- 1g KCL in 100cc NS in 1 hour

                or

    2g KCL in 200cc NS over 2hour (according to K+ level)

- with continuous cardiac monitoring

- Add KCl in drip (if patient on drip), mist kcl 15mls tds OR T. slow K 600mg/1.2g OD

- Check TFT, RP, VBG, UFEME

- Monitor v/s

- ECG (any ecg changes)

- Inform MO stat if symptomatic

- Off potassium supplements once K+ >4

- Repeat RP 1 hour post correction

- Daily RP until K+ stable

     

 2. Hyperkalemia (K+ >5.2)

- ECG STAT to look for hyperkalaemic changes, check whether patient symptomatic

- Off potassium supplements

- To serve lytic cocktail 

(10cc of 10% calcium gluconate in 10 minutes - slow bolus with cardiac monitoring + 50cc D50% glucose + 10 unit actrapid)

- If still high, repeat lytic cocktail 

Peritoneal dialysis?? Haemodialysis??

- T. kalimate 5-10g TDS

- Off kalimate once K+ <5

- Repeat RP 1 hour post correction

- Monitor RP daily till stable

3. Hypoglycemia (Reflo <4)

- Omit insulin

- Encourage patient to take orally (sweets, bread with jem, milo)

- If too low (<3.5) with symptoms, give 20-50cc D50% then repeat reflo 30mins

- If reflo 4-6, half the dose of next insulin

4. Hyperglycemia (Reflo >12)

- Serve S/C 6-10 unit actrapid STAT (depends on reflo) if patient not on insulin/insulin served earlier on.

- If patient already on insulin and not served yet, to serve usual dose.

- If persistently high despite insulin to start top up regime based on BMI. Take VBG, lactate and urine ketone dipstick TRO DKA.

5. Chest pain

- ECG STAT.

- If suspected ST elevation, to inform MO for referral to cardio KIV thrombolyse.

- S/L GTN, maximum 3 times. If persistent pain to start IV morphine with IV maxolon. If pain persists despite morphine to start IVI GTN.

- Oxygen

- Aspirin crush 300mg, Plavix 75mg

- Take cardiac enzymes(CK) and Trop T as baseline, to repeat at 6 hours later with ECG

6. Hypotension

- Determine cause (Septic, hypovolaemia, cardiogenic etc)

- Repeat manual BPx2 first to confirm

- Run 1 pint (250cc) NS fast 15-30minutes

     if no contraindication (watchout if patient have ROF).

     If still low, for another try.

- Inform MO is persistently low, KIV start IVI noradrenaline and adjust accordingly

- Regular BP monitoring (ideally every 15mins)

- KIV Gelafundin (colloid) @ inotrope

- Grey branula at neck/femoral line

- IV Noradrenaline 0.2mcg/kg/min

- KIV add another intropes if low despite high dose 1st intropes

7. Asystole

- Inform MO and call CRASH 

- Prepare Resus trolley and intubation kit

- Manual bagging 15L/m (even for ventilated patient)

- Straighten bed and commence CPR

- Transfer to acute bay

- Vital signs, reflo and cardiac monitoring

- Insert 2 large bore branula at least green at big veins (femoral/neck/cub fossa) and take all routine bloods including ABG, reflo and cardiac enzymes (run urgently)

- Run 1 pint NS fast if no contraindications

- Prepare IV adrenaline (1mg every 5 mins 3 cycles)

                IV Atropine 1mg every 3-5 mins (3x)

- If patient survive,

•     take ABG post intubation,
•     ECG,
•     septic workup (if infection is suspected),
•     D dimer (if PE is suspected)

- Keep BP >90/60, MAP >60.

- Insert CBD and strict IO monitoring (Keep U/O > 30cc/hr)

- Start inotropes if low BP

- IV panto 40mg OD to prevent gastric ulcer

- Insert Ryles tube, KIV start feeding later (refer to dietitian)

8. VT

- Inform MO

- Prepare resus trolley

- Vital signs and continuous cardiac monitoring

- If pulseless, for defib and 5 cycles of CPR. Repeat if unsuccessful.

- If pulse present but hemodynamically unstable, for urgent cardioversion and IV

lignocaine

- If pulse present, for IV amiodarone

9. Atrial flutter

- Inform mo

- Vital signs and continuous cardiac monitoring

- If hemodynamically unstable, for urgent DC shock and rate control meds.

9a. Fast AF

- Nasal prong O2 (NpO2)

-Continuous cardiac monitoring

- IV Digoxin (if HF) 0.25mg every 2hr, up to 1.5g within 24hr

- Metoprolol 25mg/100mg BD (absence of HF)

- KIV IVI Amiodarone 300mg over 30mins

- KIV cardioversion if hemodynamic not stable

>10. SVT

- Inform MO stat

- Vital signs monitoring and continuous cardiac monitoring

- If hemodynamically unstable, for cardioversion

- If stable for carotid massage (if no bruit) dan valsalva maneuver

- If persistent, need to give IV adenosine 6mg and flush with 20cc NS.

• then 12mg then 12mg
• if not reverted, IVI amiodarone 300mg over 30 minutes

Contraindicated for Asthma patient.

• Second bolus 12mg can be given after 5 mins with NS flush.

- If persist consider another drug (verapamil etc)

11. Fit

- Remove patient from dangerous objects

- Prepare IV diazepam 5mg STAT, if persist repeat dosage (max 3 doses with 10 mins gap)

- Put on HFM 10-15L/min

- Vital signs monitoring

- Put patient on left lateral position

- If fit persist, KIV IV phenytoin (loading and maintenance)

- Repeat bloods including electrolytes, KIV for CT brain/ LP

- If resolve, continue vitals monitoring, fit charting, - GCS charting

12. GCS drops

- Vital signs and reflo

- Inform mo

- Transfer to acute bay

- Refer CRASH KIV for intubation

- Determine cause

- Insert line and repeat bloods including ABG, septic workup Request for CT brain

-Treat according to cause

13. Aggressive behaviour

- Approach calmly

- Ask help from security guards or male staff

- IV haloperidol 5mg STAT

- 4 points restraints

- Repeat bloods TRO causes

- Refer psych if persistent aggressive behaviour

14. Nausea/vomiting

- IV maxolon 10mg STAT

- Start ORS

- If significant loss, start IVD maintenance

- Monitor RP

- Find the cause

15. Diarrhea

- ORS per purge

- KIV lomotil

- If significant loss, start IVD maintenance

- Monitor RP

- Find the cause

16. Hematemesis

- Inform MO

- Rule out UGIB (inspect vomitus)

- PR examination to look for melena

- Vital signs (look for compensated or decompensated shock)

- If significant blood loss to insert 2 large bore branula and repeat bloods

- IV tranexamic acid 1g STAT and 500mg TDS, IVI pantoprazole 8mg/hr.

17. SOB

- Examine lungs, check vitals

- Determine cause, repeat CXR if needed

- Refer CRASH if necessary (SpO2 unable to maintain with oxygen

supplementation or clinically worsening SOB)

- If intubated, check if ETT dislodged or too deep (if yes, to readjust)

- Start ocygen supplementation (according to SPO2 and clinical). If known case of

COPD to start VM.

- Watchout for respi distress, keep SpO2 >95%

- If significant SOB with Sp02 drop, take ABG, FBC (TRO anaemia), Cardiac

enzymes, Trop I (ACS is suspected), D dimer (TRO PE)

- If ronchi (asthma) - Neb AVN STAT, IV hydrocortisone 200mg STAT (if moderate

to severe). Reassess post neb, if worsening can try back to back neb.

- If PE is suspected, to take D- dimer KIV CTPA. Chest referral, KIV start clexane

- If pneumonia (HAP/aspiration) is suspected, to take septic workup and CXR and

start antibiotics.

- If fluid overload, to serve IV frusemide 20mg STAT (to check BP before serving),

adjust IVD and fluids intake

- If pleural effusion, KIV for tapping

>18. Other electrolyte deranged management

• Hypomagnesaemia:
• IVI MgSO4 1 ampule in 100cc NS over 1 hour
• Hypocalcaemia:
• - ECG
• - IVI CaCO3 1 ampule in 100cc NS 
• over 1 hour @
• - IVI Calcium Gluconate 1 ampule in 
• 100cc NS over 4 hours
• * Mild: Tab CaCO3 500mg BD/TDS

• Hypophosphatemia:
• - IVI KH2PO4 1 ampule in 100cc NS 
• over 4 hours

• Hyponatremia:
• - If no ROF, give IV drip NS 3-4  pints/24 hour

19. Upper GI Bleeding:

- 2 large bore branula 

- Run fluid 

- FBC, Coag profile, GXM 4pint blood

- IV Pantoprazole (PPI) 80mg stat 

and IVI 8mg/hr

- Inform MO

20. Anaphylaxis:

- IV Hydrocortisone 200mg

- IV Piriton 10mg

- IV Maxolon 10mg stat & TDS

- Oxygen 

- IV fluid

- If BP drop,IV/IM Adrenaline 1:1000

21. Dengue1:

- Dengue fever day __, __ warning signs, in __ phase (if defervescence phase point taken at__˚C), V/S, on drip __cc/kg/H, latest FBC reviewed. -

- Next FBC at __am/pm, cont drip __cc/kg/h

* WARNING SIGN: 

- Tender liver - Abdominal pain

- Mucosal bleed

- Persistent vomiting ≥3x + diarrhea  ≥3x/24 hr 

- Fluid accumulation(ascites/pleural E)

- Restlessness/altered conscious level

- Inc haematocrit, reduced platelet

Dengue2:

- N haematocrit: Male: >45; Female: >40

- Raised haematocrit in active smoker & obese pt is normal

- If pt took PCM, take Temp > 6hours after that, to count defervescence phase (< 38˚C)

- Dengue IgM & IgG positive high risk DHF (If systemic bleeding, give IV Traxenamic acid 500mg TDS)

- Ideal Body Weight in Dengue: 

Male: (Ht-152.4) x 0.91 + 50

Female: (Ht – 152.4) x 0.91 + 45