COMMON TREATMENT ORDERS (for fresh graduates)

1. Unclassified ward complaints- Raised BP- Decreased BP- Decreased / no urine output- Decreased SaO2- Pain- Headache- Fever- Nasal allergy- Drug allergy- Sore throat- Skin rash- Nocturnal leg cramp- Insomnia- Dizziness- Abnormal behaviour- Violent patients- Pruritis- Red eye / eye discomfort- Drug withdrawal symptoms (drug addicts)

- Nocturnal irritability- Oral ulcer- Palpitation

2. Laboratory results- Decreased haemoglobin- Decreased platelet count (plus fulfill indication for transfusion)- Raised INR- pH<7.1- Hypokalaemia- Hyperkalaemia- Hypernatraemia- Hyponatraemia

3. Respiratory- Cough medications- Chest infection / pneumonia- Intubation- Ventilator settings- COAD drugs & Mx- Anti-TB drugs- Haemoptysis

4. Cardiac- Fast AF- Chest discomfort (ACS)

5. Gastrointestinal- Coffee ground vomiting- Conspitaion- Dyspepsia- Abdominal pain (anti-spasmotics)- Vomiting- Diarrhoea- Haemorrhoid

6. Nervous system- Stroke / CVA- Epilepsy- Seizure attack- CNS tumour / haemorrhage with mass effect

7. Endocrine- DKI drip (fasting of DM patients)- Hypoglycaemia (H'stix <3.5)- Increased H'stix

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- Sliding scale of Actrapid HM- Hyperglycemia (poor DM control)- Thyrotoxicosis8. Miscellaneous- Contrast allergy- Drug overdose

- Thyroxine replacement- Gout- Cellulitis- DVT- Menorrhagia- Unit conversion- Creatinine clearance

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1. UNCLASSIFIED WARD COMPLAINTS

Raised BP (if SBP >180 or DBP >90)- Check the stress level, previous record- Look for chest pain, SOB, headache, blurred vision, fundi changes- Adalat Retard 20mg PO stat x 1 or BD- Captopril 6.25mg po Q4H prn if SBP >=210 or DBP >=110- Betaloc 25mg BDIf eating not allowed & patient conscious, Adalat 5mg sublingual x 1 If eating not allowed & patient unconscious, labetalol 5mg IV stat ( up to 20mg IV over 2 min) Decreased BP (esp: SBP<90)- Shock, differentiate between cardiogenic and non-cardiogenic, and further identify the underlying cause; treat accordingly- Withhold anti-HT drugs- Fluid resuscitation (v cautious in CRF or HF)- Gelofusine 500ml FR x1 Or NS 500ml FR x1Inotropes 救命三寶- Dopamine - 1g in 500ml NS: give 10-40ml/hr or 4:1, 1-20ml/hrDolbutamine drip:

- 250mg in 50ml D5, 5mg/ml, 1ml/hr - Adrenaline drip ( 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 )Decreased or no urine output- Check BP/P, I/O, temperature, hydration status, CVP & drain outputs (if any)- Differentiate between causes of Post-renal:- feel for bladder +/- bedside bladder scan, check Foley patencyRenal:

- creatinine levelPre-renal:

- feel peripheries, - check hydration status, JVP, edema, crep,

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- PR exam (if indicated),- CXR (if indicated)

For pre-renal causes- if non-cardiogenic, treat with fluid challenge, e.g. NS 500ml FR or Q1H or Q2H x1- Gelofusine 500ml FR or Q1H x1- NS 250ml 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 Decreased SaO2- Some causes to consider (and many more):- Cardiac: CHF, AMI, arrhythmia, etc ECG 心- Chest: pneumothorax, pneumonia, pulmonary embolism, mucus,

COAD, APO etcCXR - Check vitals, JVP, oedema, listen to chest, heart sound- CXR (U&P) / Astrup / RLFT; +/- cardiac enzymes/ECG (if cardiac causes)- Give O2 35/50/100% (not to exceed N/C 2L/min in COAD)- Suction for sputum-Venturi mask - Intubation / Ambu bag - Treat underlying causes

Pain 痛- Panadol 500mg QID prn PO/PR- Dologesic tab 1 QID PO prn- Doloxene Co 32mg qid po prn- Doloxene Co 50mg IMI q6h prn-Voltaren 75-150mg PO daily 服他靈-Tramadol 50mg IMI Q6H prn (beware of resp distress & nausea)

(cp. Pethidine-tramadol weaker, slower onset yet longer duration? )

Higher doses 75/100mg, Frequent Q4H , IV form faster onset but need monitoring

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- Pethidine 50/75/100mg IMI q6h prn (beware of resp distress)Local application - Analgesic balm LA tds prn- Rubesal 25g LA tds prn- Voltaren gel LA tds good for post-traumatic inflammation - Morphine 4/8/10mg SC/iv q6h prn- Hirudoid LA tds prn good for drip site wound 喜療妥- Naprosyn 250mg BD POHeadache- Document GCS, brief Hx and P/E to r/o sinister causes- Panadol 500mg QID PO prn

FeverPost-op fever:- Within 48 hours: usually atelectasis- 48 hours to 5 days: chest infection, UTI, drip sites, etc…- After 5 days: wound infection, intra-abdominal abscess, DVT

Common causes:- post-op causes (as described) resp (pneumonia, URTI), UTI, drip

sites, wounds, gynae (in female), GI, ENT, drug-induced, tumour, etc…

- Review medications (? on A/B), lab results (e.g. on A/B already & WCC on decreasing trend?)

For atelectasis : - chest physio- encourage deep breathing- observe trend of fever

For other causes:- Septic workup if not done:- Bld x CBP/DC, C/ST- Sputum x C/ST/RM- MSU x C/ST/RM- CXR- If indicated, start empirical antibiotics

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- Panadol 500mg QID PO prn if temp >=38.5 degrees(For neutropenic fever, can give Fortum 1g IV Q8H) --ceftazidime 食它就掂Nasal allergy -relief of symptoms of allergic rhinitis - Phenergan 25mg TDS PO- Clarityne tab 1 TDS PO 佳力天Drug allergy- Hydrocortisone 100mg IV Q6H- Piriton 10mg IV Q8HSore throat- Cepacol/Dequadin/Strepsils tab 1 QID PO prn 得果定/ 使立消- 0.2% Chlorhexidine M/W 10ml LA TDS- Thymol gargle M/W 10ml LA TDS

Skin rash- Exclude allergic reactions

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- Synalar Cr 0.025% or 0.05% LA TDS - - Diprogenta Cr LA BD 帝普

健

(betamethasone dipropionate )Nocturnal leg cramp- Baclofen 5mg tds PO (muscle relaxant)

Insomnia- Piriton tab 1 po x 1- Ativan 0.5-1.0mg Nocte PO x 1- Imovane 7.5mg Nocte PO x 1 ( zopiclone)

Dizziness 暈If sudden onset and severe- Hx and P/E to exclude sinister causes (e.g. stroke) Cp tone & power both sides -SOL? Non specific ? Vertigo ( Hallpike’s maneuver )- H’stix stat, BP erect and supine-Bld x CBP- Stemetil tab 1 tds prn- Stemetil 12.5mg IMI q6h prn- Ser C (Merislon) tab 1 tds po prn

Vomiting/ Nausea 嘔- Look for underlying cause (e.g. S/E of medications)- Maxolon 10mg tds po- Maxolon 10mg IM/IV Q6h prn

Abnormal behaviour- For those with psychi history, not for drug overdose- Haloperidol 2-10mg Q4H-Q8H (max 18mg daily) IMI/IV; usually 5mg IMI Q6H prn; half dose for elderly

Violent patients- Haloperidol 2.5mg IMI x 1- Pulse oximetry, cardiac monitor, BP/P Q1H x 4

Pruritis 癢- After excluding allergic reactions:- Aqueous cream LA tds prn- Eurax cream LA tds prn 優力斯

- Calamine Cr /lotion LA QID- Piriton tab 1 tds po prn

Red eye or eye discomfort- Do exclude sinister causes first! (e.g. look for ciliary flush)- Gutt Hypromellose 2 drops LA BE tds- Methylcellulose eyedrop 2 drops LA BD BE

Drug withdrawal symptoms (Drug addicts)- Physeptone (methadone) 10 or 15mg tds po prn- Physeptone 10mg or 1ml iv Q6H prn- Morphine 10mg iv Q6H prn

Nocturnal irritability- Imipramine 10 or 25mg Nocte

Oral ulcer- Acyclovir Cr LA TDS

Palpitation- Inderal 10mg TDS PO prn ( propranolol) (only for symptomatic Rx; always look for underlying cause, e.g. arrhythmia, AMI..)

Hiccup 1. Paper bag for self re-breathing (布袋法) 2. largactil 25mg IV x 1

2. LABORATORY RESULTSDecreased Hb- Check vitals Look for underlying cause:- PR exam ( exclude PR bleeding –surgically obligation - Bld x iron profile, T&S (+/- CBP, clotting profile, Hb pattern)- Stool x occult blood x 3 ( if no obvious PR bleeding) - Transfuse if Hb < 8; aim at raising Hb to above 8 after transfusion

(Each unit of packed cells raise Hb for about 1g/dl)( Nowadays seldom just give 1 unit packed cells )

- Can consider giving lasix 20mg iv after each pint of transfusion if still conscious - Check post transfusion Hb (+/- RFT)- For MDS anaemia, treat only if symptomaticIf any problems related to blood transfusion e.g. Patient with Group A Rh –ve , only Group A Rh +ve blood a/v , consult haematologist

Decreased platelet count (plus fulfill indication for transfusion)- 4 or 6 units platelet conc FR x 1

Raised INR- Transfuse 4 units FFP FR x 1, then re-check INRPlatelet > 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 an hour before any procedure. If not, just waste FFP

pH < 7.1- 50ml 8.4% NaHCO3 over 1 hour ( even 100ml is fine –100ml per bottle ) - Re-check Bld x ABG afterwards

Hypokalaemia- 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 osmolarity, urine K, baseline ECG - Syrup KCl 2g PO Q2-3H x 2-3 doses

- Or slow K (8mmol K/600mg tabs) tab 1 QD/BD/TDS PO- Intravenous K supplement if severe or NPO (K<= 2.5mmol/l)- Give 40-120mmol/d: Don’t exceed 40mmol/hr, use large vein- Monitor K, ECG, urine output, consult ICU- Avoid dextrose (lead to further drop in serum K level)- Give separately or add to original IVF, e.g.:

20mmol KCl in 250ml NS, Q2H x 1 NS 500ml Q6H/pint + 15mmol KCl/pint (i.e. 60mmol

KCl/day)- Usually will re-check Bld x K after supplement if original K<3.0- Consider hypoMg for persistent hypoK- Ward has preparation of NS 500ml + 10 mmol KCl /pint or- NS 500 ml + 20 mmol KCL /pint - If ordered 15 mmol KCL /pint , Ward needs to get it from

Pharmacy -

HyperkalaemiaK >6- ECG, cardiac monitoring- 10 ml 10% calcium gluconate iv stat with cardiac monitor (over 3 min)- DI drip: 50ml D50 + 8-10u Actrapid HM IV over 30 min- Repeat ECG in 5 min (if original ECG showed hyper K changes)- Repeat Bld x Na and K, H’stix

K not very high (<6)- Resonium C 15gm Q6H/TDS PO/PR - Resonium A (watch-out Na and H2O overload) 15gm Q6H/TDS PO/PR-以上慢的補 k 法- Recheck Bld x Na/K afterwards

Hypernatraemia- Recheck blood, clinical sign (palpitation)- 500ml D5 over 4 hr 沖淡Hyponatraemia- Check serum osmol, cortisol, TSH, urine osmal, Na ( always remember adrenal insufficiency) - Check drug (lasix), RFT- Treat according to underlying causes- Re. Houseman HandbookIf 130-134 reduce diuretic doseIf 125-129 Stop diuretics & fluid restriction intake to 1.5 L/day If <125 Stop diuretics & fluid restriction to 1 L/day

3. RESPIRATORY

Cough medications- Mucolytics: fluimucil 200mg tds ( more expensive) , 橙樹化痰素 acetylcysterine- bisolvon 8mg tds ( cheaper) 氣舒痰- Expectorants: MES 10ml tds 馬尿- Cough suppressants: ethnine or phensedyl 10ml tds, promethasine compund 10ml bd- Others: Elixir Benadryl, Coxillana

Chest infection / pneumonia- Bld x CBP (CBP/DC if febrile), L/RFT, C/ST (if febrile)- Sputum x C/ST/RM, AFB smear, C/ST- Septic workup if febrile- CXRAntibiotics:- Augmentin 375mg tds po or Augmentin 1.2g iv Q8H- Unasyn 375mg BD po or Unasyn 750mg iv Q8H- Klacid 250mg or 500mg BD po ( Clarithromycin) - Zinacef 750mg IV Q8H or Zinnat 250 or 500mg BD PO- Flagyl 500mg IV Q8H or Flagyl 200 or 400mg TDS PO - -

- Sulperazone 1g iv Q8H or Q12H- Tazocin 4.5g IV Q8H-Ciprofloxacin 200mg iv Q12H or Ciprofloxacin 250mg po BD-Levofloxacin (Cravit ) a. Community acquired pneumonia: 500mg daily PO/IV x 1-2 weeks b. Complicated UTI : 250mg IV/PO Daily x 10 days c. Uncomplicated UTI : 250mg Daily x 3 days Uncomplicated abdo. OT Pre-op 1 dose and then post op 2 doses Copmplicated abdo OT e.g. appendicitis with rupture 1 week course of antibiotics

( single does of prophylaxis antibiotics is effective in most clinical situation ( should be given just prior to the OT or at the time of OT. A further dose us given in prolonged operation lasting > 4 hours. In complicated OT, a full course of antibiotics should be given )

For aspiration pneumonia:

- Remember to ask choking Hx- occup x swallowing assessment- Flagyl 500mg iv Q8H plus iv augmentin- Zinacef 750mg iv Q8H- Zinnat 250mg or 500mg BD po- Ciprofloxacin 200mg iv Q12H- Ciprofloxacin 250mg po BDIntubation ( 2 drugs would be given) - Thiopenton 150mg iv- Suxamethonium 50mg iv- Endotracheal tube marked at 22-24cm help with cricoid pressure -make sure suction ready - Air Entry( Rt = Lt ) 5 points auscultation , See chest expansion - SaO2 100%- Check CXR exclude any pneumothorax/ check position post-intubation

Ventilator settingsInitial settings:- SIMV mode (if spontaneous breathing)- CMV mode (if resp muscle paralysed)- Tidal volume (TV): 0.5L (500ml/50kg)- Pressure support: 8-10mmHg- Sensitivity: +/- 2mmHg- FiO2: 100%- RR: 12-15/min (if raised ICP, need hyperventilation; RR:

18-20/min)- PFR: 40- IE ratio: 1 to 2 or 1 to 3 (for obstructive airway disease);

1 to 1 for restrictive airway disease)- PEEP (positive end expiratory pressure): 4-5 cmH20

If need sedation: Fight機 - Dormicum 3 or 5mg IV stat x 1, then 30mg in 50ml NS infuse 2-

3ml/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)- Fighting vs machine => sedate- Pneumothorax / pleural effusion- Block tube => suction- Alarm (high TV; low pressure)- Leaking air => check- BP low- Must check whether pneumothorax

COAD drugs & Mx- Ventolin 2.5 or 5mg neb (no longer used after SARS)- Atrovent 0.25 or 0.5mg neb (no longer used after SARS)- Ventolin 2 or 4 puff Q4h or QID- Atrovent 2 or 4puff Q4h or QID- Bisolvon 1 tab TDS PO or Fluimucil 200mg TDS PO- MES 10 ml TDS PO- Prednisolone 30mg QD PO or Hydrocortisone 100-200mg IV Q6H or Q8H- Bricanyl 0.25/0.5mg SC q12h or Bricanyl durule 5mg BD PO- Theodur 100 or 200mg BD PO- Aminophylline drip 250mg in 500ml NS over 20min q12h- Chest physio & PFR BD

Anti-TB drugs- Rifampicin 450mg QD- Isoniazid 300mg QD- Pyrazinamide 1.5g QD- Ethambutol 800mg QD- Vit B6 10mg QD

Haemoptysis ( CA lung, tuberculosis & bronchiectasis

- Bld x ABG- Sputum x AFB x3, cytology, C/ST, R/M- MT-2 test if TB suspectede- Transamine 500mg IV stat then Q6H or QID PO- Inform if increased haemoptysisThree airborn transmitted dis: TB, measles, varicella zoster 4. CARDIAC

Fast AF- Cardiac monitoring, ECG 12 leads ( note the rhythm- sinus tachycardia ) - Urgent consult medical- Digoxin (omit if AR <60) - Loading dose: 0.25mg iv stat, then Q8H x3 ( need to be diluted

first ) - Maintenance: 0.125-0.25 mg QD po (0.0625mg for elderly)- Amiodarone drip- Loading: 150mg in 100ml D5 over 30 min- Maintenance: 600mg in 500ml D5: 20ml/hrNarrow complex tachycardia :Confirm it is the case with ECG 1. Vagal maneuvers contradicted in patient with carotid bruit 2. ATP 10mg rapid IV push (short half life) 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 15 minutes if tachycardia persists & BP stable

4. If BP not stable, then synchronized DC cardioversion

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 review drug chart b. Physiological: hypothermia c. Pathological: rhythm sinus node disease ( sick sinus

syndrome) & Atrioventricular block 3 degrees, hypothyroidism

Chest discomfort (ACS)- Blood x CK, LDH (cardiac enzymes) , Troponin T Q8H x3 - ECG stat, then Q8H x3- Inform MO +/- urgent consult medical (if likely ACS, e.g. raised TnT)- Aspirin 160mg chewed stat- Nitrates: TNG tab 1 SL prn

If chest pain at rest regardless of TNG:- Isoket infusion 50mg in 100ml NS, at 4ml/hr (max 20ml/hr)- Nitrocine 25mg in 100ml NS, at 4ml/hr

If chest pain subsided- Isordil 10mg tds po- Nitroderm 10mg LA QD- Aspirin 160mg chewed stat, then QD (with triact)- Cartia 100mg QD PO- Beta-blockers (if no contraindications, and not in HF)

- Betaloc 25mg BD PO- LMW heparin (if pain not controlled or high risk features present)

- Enoxaparin 0.1mg/kg SC Q12H- Fraxiparine SC: 0.4ml BD if BW <50kg 0.5ml BD if BW 50-59kg 0.6ml BD if BW >60kg- Others if indicated: ACE-I, Ca blocker

DVT : A. Really DVP ?

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 rest2. ECGlook for S1Q3T3, right ventricular heart strain

3. CXR: any linear atalectasis 4. Monitor BP/P/SaO2 Q1H x 6 , if stable then Q4H 5. Enoxaparin 0.4ml SC Q12 H ( for BW < 40kg) 6 .Consult medical for warfarin dosage

5. GASTROINTESTINAL

Coffee ground vomiting- Check BP/P, U/O, do abdominal, PR exam, +/- CXR (free gas)- Stop aspirin or warfarin- Special alert if Hx of cirrhosis (? bleeding esophageal varices):

- urgent consult surgical- NPO except med, give IVF, BP/P, U/O Q1H-Q4H ( IV angiocatheter) - R/T to BSB, aspirate Q1H-Q4H Foley insertion if in shock - Blood x CBP (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)- Zantac 50mg iv Q8H 食米唔知米貴 - Anti-encephalopathy: lactulose 10-20ml Q4-8H- Consult surgical x OGD

If massive / vomiting fresh blood:- Vitals Q1H- Haemocue stat; Bld x CBP, clotting profile, Type and Screen- Losec 40mg iv Q24H (omeprazole) - Urgent consult surgical x ?assessment +/- urgent OGD (Call for senior for help ! )- Transfuse packed cells / FFP according to bld results

Constipation- Dulcolax tab 1 PR x1 stat- Fleet enema PR x 1 stat- Senokot 7.5 or 15mg Nocte po prn- Lactulose 10ml bd/tds po prn-Metamucil 10ml BD/TDS PO ( orange in color)

Dyspepsia- MgTri 10ml tds po- Triact or Mylanta tab 1 tds po- Gelusil tab 1 tds po- Gasteel tab 1 tds po prn 散胃氣

Abdominal pain (anti-spasmotics)- Exclude surgical causes first by examining the patient- Holopon tab 1 tds po prn- Buscopan tab 1 tds po prn or Buscopan 20 or 30 or 40mg IM/IV Q6H prnDon’t use it in I.O.Myasthenia Gravis, urinary retention due to prostate hypertrophy

Diarrhoea- Chart I/O, +/- IVF supplement- Look for underlying causes, prescribe the followings only if indicated:- Kaopectate 10ml qid po prn- Lomotil tab 1 qid po prn ( to overcome the side effect of neotigmine in MG) - Imodium tab 1 qid po prn

Haemorrhoid- Faktu supp tab 1 BD or ointment LA tds- Xylocaine jelly LA tds prn- Metamucil 1 sachet tds po-Anusil 1 tab Daily PR

6. NERVOUS SYSTEM

Stroke / CVA- NPO except med, IVF- BP/P/SaO2 Q4H- Neuro Obs Q1H x 1/7 (GCS) - Bld x CBP, L/RFT, clotting, glucose, fasting lipid, fasting glucose- 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, anti-platalets until haemorrhagic stroke excluded by CT brain- Limb and chest physio- Consult occupation x swallowing assessment

Epilepsy- ABC, O2, glucose, H’stix, electrolytes- Give D50 50ml iv, thiamine 100mg iv

- IV diazepam 10mg bolus- Repeat dose in 5 min- Phenytoin 16-18mg/kg iv over 30min, then 300mg po/iv- Consult anaesthetist, ICU- Monitor BP/P, RR, ECG, temp- r/o infection, poisoning, anti-convulsant withdrawal

Seizure attacks- Convulsion chart, +/- neuro-obs- If not spontaneously subside in 10min, can consider:- Valium 5mg iv stat x 1

CNS tumour or haemorrhage with mass effect- Dexamethasone 10mg IV x 1 then 4mg Q6H IV- Dilantin 500mg IV x 1 or 500mg in 100ml NS over 30min x 1; then 100mg Q8H IV- Pepcidine 20mg iv Q12H- Mannitol 250ml iv over 20min, then Q8H- Transamine 1g IV x 1 then 500mg Q6H iv

7. ENDOCRINE

DKI drip (for fasting of DM patient)- D10 500ml Q6-8H, plus the followings:

H’stix Actrapid HM KCL4-7 0 07-11 5 511-17 10 1017-22 15 15>22 20 20

(e.g. D10 500ml + 10u Actrapid HM + 10mmol KCl Q8H/pint)

Hypoglycaemia (H’stix <3.5) –sweating , dizziness, feel weak - 50ml D50 iv stat x1 ( better to give either 40ml or 60ml as the package limitation) +/- D10 q6h or q8h /pint

+/- H’stix Q1H +/- neuro-obsOral form dextrose even better as the sugar would not overshot and then dropped quickly

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

Sliding scale of Actrapid HMAlways exclude infection before giving insulin ! - Check H’stix Q4H or Q6H, then Actrapid HM according to the following scales:

- Version 1:H’stix Actrapid HM<13 0

13-15 415-20 620-25 8>25 Inform

- Version 2:H’stix Actrapid HM<11 0

11-14 214-17 417-21 621-28 8>28 10 + Inform

- Or just order single strength according to H’stix reading, e.g.- Actrapid HM 6u sc tds prn if H’stix >16 (or omit if H’stix <10)

Hyperglycemia (poor DM control)- Check HbA1c, glucose, ABG if DKA suspected- Urine for ketone, sugar, albumin

Thyrotoxicosis- Propranolol 20mg BD PO Or Inderal 20mg TDS PO- Propylthiouracil 100mg TDS PO- Carbimazole 10mg TDS PO

8. MISCELLANEOUS

Contrast allergy- Hydrocortisone 200mg IV on call to radiology department

Drug overdose- NPO, give IVF- BP/P/SaO2 Q4H; Neuro-obs Q1H for 1/7; Cardiac monitor- Suicidal precaution- Urgent bld x CBP/DC, clotting, ABG, L/RFT, glucose, CaPO4, amylase, toxicology

(paracetamol, salicylate, benzodiazepam, ethanol)- Urine for toxicology- Gastric lavage for toxicology

Thyroxine replacement- Start at 0.025mg QD; check TFT to monitor the dose

Gout- Colchicine 1mg stat, then 0.5mg Q2H until pain subside/diarrhoea/max dose of 6mg reached- Naprosyn 250mg BD PO

Cellulitis- On exam, note any fluctuation (which indicate underlying abscess), if +ve, bedside needle aspiration to look for pus aspirates (usually done by MO)

- Note DM; bld x CBP, L/RFT, 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

DVT- Warfarin:

- INR <1.5 : 4mg- INR 1.5-2: 2.5mg- INR 2-2.5: 1.5mg- INR 2.5-3: 1mg- INR >3 : omit

Order: -Complete bed rest -BP/P Q1H x 4 -INR -Urgent CXR, ECG -Enoxaparin 0.4ml Q12H S.C.- Urgent consult medical x DVT

Menorrhagia- Transamine 500mg QID PO

Unit conversion- mmHg x 0.13332 = kPa

Creatinine clearance(140-age) x BW(in kg)--------------------------- X 1.02 (female) or 1.23 (male)serum Cr

OrCrCl = (24 hr Cr / serum Cr) x 0.7

~ END ~

Common Clinical /Emergency case 1. GI: a. Barium Enema: - Fluid diet - HB - Consent & allergic Hx - Klean prep 2L PO x 1 b. Colonoscopy: - Fluid diet - HB - Consent & allergic Hx - Klean Prep 2L PO x 2 ( Nocte, Am ) Avoided in closed loop I.O c. PPP x hemicolectomy -FMN with IVF 2D1S /day -Consent -Bld CBP, R/LFT, CEA& X match -CXR & ECG -HB x Prophylastic Antibiotics IV zinacef & IV flagyl -Foley & Ryle’s tube on call to OT -Klean Prep 2L PO x 2 2. HBP ( follow protocol) : a. TACE: -FMN with IV fluid -Bld: CBP, L.RFT, INR/APTT, AFP, ABG -Consent & allergic hx -HB prophylactic antibiotics e.g. augmentin 1.2gm on call to X ray -Cisplatin 20mg IV 3. Urology: a. AROU: - Feel for bladder/ bladder scan

- DAT - CBP, L/RFT, CaPo4 Glucose - CSU x C/ST - KUB -Foley to BSB b. Haematuria : - DAT - Encourage fluid intake - CBP, L/RFT, CaPO4, Glu, INR/APTT - Save urine x inspection - MSU x C/ST

- EMU x AFP x 3 - Urine x cytology x 3 - KUB - Pyridium 1 tab tds x 1/52 - Nitrofurantoin 50mg QID x 1 /52 if febrile c. Loin pain: - DAT - CAP, L/RFT, CaPO4 , Glu - MSU x C/ST - KUB - Dologesic 1 tab QID / Votaren 25mg tds prn 4. Vascular a. PVD : - FMN with IV fluid -CBP, L/RFT, INR/APTT -HB -consent & allergic Hx

5. Pre-op care: Bowel preparation for colon Steroid for drug allergy IV heparin for oral warfarin 6. Post-op care: Post op Day ? Pain: PCA pain affects breathing , thus easy to have pneumonia Post-op fever: causes according to the post-op days Urine output Wound care

TACROLIMUS (FK506 / PROGRAF)Therapeutic action:

The mainstay of immunosuppressive drug for you after liver transplantation. Tacrolimus is similar to that of Cyclosporin A. It lowers the activity of the immune system and in turn keeps the body from rejecting the transplanted organ.

Dosage: A small yellow capsule 0.5 mg per capsuleA small white capsule 1 mg per capsuleA red-grey capsule 5 mg per capsuleThe dosage needs to be adjusted in accordance with the blood levels, graft function and evidence of side effect, such as renal impairment.

Adverse / side effects:

Nausea, vomiting, diarrhea, constipation Shaking hands, headaches Alopecia, sweating Hypertension Nephrotoxicity

Increased calcium and blood sugar levels Remark: 1. Tacrolimus is best given on an empty stomach, so it is

ideal to give it before meals or 2-3 hours after meals. 2. Tacrolimus needs to be given approximately 12 hours

apart so that a constant level is in the blood stream to prevent organ rejection. Before breakfast and after dinner are ideal times.

3. The dosage of Tacrolimus is different for each individual patient. Only the doctor can adjust the dosage in accordance with the blood FK506 level.

4. Post-liver transplantation patients must have regular follow-ups and blood-taking after discharge.

 

CYCLOSPORIN A (SANDIMMUM NEORAL)Therapeutic action:

One of the immunosuppressive drugs. It acts by inhibiting T-cell activation. By lowering the activity of the immune system, it keeps the body from rejecting the transplanted organ.

Dosage: A 25 mg per capsule and 100 mg per capsule.The dosage needs to be adjusted in accordance with the blood levels, graft function, and evidence of side effect, such as renal impairment.

Adverse / side effects:

Nausea, vomiting, diarrhea Shaking hands Headaches, sweating Hypertension

Nephrotoxicity Remark: 1. Similar to FK506, Cyclosporin A is best given on an

empty stomach, so it is ideal to give it before meals or 2-3 hours after meals.

2. Cyclosporin A needs to be given approximately 12 hours apart so that a constant level is in the blood stream to prevent organ rejection. Before breakfast and after dinner are ideal times.

3. The dosage of Cyclosporin A is different for each individual patient. Only the doctor can adjust the dosage in accordance with the blood Cyclosporin A level.

4. Post-liver transplantation patients must have regularly follow-ups and blood-taking after discharge.

5. Patients who develop hypersensitivity to this drug should stop to take it and inform the Transplant Team doctor immediately.

 

MYCOPHENOLATE MOFETIL (MMF)Therapeutic action:

Mycophenolate mofetil has been used for the treatment of acute rejection and for prevention of rejection. It could be used in conjunction with other immunosuppressants.

Dosage: 250 mg per capsuleAdverse / side effects:

Nausea, vomiting, diarrhea Hyperlipidemia

Lower the white cell count and increase the risk of bacterial or viral infection

Remark: Contraindication to known hypersensitivity to MMF and for breast-feeding women.

 

MYFORTIC (MYCOPHENOLIC ACID)Therapeutic action:

It is indicated for the prophylaxis of acute transplant rejection in adult patient.

Dosage: A lime green tablet 180 mg per tabletA pale orange red tablet 360 mg per tablet

Adverse / side effects:

Diarrhea, Leukopenia, Infection

Remark: 1. Contraindication to known hypersensitivity to mycophenolate sodium, mycophenolic acid and MMF.

2. Precaution to pregnancy and breast-feeding women.

3. Myfortic tablets should not be crushed and should be swallowed whole.

 

PREDNISOLONETherapeutic action:

Prednisolone is given with other drugs to prevent acute rejection.

Dosage: A white color tablet with 5 mg per tablet. This drug will be withdrawn during the first post-transplantation year.

Adverse / side effects:

High blood pressure from fluid retention Gastric ulcer Weight gain due to increase appetite Night sweating Cushingoid facies Muscle weakness, osteoporosis Increase blood sugar level Increase risk of infection Increase bruising

Impaired vision Remark: Prednisolone is best given with milk and food.

Inform doctor if there are signs and symptoms of infection.Regular body weight check up.

 

 

LAMIVUDINE (ZEFFIX)Therapeutic action:

Inhibits the replication of hepatitis B virus.

Dosage: 100 mg per tabletAdverse / side effects:

Nausea, vomiting, diarrhea, abdominal discomfort Fever, malaise, musculoskeletal pain, rash Cough, insomnia, headache, alopecia Lactic acidosis Thromobocytopenia

Raised liver enzymes and serum amylase Remark: Contraindication to breast-feeding women.

Lamivudin is best used in patients with active hepatitis B infection and post liver transplantation. Close monitoring is necessary to prevent the reverse of hepatitis B virus.

 

 

URSODEOXYCHOLIC ACID (URSOFALK)Therapeutic action:

Dissolution of cholesterol gallstones in the gall bladder and the gall bladder function must be intact.

Dosage: A white color capsule 250 mg per capsule, 500 - 1250 mg daily

Adverse / side effects:

Calcification of gallstones may occur during treatment. Liver function parameter should be monitored.

Remark: Contraindication to existing pregnancy and breast-feeding women.

 

FLUCONAZOLETherapeutic action:

An anti-fungal drug for prevention and treatment of candidal and cryptococcal infection.

Dosage: 50 - 400 mg daily adjusted according to severity of infection; duration of therapy is about 3 months.

Adverse / side effects:

Nausea, vomiting, diarrhea, abdominal painHeadache, Skin rash, Hypokalemia

Remark: It is well absorbed by oral administration. Rinse mouth for 3 minutes before swallowing. Do not eat and drink within 30 minutes after taking the drug.

 

ACYCLOVIRTherapeutic action:

An anti-viral drug for prevention and treatment of viral infection such as herpes.

Dosage: 400 mg per tablet and 3 times daily; duration of therapy is about 3 months.

Adverse / side effects:

Nausea, vomiting, diarrhea, abdominal pain

Remark: Not suitable for patients with known Acyclovir hypersensitivity and impaired renal function.

 

 

SEPTRINTherapeutic action:

Antibacterial drug to prevent bacterial infection

Dosage: 480 mg per tablet daily; duration of therapy is about 3 months.

Adverse / side effects:

Nausea, vomiting, diarrhea, rash

Remark: Contraindication to pregnancy and breast-feeding women. 

NYSTATINTherapeutic action:

An anti-fungal drug for prevention and treatment of candidiasis and oral infection

Dosage: Oral suspension 5 ml each time and 4 times daily; it is well

absorbed by rinsing mouth for 3 minutes before swallowing. Do not eat and drink within 30 minutes after taking the drug.

Adverse / side effects:

Nausea, vomiting, diarrhea