Archive for November, 2010

A&E Checklist For Students

Posted: November 8, 2010 by smarinz7 in A & E


1. Cardiovascular• Acute coronary syndrome• Hypertensive crisis• MI• Cardiogenic shock

2. Gastrointestinal• Cholecystitis,biliary colic

3. Neurology• Meningitis• Coma• Intracranial hypertension

4. Endocrinology• Addisonian crisis,DKA.

5. Pulmonology•Bronchial Asthma. ARDS• Pulmonary edema and congestive heart failure

6. Toxicology• General poisoning

7. Nephrology• Acute renal failure

8. Others• Pain management.Chest Pain


1. Arrest of bleeding

2. Transport immobilisation

3. Airway. Breathing and circulation (ABC)

a. Cardiopulmonary resuscitation (CPR)

b. Intubation

Note: This is not the only practical skills fornecessary to manage in A&E dept.

For other necessary skills, pls refer to the listof Medicine and Surgery Department.



1. Oxford Handbook of Clinical Medicine(7th edition) – Emergency section

2. Tarascon Adult EmergencyPocketbook(Steven Rothrock)


3. Sarawak Handbook of MedicalEmergencies (2nd edition)

Sarawak handbook of medical emergencies

4. Singapore Handbook of Emergency

Visit also:For CPG update: care & CPR:


Chest Pain

Posted: November 7, 2010 by smarinz7 in A & E

Chest Pain

  • Usually we send this pt to RED ZONE


a)      Life threatening

  • Thoracic aortic dissection
  • Esophageal rupture
  • Tension pneumothorax
  • ACS(e.g. MI,UA)
  • Pulmonary embolism

b)      Most common

  • CVD
  • Pulmonary
  • Musculoskeletal
  • Psychological

Things to ask:

O – Onset: “When did the pain starts?”

P – Provocation: “during cough, stress, after food and RECENT SPORT that might lead to overuse of chest muscle.

Q – Quality: “describe your pain; dull, sharp”

R – Radiation: to the head, scapula, left hand.

S – Severity:“I give u the scale from 1-10,10 is the most painful…which number is your severity?”

  • PMH: HT, DM, cerebrovasc dss, PE.
  • Medications? – drugs can trigger coronary artery spasm(e.g. cocaine, NSAID)

*If possible, ask the pt to hand the drugs to you.

  • What position relieves the pain?
  • Palpate and check skin of chest – trauma, abrasion, bruises, subcutaneous emphysema(crackles sound when palpate)


*Main Aim: TRO Life threatening causes!!

  • Pulse oximetry
  • ECG within 10min
  • CXR
  • Look for cardiac markers: TRO ACS etiology(e.g. troponin,CK-MB)

*If STEMI à start PCI or thrombolytic therapy within 90 min standard.( refer STEMI)

Suspect PE if

  • Leg swell
  • HR > 100
  • >3days immobilization
  • History of surgery within the last 4 weeks
  • Hemoptysis

Thoracic Aortic Dissection

  • Blood penetrates the tunica intima and the pressure tears the tunica media of the blood vessels.
  • 2 type

1)      Type A – in ascending aorta (typically chest pain)

2)      Type B – in descending aorta (usually abdominal pain)

  • History of HT,blunt trauma to chest.
  • Dx: TEE(transesophageal echochardiography)and MRI-gold standard, CT scan.
  • Within 2 weeks(80% mortality).
  • Tx : surgery or HT tx

Cardiac tamponade

  • a minimum of 100ml fluid in pericardium is enough to cause this.
  • Beck’s triad:

1)      Low arterial BP – bcos low stroke volume.

2)      Jugular vein distension – in non-supine position due to diastolic filling of RV.

3)      Muffled heart sound (decrease heart sound)– effects of passing thru fluid in pericardium.

  • Etio: pericarditis,myocardial rupture, blunt trauma.
  • Dx: ECG – low voltage QRS complex
  • Signs n symptom of shock(tachycardia, apnea, decrease level of consciousness .
  • Tx: pericardiocentesis at 5th intercostals space.

Tension Pneumothorax

  • chest pain is sharp and pleuritic,dyspnoe,cyanosis,tracheal deviation,jugular venous distension
  • do CXR to confirm
  • Tx: insert largest cannula into the 2nd intercostal space in the midclavicular line at the site with the absent or reduced breath sounds.
  • If air rushes out,leave the cannula in place until a chest drain is inserted.


Auscultation of abdominal aorta : at the back of the patient lower a bit from interscapular region,slightly left from the vertebra.

Acute Pulmonary Oedema(APO)

Posted: November 7, 2010 by smarinz7 in A & E

Def: acute,severe LV failure with pulmonary venous hypertension and alveolar flooding; usually as a secondary to other dss.

*suspected in pt had history of CVD.


  • Extreme dyspnea
  • Cough producing blood tinged sputum (pink color)
  • Diaphoresis(profuse sweating)
  • Cyanosis,pallor.
  • Paroxysmal nocturnal dyspnea (PND): pt need to use pillow to sleep.
  • Crackles heard all the time.

*In pneumonia,crackles heard at the peak of inspiration.


LV failure—heart fail to pump—blood pooling in pulmonary circ—plasma moves frm pulmonary capillaries into interstitial spaces n alveoli—APO


  • CHF
  • Kidney failure
  • ACS
  • HT
  • Valvular disorder.


  • CXR – increase fluid in lung
  • ECG – to find the etiology
  • Serum BNP(brain natriuteric peptide)

–          BNP is secreted by heart ventricle in response to excessive stretching of cardiomyocytes.

–          >100picogram per ml indicates CHF.

  • ABG


  • O2  100% – nonrebreather mask,upright position.
  • Furosemide 1mg/kg IV
  • Nitroglycerin 0.4mg SL(5min) followed by IV drop 10-20µg/min
  • Morphine 1-5mg IV

Additional(etiological tx)

  • PCI
  • Digoxin

Emergency measures:

  • A – airway

–          Max 3L/hr nasal prong(s/e: septal damage)

–          Max 5L/hr mask

–          Max HFM 8L/hr

–          In peads,max 2L /hr

  • B – breathing in upright position
  • C- circulation (BP checking TRO shock)

how to H.o.w

Posted: November 7, 2010 by gerardloh in Uncategorized







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Advice and tips for fresh grads

Posted: November 2, 2010 by gerardloh in Uncategorized

advices/ tips for new born dr..
by Dr. Ng Kean Seng, CSMU (ukr) 2010
on Tuesday, November 2, 2010 at 12:40pm

Hi, congrats everyone for starting another new stage in life. There are some tips or advices to those who started their housemenship, which is a new born.. especially csmu or russia new born doctors

1. Correct attitude
– Correct attitude mean willing to learn, be humble, willing to do more, be friendly n polite to ur colleague or ur superiors, be helpful
– Dun b cocky, dun show unhappy face even though u r, dun b calculative
– Be in the ward earlier, start ur work fast..dun b lazy

2. Study when u dunno a thing
– When ur mo or specialist ask u a thing, or u encounter something tat u dunno, pls learn fast, either online search the info or ask around ..when dunno , dun simply say dunno, say “ boss, I will search it today n let u know tmrw? , thank u for asking me question “

3. Oncall time
– pls be in the ward 1 hour earlier
– Be there earlier to get all the Passover, get to know all the acute cases, ask them agak agak how to handle if emergency happen n if u dunno n write down in a paper.
– Another reason to b there earlier is to secure all the branula in the ward, is to help u reduce ur workload when u r busy, n those hard to set, ask for help to set before ur colleague leave at 5.

4. Be thankful for ur ho leader or ward leader
– They r doing extra works tat dun get paid, so pls respect them.

5. Write down everything that u do in bht
– After u refer a case, or do any procedure, kindly write down n cop in the bht, is to protect urself.. Recently quite a number new baby graduated from csmu or Russian get bad feedback during their works.

Actually I am no one here to gv advices, but I do hope, csmu buddies, pls be smart, pls ask seniors how to survive or adapt.. I believe senior will b helpful n willing to share their advices but v also hv to work hard la..

thank u very much,

Dr. Ng Kean Seng
CSMU (UKr) 2010,
Co-Founder of H.O.W.