Contents

Antibiotics 3

Common medications 4

PEDIATRICS (GENERAL ADMISSIONS) 5

Fever (general) 6

Febrile convulsion 8

GE (with anal rash) 10

Prolonged fever 12

Kawasaki 14

Syncope 16

Breakthrough seizure 19

Afebrile convulsion 21

Allergy 23

Hematological malignancy (ie case of unexplained anemia) 25

Petechiae 28

UTI 29

PEDIATRICS (DAY WARD CLINICAL ADMISSIONS) 31

IVIG infusion 32

Palivizumab injection 33

Infliximab infusion 34

Thalassemia blood transfusion 35

BAER 36

DMSA / MAG3 37

MRI brain 39

CT brain 40

Entriflex change 41

Drug overdose 42

MSE 45

HEADSS framework (for adolescents) 45

O&G 46

Labor 47

1
Antenatal 49

Decreased fetal movement 50

Preterm 50

Abd pain cx pregnancy 50

Antepartum hemorrhage 50

BP monitoring 51

Elective C/S 51

Gynaecological hx taking 52

Threatened abortion 53

Hyperemesis gravidarum 54

Menorrhagia 54

Bartholin’s abscess 54

Gaped episiotomy wound 54

Pelvic inflammatory disease 55

Post LEEP bleeding 55

Persistent lochia 55

SURGERY 56

(Literally the most basic template you need for Surg) 57

Hematuria 58

Loin pain 59

AROU 60

Green OT 61

FBI 62

PTX 63

2
Antibiotics
1) Augmentin

     a) IV augmentin 1.2g Q8H

         - if eGFR 15-30: loading dose 1.2g, then 600mg Q12H

         - if eGFR <15: loading dose 1.2g, then 600mg Q24H

     b) PO augmentin 1g BD

         - if eGFR 15-30: PO augmentin 375mg TDS

         - if eGFR <15: PO augmentin 375mg BD

     c) syrup augmentin 457mg/5ml 10ml BD

2) Tazocin (anti-pseudomonas)

     a) IV tazocin 4.5g in 100ml NS over 30 mins Q8H

         - if eGFR <20, loading dose 4.5g, then 2.25g in 100ml NS over 30 mins Q8H

3) Levofloxacin

     a) IV levofloxacin 500mg over 60mins Q24H

         - if eGFR 20-49: loading dose 500mg, then 250mg Q24H

         - if eGFR 10-19: loading dose 500mg, then 250mg Q48H

     b) PO levofloxacin 500mg daily (+/- 250mg)

4) Ciprofloxacin (anti-pseudomonas)

     a) IV ciprofloxacin 200mg or 400mg over 60 mins Q12H

         - if eGFR 5-30: 200mg or 400mg over 60 mins Q18H to Q24H

         - if eGFR 10-19: loading dose 500mg, then 250mg Q48H

     b) PO ciprofloxacin 500mg (+/- 250mg) BD

         - if eGFR 30-50: PO ciprofloxacin 250mg to 500mg Q12H

         - if eGFR 5-29: PO ciprofloxacin 250mg to 500mg Q18H

IV contrast steroid cover:

- PO prednisolone 40mg 12 hours and 40mg 2 hours before examination

Meningitic dose (peds)

For meninigitic dose of IV ampicillin and IV cefotaxime

IV Ampicillin 300mg Q6H (50mg/kg/dose) Q6H

IV Cefotaxime 300mg (50mg/kg/dose) Q6H

3
Common medications

1) Hypertension

     - PO Norvasc 2.5mg or 5mg stat x1

     - PO hydralazine 25mg stat x1

     - PO betaloc 25mg PO stat x1 (C/I: heart failure, bradycardia, asthma, PVD)

     - IV labetalol 5mg IV stat or 100mg in 100ml NS (30ml/hr +/- 5ml/hr)

2) Cough

     - PO fluimucil 200mg TDS

     - PO bisolvon 8mg TDS (mucolytic)

     - PO cocillana 10ml QID PO prn

     - PO MES 10ml TDS PO prn (expectorants)

     - PO Phensedyl 10ml TDS PO prn (cough suppressant) --> may cause AROU

3) Sore throat

     - PO Dequadin 500mg QID prn

     - LA Thymol gargle MW 10mg TDS

     - LA 0.2% Chlorhexidine MW 10ml TDS

4) Oral ulcer

     - LA Bonjela TDS prn

     - LA Thymol gargle MW 10mg tds

5) Skin itchiness

     - LA aqueous cream TDS prn

     - LA Eurax cream TDS prn

     - PO piriton 4mg TDS prn

     - PO atarax 25mg TDS prn

6) Insomnia

     - PO piriton 4mg nocte prn

     - PO imovane 3.75mg nocte prn

7) Gout

     - PO colchicine 0.5mg TDS prn (omit if diarrhea)

8) Alcohol dependence

     - PO ativan 1mg TDS or BD

     - PO thiamine 100mg daily (50mg if chronic drinker)

     - IV thiamine 100mg Q8H if Wernickes

4
PEDIATRICS (GENERAL
ADMISSIONS)


5
Fever (general)
[Age]

NKDA

Informant: mother / father / self

NSD / VA / forceps / c-section at FT / weeks days in _____ hospital

Birth weight     kg

AN / PN uneventful

Development normal so far (details if febrile convulsion / growth problem / syndromal)

GM:

FM:

Social:

Language:

No visual or hearing concern

Vaccination up to date (any flu vaccine)

GPH and important PMH

===================

Admitted for fever x day

Seen with (informant)

Fever since

Temp up to 'C (tympanic / rectal)

No chills / rigors

No cough / RN / sore throat

No SOB / noisy breathing

No vomiting / diarrhea (if suspect GE: ask abdominal pain)

No foul smelling urine / hematuria / tea colored urine

No rash

No jaundice

TOCC

Attended ___ on ____ for D_ fever.

Given _________.

Taken ____ doses of Augmentin so far.

In view of persistent fever tonight, attended ______

<For prolonged fever>

No coryzal symptoms

No GE symptoms, no V/D/ abdominal pain

No foul smelling urine

No sign of Kawasaki, no red eyes/lips, no limb edema, BCG scar normal

--> Add Ix: Blood x CBCdc film comment LRFT CaPO4 CRP EBV ASOT ANA anti-dsDNA ANCA
C3 C4 + HB

--> PE: any sign of Kawasaki disease / joint swelling

<For rash>
Developed rash over body since _____ (D_ of fever)

Rash distributed over buttock / thighs / limbs / back

Started in _____ and then spread to _____ over ___ days

Not itchy

No vesicles

Not vasculitic

No more rash now

6
Oral intake     (% of baseline)

Baseline of     feeds per day (both solid food and breast milk / formula milk)

Water (all compare baseline and now)

Urine output   per day

BO normal     per day, yellow/brown stool, no pale stool, no blood/mucus

Remained active and playful / Patient unwell, more agitated than usual

TOCC:

No recent travel history

No sick contact

No poultry contact

Social hx:

Lives with

Family members all healthy

PE:

BW: kg (th centile)

BH: cm (th centile)

HC: cm (th centile)

Temp: 'C

HR: /min        BP: mmHg

SpO2: %RA     RR: /min

GC well, alert

Hydration good, oral mucosa moist

Capillary refill <2 seconds

Throat not congested, no ulcers/vesicles

No red eyes

No cervical LNs palpable

Chest clear, AE equal

HSDNM

Abdomen soft, non distended, T-G-R-, BS +ve

No rash

Ix:

Imp:

Mx:

Single isolation until COVID negative

DAT

Routine obs

NPS x resp viruses

NPS + TS x CoVID-19

Urine MS

Blood x CBC LRFT CaPO4 CRP C/ST amylase (if GE)

Panadol (10-15mg/kg) mg Q4H PO PRN (usually lowest possible dose)

ORS

Stepdown if n-COV -ve

Await MO assessment


7
Febrile convulsion
[Age]

NKDA

Informant: mother / father / self

NSD / VA / forceps / c-section at FT / weeks days in _____ hospital

Birth weight     kg

AN / PN uneventful

Development normal so far (details if febrile convulsion / growth problem / syndromal)

GM:

FM:

Social:

Language:

No visual or hearing concern

Vaccination up to date (any flu vaccine)

GPH and important PMH

===================

Admitted for fever x day and     episodes of convulsions

Seen with

Fever since

Temp up to 'C (tympanic / rectal)

No chills / rigors

Witnessed by

Developed 4 limbs stiffness GTC at 12pm. 

LOC +

No teeth clenching, up rolling eye balls, cyanosis or drooling of saliva.

No incontinence, no vomitus noted around mouth

_______ can't recall exact duration: ~5 minutes. 

Given PR Valium once at A&E R room and convulsion stopped.

Regained full consciousness afterwards and recognized ____.

Post ictal drowsiness +

Mild head injury last Friday, hit corner or table.

Developed bruise over left frontal area.

Did not cry. Playful as usual. 

No cough or runny nose

No sore throat

No headache, no aura, no photophobia

No vomiting or diarrhea

No foul smelling urine

Appetite satisfactory

B/O: normal, once per day on average

Father has history of hydrocephalus. FU at QEH neurosurgery.

Conservative monitoring. No surgical treatment required. No seizure or focal neurological deficit.

No other family history of neurological condition

TOCC:

No sick contact

No recent travel

No poultry contact

Been to Disneyland on 28/6/2020

8
Development:

GM: runs well, walks up and down stairs without support, can ride bicycle

FM: writes alphabets, numbers, draws circle, tripod grasp

Language: no concerns

Visual and hearing normal

P/E:

BW: kg (th centile)

BH: cm (th centile)

HC: cm (th centile)

Temp: 'C

HR: /min        BP: mmHg

SpO2: %RA     RR: /min

Alert and GCS full

Sleeping (post ictal drowsiness)

GC well, not septic looking

Well perfused, cap refill 1s

Hydration satisfactory 

No respiratory distress

Neck soft, no enlarged LN

No rash

Throat not congested, no exudate / ulcer

Bilateral ears waxy

CN grossly intact

All 4 limbs power full, reflexes all normal

Bilateral plantar downgoing

No cerebellar signs

Chest AE equal, no audible crep/wheeze

HS dual no murmur

Abdomen soft, non tender

No rash

Ix:

CXR: perihilar haziness

CT Brain (plain): no obvious acute infarct or haemorrhage, no space occupying lesion, no

Impression:

1st episode of febrile convulsion

Explained diagnosis and condition to parents.

Mx:

Single airborne isolation until COVID-19 results negative

DAT

Routine obs Q4H

Convulsion chart

NPA x resp viruses

NPS and Throat swab x COVID-19

Blood x CBCd/c, LRFT, CaPO4, glucose, Mg, C/ST (Set HB)

NPA x resp virus

Urine multistix

Panadol 150mg PO Q4H PRN

Inform if convulsion recurs

9
GE (with anal rash)

[Age]

NKDA

Informant: mother / father / self

NSD / VA / forceps / c-section at FT / weeks days in _____ hospital

Birth weight     kg

AN / PN uneventful

Development normal so far (details if febrile convulsion / growth problem / syndromal)

GM:

FM:

Social:

Language:

No visual or hearing concern

Vaccination up to date (any flu vaccine)

GPH and important PMH

===================

E admitted for D_ fever and diarrhea

Fever since 2/7/2020 night

Max temp up to 39.2'C (tympanic)

No chills or rigors

Diarrhea since 2/7/2020 morning with loose greenish stool, no blood/ mucus

Intially loose then more watery after intake of Zinnat from private

Increase in frequency, 13x of small amount in each nappy today

Usual 2x BO/day

1 episode of vomiting after ingestion of medication

Mother complaint rash in patient's anal region

Fatigue and less playful

Seen by GP yesterday

Given antibiotics (zinnat), antipyretics, antidiarrheal drug and cream for rash

Usually on EBF 6x + supp AF 120ml/day

Yesterday appetite same

Switched to Soy milk since this afternoon and decrease in oral intake

UO unknown due to mixed with stool, heavy diaper

Last PU upon admission

No cough/sputum/RN/sore throat

No SOB/ noisy breathing

No vomiting

No foul smelling/ turbid/ hematuria

No ear tugging

TOCC -ve

Lives with mother, uncle, maternal grandmother (all no recent illness)

No recent travel Hx

PE

BW: kg (th centile)

BH: cm (th centile)

HC: cm (th centile)

10
Temp: 'C

HR: /min        BP: mmHg

SpO2: %RA     RR: /min

Moist mucosa, warm peripheries

AFNT, no sunken fontanelle

Throat not congested, no exudate/ vesicles

Neck soft

No Rash

No enlarged cervical LN

HS normal, no murmur

Chest AE well, no creps/ wheeze

Abdomen soft, non-tender, no hepatosplenomegaly, BS active

Sore buttock+, no anal fissure

No imaging

Imp: Viral GE, not dehydrated

Mx

Single isolation till COVID -ve

DAT, encourage oral intake

routine obs Q4H

Chart IO

NPS + TS x COVID

NPS x resp virus

Urine multistix

Stool c/st, virus

panadol 100mg po Q4H prn

Zinc cream TDS to buttock

ORS po prn

For IVF if poor oral intake


11
Prolonged fever

[Age]

NKDA

Informant: mother / father / self

NSD / VA / forceps / c-section at FT / weeks days in _____ hospital

Birth weight     kg

AN / PN uneventful

Development normal so far (details if febrile convulsion / growth problem / syndromal)

GM:

FM:

Social:

Language:

No visual or hearing concern

Vaccination up to date (any flu vaccine)

GPH and important PMH

===================

E' admitted for prolonged fever & GE symptoms

On & off fever since ___, ~_ weeks

Temp up to ___ (tympanic)

No chills or rigors

Cough + RN +

No sputum / hemoptysis / night sweats

No sore throat / SOB

No urinary symptoms

No rash / red lip, no limb edema / joint swelling

Seen GP twice, given antipyretics but fever persisted

Attended private pediatrician, given antipyretics and antibiotics

Private CXR yesterday, told L lung haziness

Developed diarrhea & vomiting since last night, BO 4-5x, brownish loose to watery stool, with
mucus, no blood or melena

Vomiting 2-3x, bile stained fluids, no blood

Associated with abdominal bloating, but no abdominal pain

No fatigue, myalgia or limb weakness

No suspicious food intake

No GE symptoms in family

Appetite fair, sometimes reduced to half of usual

Fluid intake satisfactory

TOCC: -ve

No recent travel history

No contact with confirmed cases / known sick contact

No poultry contact

Social:

Lives with parents

Family members all healthy

F1 student, mainstream school, MOS St Joseph

PE:

12
BW: kg (th centile)

BH: cm (th centile)

HC: cm (th centile)

Temp: 'C

HR: /min        BP: mmHg

SpO2: %RA     RR: /min

[PE as above - refer to fever (general)]

Ix:

CXR: clear, no definite consolidation

Impression: viral illness / GE

Mx:

Single isolation until COVID negative

DAT, encourage oral rehydration

Routine obs Q4H

Chart I/O

Recheck HR once

NPS x resp viruses

NPS + Throat Swab x COVID-19

Urine Multistix

Stool: C/ST, viruses

Blood x CBC LRFT CaPO4 CRP C/ST

PO Panadol 500 mg Q4H PRN


13
Kawasaki

[Age]

NKDA

Informant: mother / father / self

NSD / VA / forceps / c-section at FT / weeks days in _____ hospital

Birth weight     kg

AN / PN uneventful

Development normal so far (details if febrile convulsion / growth problem / syndromal)

GM:

FM:

Social:

Language:

No visual or hearing concern

Vaccination up to date (any flu vaccine)

GPH and important PMH

===================

E- Admitted x Fever (D4-5)

Fever since 4/7/2020 (Sat) 5AM, noted warm to touch by mother

Temp up to 38.3C (forehand)

No Chills/Rigors

Widespread MP polymorphic rash since yesterday, start in chest and spread to limbs

Non-pruritic, non-vesicular

BCG scar reactivation

Red lips, red tongue

Conjunvtivits

Attended  PWH AED on 4/7/2020 (Sat) evening 11PM for D1 fever.

Given panadol syrup, and advised to seek medical attention if fever persists.

Monday swinging fever, 37-38C.

Activity: Irritable and poor sleep

No Dry cough/ RN / Sore throat

No SOB / some noisy breathing

No vomiting / Diarrhea (1 x green stool ystd, no blood or mucus, self-resolved)

No foul-smelling urine / haematuria/tea-colorued urine

No jaundice

No coryzal symptoms

No GE symptoms, no V/D/abdominal pain

Oral intake

Baseline: EBF x 10 min/meal, feed every 3 hours . Supplement with formula milk if needed.

Now: 50% of normal feedtime. Refuse formula milk supplementation.

Urine output: 8-10 nappy changes/day. Maintained.

BO normal.

TOCC:

No recent travel history

No sick contact

Social:

Lives with parents, sister (7y/o)

Family members all healthy

14
<PE>

[Refer to fever (general)]

CXR done at AED:

Imp: Kawasaki's Disease

Features: Prolonged fever (D4-5), polymorphic MP rash, BCG reactivation, conjunctival injection,
mucosal changes

Mx:

Single isolation room until COVID-19 -ve

DAT

Routine Obs

NPS x resp viruses

NPS + TS x CoVID-19

Urine MS

ECG with long lead II, consult Cardiology for Echocardiogram

Blood x CBC, L/RFT, CaPO4, CRP, C/ST

Panadol 70mg Q4H PO PRN

IVIG (Intragam P Infusion) 16g (2 gram/kg) over 12 hours

Aspirin (42mg/kg/day) (High dose: 80mg/kg.day -> taper to 30mg/kg/day)

ECG done: sinus rhythm (165bpm), QTc 380ms, no ST changes


15
Syncope
[Age]

NKDA

Informant: mother / father / self

NSD / VA / forceps / c-section at FT / weeks days in _____ hospital

Birth weight     kg

AN / PN uneventful

Development normal so far (details if febrile convulsion / growth problem / syndromal)

GM:

FM:

Social:

Language:

No visual or hearing concern

Vaccination up to date (any flu vaccine)

GPH and important PMH

===================

Admited for __ episode of syncope

Syncope during school orientation today at around 3pm

Was walking, then smell something unuasal (was passing chemistry lab)

Then felt dizzy and LOC afterwards

Unresponsive

Wtinessed by teacher and classmate

Lasted for ~3-4 mins

Told pale looking

No twitching/drooling/uprolling of eyeball/incontinence during LOC

Woke after 3-4 mins but felt tired, no residual neurological symptoms

Deny HI/injury

Escort by teacher to rest room

Then 2nd episode of syncope happened

Sudden onset LOC again, witnessed by teacher and classmate

Unknown duration

No twitching/drooling/uprolling of eyeball/incontinence during LOC

Escort to rest room with wheelchair afterwards

But felt tired. No residual neurological symptoms

Fully awake on arrival of ambulance (not sure exact duration)

No preceeding symptoms

No chest pain/SOB/headache/vertigo

Did not miss meal, had breakfast and dinner

Enough sleep for >8hr

Deny alcohol/illicit drug intake

Afebrile all along

No coryzal symptoms/GI/GE symptoms

Menarche 8/2020(early August)

Last for 7 days, heaviest flow day on D2-3

Dysmenorrhea+

Mild dizziness during mensturation

No personal history of syncope/LOC

16
No postural dizziness previously

No family history of epilepsy/cardiovascular disease

No famioy history of sudden death

TOCC-ve

Ix done in AED

- Temp 36.6'c BP 88/53 P 84 SpO2 96% RA

- Hstix 5.2

- Hemocue 13.4

- Urine PT -ve

- CXR clear, no consolidation

- CTB: no SOL/MLS/ICH

- ECG: SR 78bpm, PR normal, QTc (calculated): 430ms

PE

BW: kg (th centile)

BH: cm (th centile)

HC: cm (th centile)

Temp: 'C

HR: /min        BP: mmHg

SpO2: %RA     RR: /min

GCS full

Well hydration and perfused

Pulse ~100bpm, regular, no RR delay 

Apex 5th ICS, not displaced

HS normal no murmur

No carotid bruit

Chest clear, AE equal

Abdomen soft, no T/G/R

No hepatopslenomegaly

No rash

Neurology exam:

GCS full

Orient to place and space

PEARL

EOM full

No facial asymmetry

CN intact

4 limbs power full 5/5

 5 | 5

 5 | 5

All reflexes present and symmetrical , not brisk

No ankle clonus

Bilateral plantar equivocal

Sensation intact

Propioception normal

Gait normal

Imp: ? Vasovagal syncope

Mx

DAT

Routine obs

Postural BP x 1

17
Blood x CBC LRFT CaPO4 CRP Mg RG Trop T


18
Breakthrough seizure

[Age]

NKDA

Informant: mother / father / self

NSD / VA / forceps / c-section at FT / weeks days in _____ hospital

Birth weight     kg

AN / PN uneventful

Development normal so far (details if febrile convulsion / growth problem / syndromal)

GM:

FM:

Social:

Language:

No visual or hearing concern

Vaccination up to date (any flu vaccine)

GPH and important PMH

===================

E adm x breakthrough seizure

 episode of afebrile convulsion

(Details of the event)

   am / pm today at home

Witnessed by

Any UL/LL extension

Any increase in muscle tone

seizure with

 - uprolling eyeballs

 - 4 limbs twitching

 - face cyanosis

 - LOC

 - drooling of saliva

 - no tongue biting

 - no incontinence

 - no head injury

(Any intervention by family members)

Last for    , aborted spontaneously

Any post ictal drowsiness for  mins

Regained full consciousness after

Could recognize

Back to normal self on ambulance

no crying all the way to AED

No prodrome / aura before seizure

No chest discomfort / palpitation

No stress / mood changes

No change in appetite / skipped meals

No sleep deprivation

Any rhythmic jerk movement noted

Any current anti-epileptics, compliance

Development

No Fhx of epilepsy/febrile convulsion in childhood/ neurological illness

no fever / URTI / GE symptoms

19
no rash

no recent head injury

no focal neurological deficit

no foul smelling urine

no neck stiffness

PE (also neurology)

 ...

 No neurocutaneous stigmata

 4 limb tone, jerk

Imp: breakthrough seizure

Mx

DAT

Obs Q4H

SaO2 monitor

Convulsion chart

CBC d/c LRFT CaPO4 Mg RG + set HB if possible

ECG with long lead II

Resume usual meds

Consult neuro x EEG mane

Acute seizure management and precautions, need of supervision during risky activity explained. 


20
Afebrile convulsion

[Age]

NKDA

Informant: mother / father / self

NSD / VA / forceps / c-section at FT / weeks days in _____ hospital

Birth weight     kg

AN / PN uneventful

Development normal so far (details if febrile convulsion / growth problem / syndromal)

GM:

FM:

Social:

Language:

No visual or hearing concern

Vaccination up to date (any flu vaccine)

GPH and important PMH

===================

E adm x 1st episode of afebrile convulsion

Patient slept at around 1am tonight, with mother

Noted to have abnormal posturing on bed ~1:30am, lying prone and folded back, 4 limbs not
seen (under duvet), unresponsive to wakening

Carried by mother to living room, and turned on light

Noted eyes partly opened, uprolling eyeballs

Face pale, lips cyaontic

Clenched teeth

UL stiff with mild twitching, not tonic clonic, uncertain about LL twitching

No drooling of saliva, tongue biting or incontinence

Stopped at around 1 min later, spontaneously

Vomited once, small amount of whitish fluid (taken yogurt before sleep), non-bilious, no coffee
ground

Attended A&E immediately

Post-ictal drowsiness x 1 hour

Able to recognize parents in A&E while seeing doctor

No focal neurological deficit noted

C/o of headache in A&E, nature and grade uncertain

No dizziness/blurring of vision

No history of head injury

No fever

No URI symptoms

No diarrhoea/GE symptoms

No urinary symptoms

No rash

Development:

GM: Can play scooter, catch bouncing ball, walks and runs and up and down stairs without
problem

FM: draws square, use scissors

Social: wash face and brush teeth on his own, uses fork and spoon well, not yet chopsticks

Language: can speak complete sentences, partial stories

No concern over hearing and vision

21
No Fhx of epilepsy/ febrile convulsion in childhood/ neurological illness

PE:

BW: 13.5kg (3-10th centile)

Temp: 36.2'C

HR: 95/min        BP: 117/76mmHg

SpO2: not recorded     RR: 24/min

Irritable but consoable

Can identify mother, tell it is night time, cannot tell place

Pupils exam difficult, patient struggling vigorously

but EOM full, no nystagmus noted

No facial asymmetry

4 limbs tone and reflexes normal

Uncooperative for power examination but quite strong

Bil plantars withdrawal

No ankle clonus

Well perfused

Hydration normal

Throat not congested, no ulcers/vesicles

No red eyes

Neck soft, no meningism

No cervical LNs palpable

Chest clear, AE equal, no distress

HS normal no murmur

Abdomen soft, non distended, no organomegaly, T-G-R-, BS +ve

No rash

No neurocutaneous stigmata

No dysmorphism

No imaging

Imp: 1st episode of afebrile convulsion

Mx

DAT

Obs Q4H

Cardiac and SpO2 monitor

Convulsion chart

Blood x CBCd/c, LRFT, CaPO4, Mg, RG, NH3, lactate, carnitine, acylcarnitine, PAA, HLA-B1502 +
set HB if possible

Urine m/s, toxicology, metabolic screen

ECG + long lead II

CT brain with oral sedation

Consult neuro x EEG


22
Allergy
[Age]

NKDA

Informant: mother / father / self

NSD / VA / forceps / c-section at FT / weeks days in _____ hospital

Birth weight     kg

AN / PN uneventful

Development normal so far (details if febrile convulsion / growth problem / syndromal)

GM:

FM:

Social:

Language:

No visual or hearing concern

Vaccination up to date (any flu vaccine)

GPH and important PMH

===================

E' admitted for allergic reaction 

Had     tonight at around

Patient usually doesn't eat       / no previous trial

Then developed generalised urticaria in trunk, limbs, and face.

No SOB or stridor

No periorbital or neck swelling

1st episode of allergic reaction to food. 

Patient was brought to local GP in view of generalised rash. GP referred patient to PWH A&E
immediatly. Patient arrived A&E at

Managed in A&E HDU.

Given one dose of IM Adrenaline 1:1000         mg at

Also given one dose of IM Piriton    mg at

Most of the urticaria resolved shortly after injections.

No recent fever

No recent insect bites

No family history of atopy or allergic reaction

No personal history of atopy

No other food allergy 

History of diarrhea in childhood (heriditary angioedema)

PE: {growth chart}

BW:      kg ( th centile)

HC:       cm ( th centile)

BSA:     m2

Temp: 'C

HR:  / min                  BP:  mmHg

SpO2: % room air   RR: / min

Alert and GC well

Not in resp distress, no stridor

No angioedema

No neck swelling

Well perfused, CR <1 second

Generalised faint urticaria rash over

Maculopapular rash and faint urticaria over trunk

23
Mild urticaria over forehead

Chest clear, no added sounds

HS normal no murmur

Abdomen soft, not distended, non tender, no organomegaly.

CXR: clear

Impression: Suspected     allergy

Mx:

DAT

HR and SpO2 monitoring

Urine multistix

Bloods x routine bloods, CRP, ESR, C3/4, tryptase

LA Calamine lotion TDS PRN to urticaria

PO Piriton 3mg TDS regular for 1 day 

Avoid       at this juncture

Resume usual medications 

Consider consult allergy team for skin prick test


24
Hematological malignancy (ie case of unexplained
anemia)
M/31m

NKDA

Informant: Mother

Main Carer: Maternal Grandma

Birth History:

-----------------------------------------------------

Born full term, via NSD in Union Hospital

AN / PN uneventful

Immunization up to date

Development unremarkable

Good past health

G6PD status: unknown

===================================================

E admitted for fever for 4 days and pallor for 2 weeks

Fever since 15/8/2020, D4 fever

Temp up to 38.1'C (tympanic)

No chills / rigors

On and off oral ulcers at gum for the past 2 months

Each episode have 1 ulcer, no major bleeding or pus from aphthous ulcer

No obvious gum bleeding

Foul smelling urine on D1 illness (15/8/2020)

Urine multistix performed at Union Hospital A&E: normal.Told UTI was unlikely.

No cough / RN / sore throat

No SOB

No vomiting / diarrhea

No rash

Mild jaundice noted

Anaemia:

G6PD status unknown (mother don't remember)

Drugs: Taken panadol for past 5 days. Also taken TCM Bo Ying Dan on 16/8/2020 afternoon
because of persistent fever. 

Dark brownish urine for past 3 days, especially in the morning.

Dark to light yellow urine during the day.

No gross haematuria

No GI bleeding

No trauma history

No vomiting

Exercise tolerance decreased subjectively, need to take a nap at 10am.

Usually takes nap at 11:30 am.

No SOB

No excessive sweating

B-symptoms: 

Night sweats present, but Mother said patient had night sweats since birth

No subjective weight loss

No bone pain

Appetite normal

25
Feeding tolerated

U/O: maintained, dark coloured urine in the morning

Remained active and playful

Family History:

-------------------------------------------

Only child. No siblings. 

Father does not have thalassemia. Checked before having children.

Mother did not check Hb pattern

No other family history of thalaessaemia

Maternal grandma has known lung CA on oral targeted therapy, now complicated with LL
cellulitis, on IV antibiotics.

Attended Union Hopsital A&E on 15/8/2020 for D1 fever.

Given antipyretics but no antibiotics, fever did not resolve.

In view of persistent fever, seen private GP today.

GP noted: pallor, hepatomegaly 1cm below costal margin, no splenomegaly.

Referred to PWH A&E to rule out haematological malignancy.

Checked H'cue at A&E: 4.2

TOCC:

Maternal Grandma has known lung CA on  oral targeted therapy, now complicated with LL
cellulitis, on IV antibiotics.

Main Carer: Maternal Grandma

No other sick contact

No recent travel history

No poultry contact

PE:

-----------------------------------------------------------

BW: 13.9 kg (75th centile)

BH not recorded

HC: 48cm (10-25th centile)

Temp: 36.5'C

HR: 118/min        BP: 115/58mmHg

SpO2: 98%RA     RR: 26/min

GC well, alert, no facial dysmorphism

No Colley's facies

Mild jaundice, pallor

Hydration good, oral mucosa moist

Capillary refill <1 seconds

Warm peripheries

Not in resp distress

No conjunctivitis

Throat not congested, no ulcers/vesicles

No gum bleeding, no oral ulcer

No cervical or axillary lymphadenopathy

Bilateral groin lymph nodes palpable, one LN on each side, non tender, 0.5x0.5cm each.  

Neck soft

Ears: waxy

No finger clubbing

Chest clear, AE good and equal

HS normal, soft grade 2 ESM over LLSB, no radiation

Abdomen soft, not distended, non tender, hepatomegaly  2cm below costal margin, no
splenomegaly, no mass, bowel sounds active

No rash or petechiae or bruises

26
CXR: bilataral perihilar haziness, no cardiomegaly

Impression:

---------------------------------------------------

1) Anaemia for investigation.To rule out haematological disorder.

2) Heart murmur, ?flow murmur, not in heart failure.  

Mx:

------------------------------------------------------

Single isolation until COVID negative

DAT

Cardiac monitor

BP/P Q4H

Chart I/O

Routine obs

NPS x resp viruses

NPS + TS x COVID-19

Urine multistix

Blood: CBC d/c, film comment, reticulocyte, LDH, urate, CK, haptoglobin, Fe profile, Ferritin, Hb
pattern, T&S

Clotting, EBV serology

LRFT, CaPO4, CRP, C/ST

(Set HB)

PO Panadol 150mg Q4H PRN

For blood transfusion if anaemic, sign blood transfusion consent.

Trace G6PD result (birth record, MCHC health book)

Review heart murmur mane

27
Petechiae
[Age]

NKDA

Informant: mother / father / self

NSD / VA / forceps / c-section at FT / weeks days in _____ hospital

Birth weight     kg

AN / PN uneventful

Development normal so far (details if febrile convulsion / growth problem / syndromal)

GM:

FM:

Social:

Language:

No visual or hearing concern

Vaccination up to date (any flu vaccine)

GPH and important PMH

===================

E' admitted x generalized petechiae

Noted petechiae over bilateral LL this morning, then extended to trunk, upper limbs and face

No easy bruising / gum bleeding / epistaxis

No excessive crying

More irritable than usual but consolable

Appetite satisfactory, 5 meals of 150-160oz breastmilk per day

No change in diet of mother, no OTC meds taken

UO and BO normal

Afebrile

No URI / GE symptoms

No family history of hematological disease

Attended private paediatrician today for petechiae and referred to A&E

PE:

BW 5.24kg (50th-75th centile)

BH 55.5cm (25th centile)

HC 37.5cm (10th-25th centile)

Temp: 37'C

HR: 137 /min            BP (could not check as baby struggling)

SpO2: 100% RA     RR: 32 /min     

Imp: ?ITP

Mx

DAT

Routine obs Q4H

Recheck BP x 1

Urine multistix

Blood x CBCd/c (urgent), film comment, T&S, CRP, LRFT, Ig pattern, clotting profile, ANA

28
UTI
[Age]

NKDA

Informant: mother / father / self

NSD / VA / forceps / c-section at FT / weeks days in _____ hospital

Birth weight     kg

AN / PN uneventful

Development normal so far (details if febrile convulsion / growth problem / syndromal)

GM:

FM:

Social:

Language:

No visual or hearing concern

Vaccination up to date (any flu vaccine)

GPH and important PMH

===================

E admit x dysuria and loin pain

Complained of dull abdominal pain since

Pain over central periumbilical area / epigastric region / loin regions on both sides

Associated with dysuria and urinary frequency (every few minutes)

Also noted turbid urine afterwards, whitish milky urine, no blood

no fever / chills / rigors

no URI symptoms

no nausea / vomiting / diarrhea

no rash

Appetite

Oral and water intake tolerated

BO normal, once every 1-2 days 

TOCC -ve

PE: {growth chart}

BW:      kg ( th centile)

HC:       cm ( th centile)

Temp: 'C

HR:  / min                  BP:  mmHg

SpO2: % room air   RR: / min

GC well, alert, not toxic

well perfused, not in distress

HS normal no murmur

Chest clear

Abd soft not distended, no palpable mass

Tenderness over central abdomen and both loin regions

No guarding/ rebound tenderness

No rash

Imp: ?UTI

Mx:

DAT

Routine obs Q4H

29
MSU / cath urine (depends on age) x multistix and c/st

Bloods x CBC d/c, LRFT, CRP, c/st

Augmentin 6.2ml BD PO if urine M/S +ve

If multistix WCC / nitrate +ve treat as UTI:

IV Ampicillin mg Q6H IV (~25mg/kg/dose)

IV Gentamicin mg Q24H (5mg/kg/dose)

CSU x m/s, C/ST

Inform if CRP or WCC ↑

30
PEDIATRICS (DAY WARD
CLINICAL ADMISSIONS)


31
IVIG infusion

[Age]

NKDA

[PMH]

===================

Clinically admitted for IVIG infusion

No active complaint

Afebrile all along

Ix 27/6

Hb 13.7 platelet 140

WCC 4.2 ANC 3.1

IgA <0.05↓   IgG 7.89    IgM 0.06↓

CRP <0.6

LRFT normal

PE

BW 39.35kg

Temp 36.2'c

BP 115/83 P 88

SpO2 96% RA RR 20

HS normal no murmur

Chest clear, AE equal

Abdomen soft

Eczema over bilateral LL

No sign of infection

Mx:

Blood x CBC, LRFT, CaPO4, CRP, Ig pattern

IVIG 15 gram over 4 hours

Home after infusion if remains well

Readmit 4/52

32
Palivizumab injection

[Age]

NKDA

[PMH]

===================

C admitted for 4th palivizumab injection

No URTI /  fever

No active complaints

Mixed feeding 150ml x 7, rarely regurgitation now

No projectile vomiting

BO and urine output unremarkable

Exam: 

BW 5.47 kg  (25-50% for PCA)  

BL 62.3 cm  

HC 42 cm

Vitals normal

Afebrile

AFNT

Well perfused

HS normal no murmur

Chest clear, no sucking

Abd soft non-distended, no organomegaly

Imp: Exprem, BPD, for 4th palivizumab injection

IM palivizumab (15mg/kg) 85mg given once, uneventful


33
Infliximab infusion

[Age]

NKDA

[PMH]

===================

No fever.

Appetite good.

Occasional abdominal pain about once per week.

No diarrhoea.

No blood/mucus in stool.

Normal formed stool, BO everyday.

No nausea/ vomiting/ oral ulcer.

No anal pain, no discharge.

P/E:

Afebrile, BP 112/64, HR 77/min.

Weight gain+

No pallor/jaundice.

No oral ulcer.

No respiratory distress.

Chest clear.

CVS normal, no murmur.

Abdomen soft, non-tender, not distended.

Mx:

DAT

Blood for CBCd/c, CRP, ESR, LRFT, CaPO4 + set hep block

Infliximab 200mg IV infusion as per protocol

Home afterwards if well

FU GI clinic as scheduled

Medications own stock

Readmit 8 weeks

34
Thalassemia blood transfusion

[Age]

NKDA

[PMH]

===================

Clinical admission for regular blood transfusion.

See progress sheet.

Well and no fever.

PE:

BW kg, 25th

BH 125.2cm, 10th

Afebrile, stable vitals

General condition good

Pallor+, tinge of jaundice. 

Abdo soft, liver 2cm soft, spleen 1 cm.

Chest clear

Heart sounds dual no murmur, apex not displaced.

Management:

DAT

Blood x CBCd/c LRFT CaPO4 ferritin Type and Screen + set hep block

Urine x multistix

____ ml packed cells over 5 hours with IV lasix in middle of transfusion

Annual checkup next admission as planned


35
BAER

[Age]

NKDA

[PMH]

===================

Clinically admitted for BAEP exam

No active complaints

Feeding tolerated

Urine and bowel opening satisfactory

Last meal: 2am, milk

PE:

BW: 4.26 kg

BH: 55.2 cm

HC: 36.5 cm

Vitals stable, afebrile

Thriving

Well perfused

AFNT

Chest not in distress

HS normal no murmur

Abdomen soft not distended no hepatomegaly

Imp: Failed hearing test, for BAEP exam today

Mx:

NPO during sedation

HR and SpO2 monitoring during sedation

PO Chloral Hydrate 300 mg once 30 min before exam (70mg/kg/dose) 

Allow feeding when fully awake

Home if feed well

FU as scheduled 


36
DMSA / MAG3

[Age]

NKDA

[PMH]

===================

Clinically admitted for DMSA

No intercurrent illness

No fever

No foul smelling urine

Feeding well, eating solid meals

good compliance to trimethoprim

P/E:

BW: 9.92 kg

Temp: 36.9'C

HR: 133 /min          BP: 114/75 mmhg

RR: 26 /min         SpO2: 99% on room air

GC well

Conscious and alert

Well-perfused, hydration normal

Chest clear, AE equal

HS dual, no murmur

Abdomen soft, non-tender, no mass

Impression: history of 3 UTIs, bilateral grade II VUR for DMSA

Management:

NPO for choral hydrate sedation

Set HB

PO Chloral hydrate 700mg, 30 minutes before DMSA exam

Home after fully awake and milk tolerated

FU renal clinic on 31/7/2020 as scheduled

Continue same trimethoprim

====================================

MAG3

Clinically admitted for MAG 3

Well and afebrile since discharge

Feeding tolerated

No coryzal/ GI symptoms

TOCC -ve

Good compliance to antibiotics

P/E:

BW 6.39kg (from 3rd to 3-10th centile)

BP 87/58 mmHg AR 138bpm

SpO2 100% RA

RR 34

Temp 36.8’C

Active and cheerful, well perfused, not in distress

37
Chest clear

HS normal, soft ESM

Abd soft, not distended, no organomegaly

MP rash over face and body

Mx:

NPO

For MAG3 today

PO chlroal hydrate as charted

Resume feed when back from MAG3 and awake

Home and FU Renal 31/07/2020


38
MRI brain
Clinically admitted for MRI Brain (plain)

No active complaints

No intercurrent illness

No fever

Feeding well

Last meal: 8pm last night

Had sip of water this morning

P/E:

BW: 16.75 kg

Temp 37'C

BH: 106.3 cm

HR: 100/min               BP: 107/72

SpO2: 99% RA           RR: 22/min

GC well

Conscious and alert

Facial dysmorphism 

Hyperterlorism

Well-perfused, hydration normal

Neck soft

No cervical LNs palpable

Chest clear, AE equal

HS dual, no murmur

Abdomen soft, non-tender, no mass / organomegaly, bowel sounds active

Impression: MRI Brain (plain)

Developmental delay

Known Axenfeld-Riegar Syndrome

Management:

------------------------------------

NPO for choral hydrate sedation

Set HB

PO Chloral hydrate 1250mg ONCE (30 minutes before MRI exam)

HR and SpO2 monitoring during sedation

Allow feed when awake after exam

If feeding well, allow home

FU as scheduled


39
CT brain

Clinically admitted for CT temporal scan

No recent illness

No active complaints

Good compliance to hearing aid

Progress noted in SCCC

GM and FM no concern

Language - can express needs in short sentences e.g. "I like car", "I want this", A-Z, 1-50

PE:

BW:  18.1kg (10-25th centile)

BH: 107.2cm (3rd-10th centile)

Temp: 37.1C

HR: 104 / min              BP: 101/51

SpO2: 99% RA           RR: 30/min

AFNT, well perfused

Chest clear

HS normal no murmur

Abd soft not distended

IMP: bilateral hearing impairment, plan for bilateral CI, today for CT temporal assessment

Management:

NPO for choral hydrate sedation

Set HB

PO Chloral hydrate before CT exam

Home after fully awake

FU as scheduled


40
Entriflex change

Clinically admitted x change of entriflex

Entriflex last inserted on 21/4/2020

Well, no active complaints

Vitals stable afebrile

Physical exam unremarkable

Mx:

Fr8 entriflex inserted  via left nostril, tied at 40cm

Home if entriflex in situ

Readmit ~ 1/12 for next change


41
Drug overdose

Informant: patient, elder cousin, mother

16/F

NKDA

FT NSD in KWH

Good past health

Vaccination up to date

Studying in F6

===================

E adm x drug overdose

Brought to A&E by ______

Unwitnessed event

At home with domestic helper, but unwitnessed event

Taken 30 tabs of 5mg melatonin and 6 tabs of 0.25mg Nalion (Alprazolam) today at 2pm in her
own room

Then fell asleep on her bed

Denied coingestion of other drugs

Claimed DO due to low mood and for self harm, but did not intend to perform suicide

Woke up to find elder cousin and boyfriend at bedside (patient messaged cousin about intention
to overdose before hand)

Brought to A&E at around 6pm

Collateral hx from cousin and boyfriend:

Found patient sleeping on her bed

Patient drowsy but arousable

No definite LOC

No convulsion

Bitemporal headache, throbbing in nature, grade 7/10

Dizziness since she woke up, non-vertigo, mainly light headedness

Mild blurring of vision (mild myopia, not wearing glasses)

?Slurred speech (self perceived)

Did not walk since drug overdose, was carried to ambulance by boyfriend

Generalized weakness

No numbness

No fever all along

No URI/GE/UTI symptoms

LMP 1 week ago

Psychiatric history:

Low mood for recent 1 year

Suicidal ideation, thinking about burning coal, no thoughts about JFH

Self harm by cutting wrist

Frequent crying, Insomnia, loss of interest, occasional loss of appetite

Previously mother wanted to bring patient for medical attention

FU private psychiatrist since last year, prescribed SSRI and sedatives before

Last seen 3 months ago, defaulted FU due to COVID

Prescribed Alprazolam and ?sleeping pills

Fair compliance only

According to mother, patient's mood fluctuates but seems to be improved after meds

According to patient, sleeping pills already used up, so she bought OTC melatonin herself

Has been taking 1-2 tabs of melatonin usually, previously also taken 30 tabs in one go

Stopped alprazolam 1-2 weeks ago

42
No known family history of psychiatric illness

Social history:

Studying in F6 in Yow Kam Yuen College

Academic performance fair, did not need to repeat, did not fail subjects

Lives with father, mother and domestic helper

Fair relationship with parents

Courtship with boyfriend age 20 years old, for ~4-5 months, occasional quarrel

Non-smoker, non-drinker

Denied illegal drug intake

Attended A&E ~6pm

BP 117/89 mmHg HR 66

Spo2 100% RA RR 14/min

No desaturation or hypotension

GCS full all along

No treatment given

PE:

BW 45.1kg

BH 158cm

BP 99/65mmHg HR 74/mi

SpO2 100% RA RR 24/min

Temp 36.8

GCS E4V5M6

Oriented to time place person

Well perfused

Hydration normal

No distress

PEARL 3mm bilaterally

EOM full, no nystagmus, diplopia on left lateral gaze

No facial asymmetry

CN grossly intact

5|5

5|5

↓   ↓

Tone and reflexes normal over 4 limbs

No ankle clonus

No cerebellar signs

Unsteady gait, not particularly ataxic

Unable to test tandem gait

Chest clear, AE equal

HS normal no murmur

Abd soft, T-G-R-, not distended, no organomegaly, BS active

Eczema over bilateral UL flexor areas and face

Cut wounds over both wrists

Ix

PT done -ve

Hb 12.4 WCC 5.4 PLT 266

Glucose 4.6

TnT <14.0

LRFT, CaPO4 grossly hemolysed

PT 11.4 INR 1.01 APTT 40.6

Paracetamol, ethanol, salicylate T/F

CXR: no consolidation, bil breast shadow

ECG: sinus rhythm, 53bpm, no ST/T changes, QTc 373ms

43
Mx

Suicidal precaution and fall precaution

DAT

Routine obs

Cardiac and SpO2 monitor

Neuro obs Q1H x 4 then Q4H

Urine toxicology, m/s, PT

Blood x LRFT CaPO4

Contact poison centre

Consult CP, child psy mane

44
MSE

Mental state examination:

Calm and settled, good eye contact, social smile

Not anxious looking

No psychomotor retardation

Mood euthymic affect congruent

Speech circumstantial, largely C/R, poor in expressing herself

Not psychotic

Not suicidal

hair to shoulder length, dyed in dark olive

on ? color con, and nail art

on make up long eyelash

mood on low side, would broke into tears, yet able to resume talking reasonably soon

slightly histronic in body language

affect reactive

some social smile and was polite

speech C&R, mixed with English speaking

non aggressive

non psychotic

denied further deathwish if she could end her pregnancy as it was her major stressor

HEADSS framework (for adolescents)

Home

- living with parents, elder sister, maternal aunt

- father, 50, construction officer

- mother, 50, sales

- elder sister, 20, university student

- fair relationship with parents all alnog, but started to have more frequent quarrels in recent 6
months, as TinWai went go at night to meet her boyfriend more frequently

- poor relationship with elder sister

Education

- F.3, POH 80th Anniversary Tang Ying Hei College

- below average academic results, only passed English in previous tests

- enjoy studying English

- fair relationship with classmates, but poor relationship with teachers

- low attendance for zoom lectures in recent 0.5 years, and stopped going to school since Oct

- parents planning to find private school/ VTC for TinWai

Activities

- enjoy learning & doing make up

- enjoy hanging out with primary & secondary school friends

Drugs

- drink alcohol since 1/2020, 1-2 times/mth, half a can of beer each time

- smoking since end of 2019, 1-2 electonic cigarrete/day

- ilicit drug use +ve, inhaled drugs, unsure abt exact name of drungs, usu took in public parks
with boyfriend & his friends

Mood

- stable mood

- Hx of wrist slashing since F.1, last act in 10/2020

- no other act of self-harm

- all along no suicidal ideation/ act


45
O&G


46
Labor
NKDA

NSND

GPH

P___

Gestation ____

SVD x 1 UCH 2018

AN UCH

AN bloods normal

1TDS -ve

Private morphology scan told normal

SG

GBS

__________

E admitted x labor

Irregular UC since ___, Q__mins

Show at __

No leaking sensation / gush of fluid

PE:

BP , P

Afebrile

Abd:

Soft non tender

Cephalic

T/S

3/5 ab

CTG reactive

UC Q 10mins not felt

PV:

Os closed

(HVS, GBS taken)

If suspected leaking:

Cough test -ve

No liquor seen

Leaking not confirmed

Imp: Early labour

< LABOUR >

PV

2 F PTU

Membrane +ve

S -2

AROM done, clear liquor

Imp: SROM

PPROM:

Placenta swab, histology

MSU

HVS

Fibroid (large): CBC, T&S

47
Mx:

To ward 4B

Observe for progress

Start IV abx for GBS when in labor

(HVS, GBS)

Allow labour when in labour

CBC, LRFT, Amylase, T&S

Keep HB

Mx (if established labor):

Stay labour ward

Observe for progress

Start IV abx for GBS when in labor


48
Antenatal

Past medical History (if any)

Para ___

SVD in ____, BW ____

Previous C/S for ____ in _____

Mat ___w ___ d

AN in UCH / TKOH/ MCH

AN blood normal

1st / 2nd tri DS –ve/ NIPT low risk

Morphology scan normal, placenta ____ not low

RG / OGTT ____

GBS-ve

Previous admissions and details

__________

Admitted for

- show at ___ (time)

- leaking at ____ (time) (ask if gush of water from vagina or just leaking sensation)

- UC Q__mins since ___ (time)

- FM active

P/E:

BP ____ P_____   Afebrile

Urine albumin –ve

Ut T/S ceph __/5 AB

PV at ____:  

os closed / __F / __cm

long tubular / short tubular / PTU / FTU

Vx / Br

S-2 / S-3…..

membranes felt / not felt

cord, placenta

(for suspected leaking)

Speculum: pool of clear liquor in posterior fornix, cough test +ve (leaking confirmed)

Speculum: whitish discharge only, no liquor seen, cough test –ve (HVS taken, leaking not
confirmed)

CTG: reactive, UC Q__mins

Early labour / Leaking confirmed ------------------------> DAT, To AN ward


49
Decreased fetal movement

Hx:

Describe the FM clearly – usual frequency, when started to note decreased FM, frequency/
amplitude change

Risk factors:

Abd trauma

FGR

SGA fetus

Placental insufficiency

Congenital malformation

PE:

Measure the SFH (symphysial fundal height)

- see the CTG carefully -> DAT if CTG reactive

• Look for Ut < date, (measure SFH by tape)

• Look for risk factors for IUGR (previous IUGR/IUD, HT, DM, Obese, Smoking…etc)

Preterm

-check any date problem (any dating scan?)

- Hx: Hx of abd trauma/ coitus

Any abnormal PV discharge

Any urinary/ bowel symptoms

-better inform MO when there is preterm labour / PPROM

- note presentation

- if PPROM/ TPL, take HVS, MSU, GBS

- whether start steroids / tocolytics /antibiotics

 ask MO (read Dept guideline as reference)

Abd pain cx pregnancy

Hx:

look out for any regular UC

Compare with CTG for any UC.

If have regular UC --> TPL, inform MO

Perform spec: ascertain os closed

Check CBC, LRFT, MSU

USG not necessary if for abd pain Cx preg

Antepartum hemorrhage
Hx:

Unprovoked fresh/ brownish PVB/ spotting/ soaked ?minipad/ pads

Hx of coitus/ abd trauma

Spec:

Os closed/ open, no polyp/ ectropion, no active oozing from os

Mx:

(Heavy PVB)

NPO

CBC, T&S

(If no heavy PVB)

DAT

To 4B

USG mane 


50
BP monitoring

Hx:

No pre-existing hypertension/ renal disease

No family history of young onset hypertension

PE:

BP  /    P

Urine albumin

Jerks normal

No ankle clonus

Mx

DAT

BP monitoring

Bld x CBC, LRFT, clotting, urate

Spot Ur Pr/Cr ratio/

24hr UP+ CrCl

(please choose from

 departmental Ix for the correct Ix)

Elective C/S

<AN history as above>

“C” admitted for El LSCS x previous C/S / x breech / x PP….etc

no s/s of labour

FM active

P/E:

BP

urine albumin

Ut T/S ______

CTG:

Mx

Keep NPO (same day)

CBP,T&S

Augmentin 1.2g IV x1 after delivery

Follow anaes premed


51
Gynaecological hx taking

F/

NSND NKDA

Married

PMH:

Para

(if recurrent miscarriage - do workup ACA, LA, TFT)

Contraception:

Last PS

Past gyn hx -ve

Planned and wanted pregnancy

Mat weeks by date

Mat weeks by PT

LMP:

Regular  days per cycle, lasts  days

No dysmenorrhea

Normal flow

No IMB / PCB

1st PT +ve by self

2nd PT +ve by private clinic

No –ve PT

No USG done in private clinic

Not yet booked antenatal

Plan book AN in UCH


52
Threatened abortion
F/

NSND

NKDA

Past Medical History

Para  +

SVD in   , BW

STOP in

MTOP in

Contraception

PS

Past gyn hx -ve

Planned and wanted pregnancy

Mat  + week by date (  week by PT)

LMP:

Regular  days per cycle, last   days

No dysmenorrhea

Normal flow

No IMB / PCB

1st PT +ve by self on

2nd PT +ve by clinic on

No –ve PT

USG in private on   (date)/ at    wks showed IU sac/ fetal pole/ CRL   cm = ?wks)/ fetal heart
positive/ negative

__________

“E” admitted for ___________

PV bleeding/ spotting since

Soaked minipads/ daytime pads/ nightime pads/ underpants/ pants

Fully soaked/ ? soaked/ 1/3 soaked/ Centrally soaked

Fresh blood/ Brownish

No clots/ tissue mass passed

No abd pain

No abnormal PVD/ vulval itchiness  (**only symptomatic patients that we need to take HVS)

PU/BO well

PE:

Afebrile

BP  /   P

Abd soft, no T/G/R

Speculum/ PV  (No PV if 2nd tri TA)

V/V ___ml blood in vagina/ blood stained/ no blood/ discharge

Cx os closed/ open, no TM/ polyp, any excitation

Ut AV/RV, NS/ wk size

Adnexa clear/ excitation/ adnexal mass

Imp:TA

Mx:

DAT

Fast after 0500 (no need fast 0500 if Doptone +ve)

USG pelvis mane

Pad record

+/- HVS (only if patient complained of abnormal PVD)

+/- CBC, LRFT, amylase (if patient complained of abd pain)


53
Hyperemesis gravidarum
Mx: 

DAT

Chart IO 

CBP, LRFT, pTFT

MSU    

USG pelvis  

Urine ketone daily (+/- body weight daily)  

Avomin 25mg TDS prn

If unresponsive to avomine:

Maxolon 50mg Q6-8H IV prn

Thiamine 50mg Daily  

Menorrhagia

Anaemic symptoms: dizziness/ SOB/ palpitations

Thyroid symptoms: hand tremor/ fatigue

If symptomatic anaemia:

No PRB/ malena/haematuria

No bleeding tendency

Not vegetarian

Mx:

DAT

Pad record

Bloods x CBC, LRFT, clotting, amylase +/- T&S

Bloods x ferritin, HbP (if prev HbP results not available, and all prev MCV are low), TFT

FOB x 2

USG mane (please clearly state VIRGIN if virgin)

Transamin 500mg QID PO prn

Ponstan 500mg TDS PO prn

+/- FeSO4 + Vit C

+/- Urine PT (for women at reproductive age, presented with PVB, to r/o miscarriage)

+/- HVS

+/-  MSU

You can also learn how to start NE ! – NE 5mg TDS po

If on discharge: Norethisterone (advanced options choose cyclic) 5mg TDS po D5-25 

3 cycles

Bartholin’s abscess

Mx:

DAT

FAMN (for Marsupialization or I&D next day)

Bloods x fasting glucose

Ampicillin + Cloxacillin 500mg QID PO

Panadol for pain

Gaped episiotomy wound

* on BF or AF

* remove redundant stitches

Mx:

DAT  

54
Dressing daily / BD / TDS  

Wound swab  

HVS if foul smelling PVD/lochia        

Ampicillin 500mg QID

Cloxacillin 500mg QID

Pelvic inflammatory disease

Gynae hx eg LMP, menstrual cycle, contraception….. etc

Risk factors (eg. Multiple sexual partner, hx of STD / PID… etc) and write down too!

Speculum / PV:

-v/v: _____ (colour) discharge

-Cx: any excitation tenderness

-Ut size, AV/RV

-Adnexa: clear / excitation / adnexal mass

Mx:

DAT / NPO (if acute abdomen)

Bloods x CBP, LRFT, Amylase +/- T&S

Triple swabs (make sure ECS taken for chlamydia into special medium bottle)

MSU

USG pelvis mane

Augmentin 1g BD PO/ Augmentin 1.2g IV Q8H IV

Flagyl 400mg TDS PO / 500mg Q8H IV

Doxycycline 100mg PO BD or Azithromycin 1g PO once if vomit

Post LEEP bleeding

Hx:

bleeding (onset, amount… etc)

foul smelling PVD

fever, pain….

P/E:

Speculum: mild oozing at 3 o’clock, Monsel’s solution applied, haemostasis observed

Consider performing PE with MO

Remember to take HVS

Start oral Augmentin 1g BD

Persistent lochia

-lochia (amounts, any clots)

-any tissue mass passed

-any vasoactive substance intake (e.g. ginger-vinegar, chicken wine)

-any abd pain

-any fever

always ask if BF or AF

-PV as usual, remember to take HVS

-Fast 0500, USG mane

-Ddx: endometritis / RPOG


55
SURGERY


56
(Literally the most basic template you need for Surg)
[Age]

NKDA

[PMH]

Some MOs like to put the most recent CLN / OGD results here

=======

E admitted x _____

(Abdominal pain case)

______ (area - LLQ, RUQ, central etc) pain since _____

No radiation

(Surgeons don’t really care about nature of the pain and all that)

No nausea / vomiting (If vomiting - how much (can quantify by ml / bowls), content ie undigested
food / bile stained fluid / coffee grounds)

BO well, no PRB / tarry stools (If PRB - also ask about duration, presence of anemic symptoms)

No hematuria / dysuria

No fever (If fever - write down temp up to ____, note if chills and rigors +; see previous C/ST
results for Abx sensitivity)

PE:

Vitals (if lazy can just put down vitals stable, afebrile if patient really is stable, some MOs do this)

Abdomen:

(Here’s where you draw the diagram with a # to denote the site of pain, watch out for guarding
and rebound tenderness esp if patient came in for abdominal pain)

Ix in AED:

(Blood results etc)

CXR (if unremarkable): clear, no definite consolidation, no free gas


Mx:

NPO except meds (true for most cases in Surgery, for urology can usually DAT though)

IVF 2D1S Q__H (some MOs prefer 1D1S, use 1/2:1/2 if DM or IFG, choose the rate based on
patient’s age and presence of renal / cardiac condition)

Routine obs

Chart IO

Chart BO color (if PRB case)

CXR, AXR (if no Ix done in AED - it happens)

Bloods x CBC, LRFT, clotting (baseline bloods), amylase (if abdominal pain)

MSU / CSU x R/M, C/ST (choose MSU/CSU at your own discretion based on patient’s GC and
willingness to cooperate lolz)

Resume usual meds

PO Panadol 1g Q6H prn

PO Tramadol 50mg Q6H prn

PO Pantoloc 40mg daily (if epigastric pain, if patient is already on Pepcidine rmb to off it first to
avoid therapeutic duplication)

57
Hematuria

[Age]

NKDA

[PMH]

========

E admitted x ___________

Noted hematuria since _________, beginning / end / entire stream

Painful / painless

Any blood clots / stones passed

Other urinary symptoms e.g. urinary frequency, dysuria

No abdominal / loin pain

No nausea / vomiting

BO well, no PRB / tarry stools

No fever

PE:

Ix in AED:

Mx:

DAT

Routine obs

Chart IO

Save urine x inspection

KUB (if not done already)


MSU / CSU x R/M, C/ST

Resume usual meds

PO Panadol 1g Q6H prn

58
Loin pain
(usually due to renal stone)

[Age]

NKDA

[PMH]

========

E admitted x ___________

Loin pain since ____, radiates to ____ (sometimes radiates to ipsilateral groin)

No abdominal pain

No hematuria / stones passed

No dysuria / urinary frequency

No nausea / vomiting

BO well, no PRB / tarry stools

No fever

PE:

(To denote loin pain they usually draw a # outside of the hexagon on the same side)

Ix in AED:

Mx:

DAT

Routine obs

Chart IO

KUB (if not done already)

Urgent NCCT x renal stone protocol (make sure to put down “to rule out renal stone” in clinical
information)

Bloods x CBC, RFT, clotting

MSU / CSU x R/M, C/ST

Resume usual meds

PO Panadol 1g Q6H prn

59
AROU
[Age]

NKDA

[PMH]

========

E admitted x ___________

Difficulty voiding since ______

Unable to void at all today

Suprapubic tenderness

No abdominal / loin pain otherwise

Foley inserted in AED


No nausea / vomiting

BO well, no PRB / tarry stools

No fever

PE:

(Also look at Foley output to see if clear / turbid, can also be pyridium stained (orange)

Ix in AED:

Mx:

DAT

Routine obs

Chart IO

Bloods x CBC, RFT, clotting

CSU x R/M, C/ST

Resume usual meds

PO Panadol 1g Q6H prn

60
Green OT
Mx:

Fluid diet

Routine obs Q4H

Chart I/O

TED stockings

CXR, ECG

Bloods x CBC, LRFT, clotting, T&S

Klean prep

Neomycin 1000mg Q4H x 3 doses

Flagyl 400mg Q4H x 3 doses

IV Augmentin 1.2g Q8H bring to OT

IV ICG 25mg bring to OT

Resume usual meds


61
FBI

F/44y

NKDA

PMH:

1) HBsAg +ve, LFT normal FU QMH Med

Noted persistent thrombocytopenia during last FU, referred to PY Hematology, appt pending

2) IMB and ovarian cyst FU PY O&G

__________

E admitted x FBI

Had yellow croaker fish on 22/5/21, complained of FBI sensation afterwards

Did not seek immediate medical attention

↑ Central neck discomfort in recent few days, hence attended AED

No odynophagia / dysphagia

No nausea or vomiting

No holdup sensation

No hemoptysis / hematemesis

No neck swelling

Oral intake maintained

No abdominal pain

PU and BO well

No fever

PE:

BP 130/75 P 70

SpO2 98% on RA

Afebrile

GC well, alert, not in respiratory distress

No stridor

Neck:

No obvious swelling / subcutaneous emphysema

Non tender

Ix in AED:

X ray C spine: no obvious foreign body / pre-vertebral swelling

Mx:

NPO except meds

Routine obs

IVF 2D1S Q6H

Bloods x CBC, LRFT, clotting

PO Panadol 1g Q6H prn

Consider OGD on Monday


62
PTX

22/M

NKDA

Unremarkable past health

===============================

"E" adm x 1st episode left spontaneous pneumothorax

Left chest pain since x 5/7 ago spontaneously

No trauma / injury / fall

Private CXR done today, found left pneumothorax

No cough / haemoptysis / sputum

No abdominal pain

No fever

Left 24Fr chest drain inserted in AED, markin 11cm

P/E

BP 115/75 P85

Temp 36.9

SpO2 98% on 2L O2

Left chest drain insitu, swinging +ve, bubbling +ve

Ix

CXR: left PTX, chest drain in situ at left lung apex, no trachea deviation / pleural effusion, right
side normal, clear, no free gas under diaphragm, no rib #

Mx

DAT

Obs Q4H

2L O2 today

ECG x 1

Blood x CBC RFT  TnI CK

CXR mane before round

Chest physiotherapy

Incentive spirometry

PO panadol 1g q6h prn

PO arcoxia 90mg daily x 3/7

PO pantoloc 40mg daily x 3/7

63