Chapter 8

This section provides help with problems you are likely to get bleeped for. In particular, it helps you to exclude serious conditions and to initiate basic mainstay management.

How to use this section

Like a recipe book, this section lists basic protocols for common calls. We recommend the following:

  • When first using the chapter, read the short blurb immediately beneath each call, which lists the most likely causes of each problem and things to watch out for. Differential diagnoses are listed in the way that makes them easiest to remember. Most of the time, this is in order of likelihood in the hospital setting.
  • Remember that unusual presentations of a common condition are more likely than common presentations of rare conditions. Always exclude serious conditions first rather than esoteric conditions. After all, common things are common.

To make this section easy to use in the middle of the night, we have kept abbreviations to a minimum.

Considerations for all ward calls

  • Never hesitate to call your seniors. It is their job to back you up. However, like everyone else, seniors do not like to feel dumped on. Unless it is a dire emergency or you do not know what to do, make sure you have assessed the problem thoroughly and if possible make a provisional differential diagnosis and management plan. Performing a quick assessment of the airway, breathing and circulation (ABC) and doing basic investigations (e.g. electrocardiogram (ECG) and bloods in chest pain) will make your handover much more effective. Resist the temptation to call them as soon as you find a problem, unless it is immediately life-threatening. You may find that after you have assessed the patient, you do not feel the need to contact them immediately.
  • If you need help, always refer problems upwards (to seniors), not sideways (to other new doctors). No one will support you if things go wrong, and your only source of advice was someone at the same level as you.
  • Always examine patients in a good light even if it means switching on the main light.
  • Even in dire emergencies, act calmly and reassure the patient. If you need urgent senior help, stay with the patient and ask someone else to get hold of your senior. You can always fast bleep them if necessary or pull the crash bell to get help quickly.
  • Keep emergency routines fresh in your mind throughout the year. Patients can deteriorate when you least expect it, such as on rehabilitation wards.
  • After seeing patients, sit down with their notes and review their history to make sure you have not missed something, and document your findings clearly.
  • Whatever you are called for, don’t forget to check the drug and fluid charts. A common error of junior doctors is not realizing that a patient’s urine output is falling.
  • When tired, try not to argue with nursing or medical colleagues. If you feel you are being bleeped unnecessarily, take the matter up when you are well rested.
  • Do not be too hard on yourself if everything seems daunting. It is! Experience is the only way to develop good clinical judgement and familiarity with practical procedures. You will learn to cope; sometimes it just takes a little time.

Abdominal pain

Your priority is to exclude signs of peritonism and bowel obstruction. Common causes of non-acute abdominal pain, such as urinary tract infection (UTI), constipation and post-op pain, are not life-threatening but may require treatment.

When answering your bleep, ask:

  • For BP, pulse and temp
  • For a dipstick of the urine to look for signs of infection (nitrites, leucocytes and blood)
  • To keep the patient nil by mouth (NBM) until you review them

Differential diagnoses

  • Intestinal obstruction
  • Constipation
  • Adhesions
  • Hernia, volvulus and tumour
  • Peritonism
  • Inflammation/infection of any intra-abdominal organ (e.g. pancreatitis, cholecystitis, appendicitis)
  • Perforated viscus
  • Complications of pregnancy
  • Ruptured intra-abdominal organs (spleen)
  • Ruptured ectopic pregnancy (a life-threatening emergency)
  • Other gynaecological causes (ovarian torsion, tubo-ovarian abscess)
  • Leaking abdominal aortic aneurysm (a life-threatening emergency)
  • Intestinal infarction
  • Peptic ulceration/gastritis/severe oesophagitis

Extra-peritoneal causes include:

  • Urinary retention
  • UTI
  • Renal colic
  • Wound abscess
  • Basal pneumonia
  • Inferior myocardial infarction (MI) (often with associated nausea and vomiting (N&V), bradycardia and ECG changes in leads II, III and AVF)
  • Retroperitoneal bleed or abscess
  • Diabetic ketoacidosis (DKA) – check urinary ketones, BM and ABG for acid–base balance


  • Do not delay analgesia. Opiates do not mask the rigidity and rebound tenderness of peritonism.
  • Involve the surgical team early if necessary.
  • Gastritis and non-perforating peptic ulcers can cause severe epigastric pain but not true peritonism. The pain is usually relieved within minutes by antacids. Prescribe them IV.
  • Consider bowel infarction in patients who are acutely unwell with abdominal pain in the absence of peritonism. This is common in the elderly patient with atrial fibrillation (AF) who is not appropriately anticoagulated.
  • Free air under the diaphragm may persist for more than a week after abdominal surgery or laparoscopy, and in such a situation, it becomes an unreliable sign, so don’t be fazed if you see it on a routine CXR!


You will usually be called by the lab for gross anaemia. In this case, your immediate concerns are to exclude bleeding. Chronic anaemia should always be investigated before transfusion unless the patient is acutely compromised, since donor blood may mask the cause (see Table 8.1). By far, the most common cause of anaemia in the United Kingdom (other than menorrhagia) is occult GI blood loss causing a microcytic iron deficiency anaemia.

Table 8.1 Differential diagnoses of anaemia.

Low MCV (<96 fl) Normal MCV (76–96 fl) High MCV (>96 fl)
Iron deficiency Acute blood loss B12 or folate deficiency
Chronic bleeding (e.g. GI) Haemolysis Liver disease
Nutritional, that is, poor dietary intake of iron Chronic infection or inflammation Alcoholism
Thalassaemia (particularly if MCV is disproportionately low compared to Hb) Anaemia of chronic disease Marrow infiltration
Sideroblastic anaemia Malignancy Hypothyroidism

Pregnancy Reticulocytosis

Chronic renal failure Acquired sideroblastic anaemia

Myelodysplastic syndromes

Antifolate drugs (phenytoin)


  • Patients with chronic anaemia are particularly susceptible to heart failure following transfusion. Check for existing heart conditions, such as LV ejection fraction; discuss with your seniors first and transfuse them as slowly as possible. In those with heart failure or at risk of fluid overload, it may be necessary to give furosemide orally or IV with each unit. 20–40 mg per unit will usually suffice.
  • Be alert to mild anaemia when checking routine blood results. Slight Hb deficits are easy to miss and can be an early sign of serious disease.
  • Leukoerythroblastic anaemia means there are primitive red and white cells in the peripheral circulation. The patient may need a bone marrow biopsy and investigation for occult malignancy.
  • Consider intra- or retroperitoneal bleeding in acute anaemia and no external evidence of haemorrhage. Look for bruising in the flanks or around the umbilicus.


Whilst abnormalities in the heart rate and rhythm are relatively common and seldom life-threatening, never be afraid to call the crash team before the patient arrests! You are not expected to diagnose and manage arrhythmias without senior advice.

When answering your bleep

Ask nursing staff for pulse, BP and temp. Give O2 if the patient is unwell, and if BP is dangerously low, consider IV fluids verbally.


  • Atrial fibrillation (normal rate)
  • Wandering atrial pacemaker
  • Ventricular ectopics
  • Variable AV block


  • Measure and document both peripheral pulse rate and apex rate.
  • AF is associated with MI, IHD, mitral valve disease, thyroid disease, hypertension, pericarditis and other causes of a dilated atrium. Rarely, it is associated with atrial myxoma, infiltration, endocarditis and rheumatic fever. It is common following cardiac surgery, when it is usually temporary but may require short-term treatment with an anti arrhythmic like amiodarone. AF is common in patients with concurrent sepsis or electrolyte abnormalities and is more likely to resolve when these are corrected.

New-onset AF should usually be treated with anticoagulation. This may not be suitable in long-standing AF or in those with a high risk of falls, but it should always be considered, particularly in hospital where treatment-dose low molecular weight heparin (LMWH) (e.g. 1.5 mg/kg of enoxaparin) can easily be administered. To aid with decisions on anticoagulation, perform CHADSVASC and HASBLED scores on patient.


  • Sinus bradycardia
  • Sudden stress, severe pain, post-systemic infection
  • Inferior MI: commonly results in first-degree AV block
  • AV heart block
  • Second-degree heart block: intermittent block with (Mobitz type 1) or without (Mobitz type 2) an elongated PR interval
  • Third-degree heart block: complete heart block
  • Drugs: amiodarone, beta blockers and calcium channel blockers, digoxin
  • Faulty sinus node: sick sinus syndrome, infiltration, significant inferior MI
  • Hypothyroidism and hypothermia
  • Raised intracranial pressure (ICP)
  • Jaundice


  • A fourth heart sound with bradycardia is common following inferior MI.


  • Sinus tachycardia (regular rhythm, normal waveform)
  • Hypermetabolic states, for example, fever, anxiety, hyperthyroidism, anaemia, pain
  • Drugs, for example, digoxin, nitrates, nicotine, sympathomimetics, theophylline, salbutamol
  • Shock, sepsis or hypovolaemia of any cause
  • Heart failure
  • Supraventricular tachycardia
  • Atrial fibrillation with fast ventricular response (fast AF) (rhythm will be irregular)
  • Atrial flutter (has regular rhythm; often 300 atrial beats per minute, with a ventricular response at 150 bpm, that is, 1:2 conduction)

Atrial tachycardia (has regular rhythm)

  • WPW syndrome (rhythm is regular unless AF supervenes)
  • Nodal (junctional) (rhythm is regular)
  • Ventricular tachycardia


  • Broad rule of thumb in discriminating between SVT and VT:

    • – SVTs have narrow complexes (<120 ms) and are not necessarily associated with serious underlying heart disease.
    • – VTs have broad complexes (>120 ms) and indicate serious underlying heart disease.

  • Carotid sinus massage can cause sinus arrest or strokes, especially in the elderly, or if the patient has had a recent MI or is digitalized. Use only if urgent action is required. Vagal manoeuvres are much better (Valsalva manoeuvre).
  • Atrial tachycardia with heart block is commonly associated with digoxin toxicity.
  • Discriminating VT from SVT with bundle branch block is not easy, and you should seek senior help. If the patient is compromised, treat as VT.
  • Whether the patient has a VT or SVT, you need to identify and treat the underlying cause, in addition to treating the arrhythmia (Tables 8.2a and 8.2b).

Table 8.2a Managing supraventricular tachycardias. If the patient has SVT and signs of compromise (hypotension, heart failure, impaired consciousness, or a heart rate of >200 bpm), get help fast. The patient may require 100–200 J of synchronized direct current (DC) cardioversion.

Atrial fibrillation Non-AF SVT

  • Irregularly irregular pulse and no P waves on ECG

  • If the patient has SVT that is not AF, they may need immediate treatment, but discuss with your senior first
  • Regular rhythm narrow complex tachycardia

  • Most common type of SVT

  • Most SVTs respond to IV adenosine. Ensure that the patient is on a cardiac monitor and that a resus trolley is close to hand. Inject 6 mg adenosine with a flush rapidly into a large peripheral or central vein. If there is no response after 1–2 minutes, give 12 mg and then a further 12 mg if necessary. Expect facial flushing, nausea and transient breathlessness. Warn the patient of transient chest pain when you inject the adenosine

  • First-line treatments of acute fast AF are rate control (with metoprolol or digoxin) or rhythm control (with amiodarone or synchronized cardioversion)

  • Adenosine cannot be given to patients with asthma. In this case, use verapamil

  • Metoprolol controls the ventricular rate, but does not resolve the fibrillation. Amiodarone can restore the rhythm but requires large-vessel IV access (central line). Amiodarone requires a loading dose. Amiodarone cannot be given peripherally

  • Record a rhythm strip before, during and after each dose of adenosine
  • Once the underlying rhythm is elicited, treat accordingly
  • If the patient becomes compromised in anyway, shock with DC cardioversion, and then load with amiodarone

Table 8.2b Management of ventricular tachycardias.

  • Treat pulseless VT in the same way that you would VF – commence CPR

  • Sustained VT usually precipitates shock unless treated with monophasic DC cardioversion (200–360 J), so seek urgent senior help
  • If haemodynamically unstable, treat with synchronized DC shock, and then load with IV amiodarone
  • If haemodynamically stable, correct low K and Mg, and load with amiodarone.
  • Avoid amiodarone in patients with long QT syndrome

  • Investigations to consider:
U&E for K, Ca, Mg, troponin, FBC if acutely unwell

  • Consider in the future the need for ICDs and long-term oral amiodarone


Most labs report total serum Ca2+, of which about half is bound to albumin. If the albumin levels are low, the lab result will underestimate total Ca2+.

To calculate the corrected calcium, use the following formula:


Alternatively, ask for an ionized Ca level which need not be adjusted for albumin (a special tube is required).


On the wards, this is often spurious and an incidental finding. However, true hypercalcaemia needs to be corrected. Rarely, it requires urgent treatment.

Differential diagnoses

  • Spurious: tourniquet left on too long or blood taken from the drip arm
  • Hyperparathyroidism (primary and tertiary)
  • Malignancy: bony metastases, myeloma and paraneoplastic syndrome
  • Drugs: thiazide diuretics, excessive ingestion of Ca2+-containing antacids and excessive vitamin D intake
  • Rarer causes: granulomatous diseases (e.g. sarcoid, TB) and endocrinopathies


Like hypercalcaemia, hypocalcaemia can be spurious and may be caused by acute hyperventilation. Hypocalcaemia is rarely an emergency, unless Ca2+ is <1.5 mmol/l (risking laryngospasm).

Differential diagnoses

  • Spurious (low albumin as in malnutrition or chronic malabsorption, blood taken from drip arm)
  • Acute hyperventilation
  • Pancreatitis
  • Hypoparathyroidism – thyroid surgery or neck irradiation
  • On TPN without adequate Ca2+
  • Vitamin D deficiency – malabsorption, renal disease, phenytoin or phenobarbitone
  • Excessive ingestion of phosphate

Chest pain

Chest pain always requires urgent attention. Whilst angina, oesophagitis, oesophageal spasm, and musculoskeletal pain are the most common causes of chest pain, never forget pulmonary embolus in the hospital setting.

When answering your bleep

Ask the ward staff to:

  • Perform an ECG.
  • Repeat the vital signs.
  • If the patient has a history of IHD, prescribe sublingual glyceryl trinitrate (GTN) two puffs over the phone. Aim for sats >94%, but take care in patients with chronic obstructive pulmonary disease (COPD).

  • Differential diagnoses (*do not miss these!)
  • Cardiac

    • Angina (IHD, LVH/HOCM)
    • Acute MI*
    • Pericarditis or myocarditis, including post-MI Dressler’s syndrome

  • Lung/pleura

    • Pulmonary embolus*
    • Pneumothorax*
    • Pleurisy/pneumonia

  • Aorta

    • Dissection*
    • Aneurysm

  • GIT

    • Oesophageal spasm
    • Oesophagitis/gastritis
    • Pancreatitis, cholecystitis and peptic ulcer disease/perforation

  • Others

    • Shingles
    • Costochondritis
    • Rib or vertebral collapse


  • Pain radiating to either arm, neck or jaw suggests cardiac ischaemia. Pain radiating to the back could be a dissection. Check BP in both arms.
  • Sublingual GTN will often provide immediate relief of angina and is a useful diagnostic aid. It also relieves oesophageal spasm, but over a few minutes.
  • Oesophageal spasm or severe anxiety sometimes causes ischaemia-like changes on the ECG. Seek advice if unsure.
  • A tachycardic patient may also show rate-related ischaemic changes but these do not normally occur with a simple sinus tachycardia. Slowing the rate should reverse the changes.


Beware of unexpected confusion in patients. In particular, hypoxia is common but easily missed in the elderly. Never assume disorientation or dementia without first excluding serious medical causes and ascertaining the patient’s usual mental state.

When answering your bleep

  • Ask for a ward capillary blood glucose test (‘BM stick’ – this stands for Boehringer Mannheim, the old name for Roche Diagnostics).
  • Temp, BP, pulse and urine dipstick.
  • Pulse oximetry if available.

Differential diagnoses

‘DIM TOP’ (Mike’s South African acronym!):

  • Drugs (especially sedatives and analgesics like opiates, anticonvulsants)
  • Infection (anywhere, commonly UTI and pneumonia)
  • Metabolic (hypoglycaemia, Na, K, Ca, liver failure, uraemia)
  • Trauma (concussion, subdural haematoma)
  • Toxins (alcohol withdrawal, drugs, others)
  • Oxygen deficit/hypoxia (pneumonia, pulmonary oedema, PE, respiratory depression (opiates), anaemia)
  • Pain and discomfort (any cause, including urinary/faecal retention)
  • Psychiatric/dementia
  • Perfusion abnormalities (stroke, transient ischaemic attack (TIA), nonconvulsive status)
  • Post-op confusion (hypoxia, urinary retention, infection, drugs, abnormal electrolytes, pain, blood loss, disorientation, alcohol withdrawal)


  • Nurse the patient in a moderately lit room and minimize noise. Give repeated reassurance to the patient. A well-loved family member or a familiar nurse caring for the patient is invaluable.
  • Consider nursing the patient on a mattress on the floor. Some hospitals have special ‘soft-walled’ beds. Bed rails and ‘hand ties’ are regarded by most nursing staff as unnecessary and potentially dangerous. Physical restraint is rarely used in the United Kingdom.
  • Soft music, surrounding the patient with pictures of family.
  • Secure NG tubes and IV lines with bandages. It is occasionally necessary to put mittens on the patient’s hands.
  • If you have excluded serious causes, consider short-term sedation with a benzodiazepine (lorazepam 0.5–1 mg IM, repeated after 4 hours if necessary). Use with caution in the elderly.

    Alternatives include:

    • – Haloperidol 5–10 mg IM or PO. (Avoid in elderly patients. Haloperidol is useful in the more acute setting. Have a resus trolley to hand. You may need to wait 10–20 minutes for the drug to take effect.)
    • – In alcoholic patients, consider clomethiazole instead.

  • You may not find any cause for the patient’s confusion. Patients may simply be disoriented from a change in environment; but make sure you exclude serious medical causes first. Clear, repeated explanation about where the patient is and why can be helpful, as is a small map showing where the toilets are and how to call for nursing assistance.


Constipation is common in hospital due to immobility, drugs and having to use a bedpan. Remember that it is a symptom and not a diagnosis. It is better to treat the cause than to blindly prescribe laxatives. Constipation is more common in the elderly and often missed. Always be alert to obstruction. Post-op ileus is common, usually resolves by itself and should never be treated with laxatives!

Differential diagnoses

  • Poor (low roughage) diet and dehydration
  • Immobility
  • Drugs

    • Ca2+-based drugs (e.g. antacids, and calcium channel blockers)
    • Ferrous sulphate
    • Opiates
    • Tricyclic antidepressants
    • Anticholinergics
    • Diuretics (furosemide)

  • Embarrassment at using a bedpan
  • GI tract

    • Pain (anal fissures, haemorrhoids, rectal prolapse, recent surgery)
    • IBS
    • Obstruction (acute and subacute) from any cause especially tumours, strictures, diverticulosis
    • Ileus (pseudo-obstruction)

  • Metabolic

    • Endocrine – hypothyroidism, hypercalcaemia or hypokalaemia

  • Neurological

    • Spinal cord compression/lesions/trauma
    • Hirschsprung’s disease
    • Chagas disease
    • Diabetic neuropathy


By far the most common cause in hospitals is drugs (antibiotics and laxatives), but infection should always be excluded. Less common but important to consider is constipation with overflow. In all cases, the patient may need to be rehydrated.

Differential diagnoses

  • Anxiety
  • Drugs: laxatives, broad-spectrum antibiotics, or antacids containing Mg sulphate and also cimetidine, colchicine, cytotoxic agents, digoxin or thiazide diuretics
  • Intestinal obstruction with overflow (neoplasm)
  • Faecal impaction with overflow, especially in elderly patients
  • Infection: Clostridium difficile or Norovirus
  • IBD, other causes of intra-abdominal inflammation, ischaemia, etc.
  • Hyperthyroidism


  • Barrier nursing is advisable until infection is ruled out.
  • Wash your hands with water and soap between patients.
  • Be wary of diarrhoea in patients on steroids. Their abdomens may be ‘silent’ despite serious intra-abdominal mischief.
  • If no cause is found, then consider referral to a gastroenterology specialist. There are numerous rarer causes of diarrhoea including carcinoid syndrome, VIPoma, amyloidosis, Addison’s disease, laxative abuse, lactose intolerance and tropical sprue that may need to be excluded.


Do not get too worried about interpreting ECGs during your first job. Whilst the range of potential anomalies is bewildering at first, practice really does make perfect and junior doctors are only expected to diagnose a handful of important conditions. For a more complete guide, consult Hampton’s ECG Made Easy and ECG in Practice. Whatever the ECG diagnosis, remember to treat the patient, not the ECG!

Common ECG diagnoses

  • Atrial fibrillation (no P waves, rate can be fast or normal)
  • Recent or past MI
  • Third-degree heart block (no relationship between P waves and QRS complexes)
  • Ventricular tachycardia

Basic ECG parameters to consider

  • Rate: 60–90 bpm (lower in athletes).
  • Rhythm: irregular or regular.
  • Axis: normal, from −30° (aVL) to +120° (III) (some use from 0° to 90°).
  • P waves: present/absent before each QRS complex?
  • PR interval (start of P wave to start of QRS): constant? Normal interval is 120–200 ms (3–5 small squares).
  • QRS interval: up to 120 ms (three small squares) is ‘narrow complex’ and represents normal conduction system. If greater than this or ‘wide complex’, then the origin of the rhythm is likely to be ventricular unless there is bundle branch block. Check height of the R waves. Are Q waves present?
  • ST segment: isoelectric (i.e. on segment, baseline is the line between the T wave and the P wave) – raised if ST elevation (STEMI) and depressed if ST depression (ischaemia, digoxin toxicity).
  • T waves: upright or inverted/flipped (ischaemia) – tented in hyperkalaemia and flattened in hypokalaemia.

If the ECG is abnormal, consider each parameter systematically:

Sep 27, 2017 | Posted by in PATHOLOGY & LABORATORY MEDICINE | Comments Off on COMMON CALLS

Full access? Get Clinical Tree

Get Clinical Tree app for offline access