NZREX Clinical cheat sheet

Acute upper GI bleed: pre-endoscopy Glasgow-Blatchford score of 0-1 identifies very low risk suitable for outpatient management; a score ≥12 predicts high risk of needing endoscopic or surgical intervention.

Acute coronary syndrome: high-sensitivity troponin rise/fall with at least one value above the 99th percentile plus ischaemic symptoms, ECG changes, or imaging evidence defines myocardial infarction; STEMI needs reperfusion within 120 minutes of first medical contact where feasible.

Diabetic ketoacidosis: pH <7.30, bicarbonate <18 mmol/L, ketonaemia ≥3 mmol/L or significant ketonuria, and glucose >11 mmol/L (or known diabetes). Fluid resuscitation with 0.9% saline precedes insulin infusion; add 10% glucose when glucose falls below ~14 mmol/L to allow continued insulin.

Hyperkalaemia with ECG changes (peaked T waves, widened QRS): give IV calcium gluconate or calcium chloride first for cardiac membrane stabilisation, then insulin-dextrose and salbutamol to shift potassium intracellularly; dialysis for refractory or renal failure cases.

Community-acquired pneumonia severity: CURB-65 (confusion, urea >7 mmol/L, respiratory rate ≥30, BP systolic <90 or diastolic ≤60, age ≥65) - 0-1 treat at home, 2 consider admission, ≥3 assess for intensive care.

Asthma acute severe: unable to complete sentences, respiratory rate ≥25, heart rate ≥110, peak flow 33-50% predicted; life-threatening adds silent chest, cyanosis, exhaustion, bradycardia, peak flow <33%. Give oxygen, repeated inhaled beta-2 agonist, ipratropium, and systemic corticosteroid.

Stroke: non-contrast CT excludes haemorrhage before thrombolysis; IV alteplase within 4.5 hours of onset for eligible patients, mechanical thrombectomy up to 6 hours (selected cases up to 24 hours) with large vessel occlusion. Blood glucose and NIHSS documented before treatment.

Hyponatraemia correction: aim ≤8-10 mmol/L rise in 24 hours to avoid osmotic demyelination; for severe symptomatic cases (seizures, reduced consciousness) give hypertonic 3% saline boluses targeting a 4-6 mmol/L rise, then slow correction.

Acute appendicitis: migration of pain to right iliac fossa, guarding, and raised inflammatory markers; Alvarado score ≥7 supports operative management. Pregnancy and elderly patients may present atypically with fewer localising signs.

Bowel obstruction: colicky pain, vomiting, distension, absolute constipation, and tinkling bowel sounds; erect chest X-ray for free gas and CT abdomen for transition point. IV fluids and nasogastric decompression first; surgery for strangulation, closed loop, or failure to resolve.

Acute limb ischaemia: the six Ps (pain, pallor, pulselessness, paraesthesia, paralysis, perishing cold). Immediate IV heparin and vascular surgery referral; fixed mottling or paralysis indicates irreversible ischaemia requiring amputation-level assessment.

Trauma: ATLS primary survey sequence - catastrophic haemorrhage control, airway with cervical spine protection, breathing, circulation with haemorrhage control, disability, exposure. Permissive hypotension and damage-control surgery for unstable bleeding patients.

Postoperative fever timing: within 48 hours consider atelectasis and drug reaction; days 3-5 surgical site infection and urinary tract infection; days 5-7 intra-abdominal abscess and anastomotic leak; after day 7 consider deep vein thrombosis and prosthetic infection.

Hernia: irreducible but non-tender requires urgent surgical review; strangulation (severe pain, tenderness, systemic upset, absent bowel sounds) is a surgical emergency. Femoral hernias have a higher strangulation risk than inguinal and are repaired promptly.

Thyroid surgery: recurrent laryngeal nerve injury causes hoarseness (unilateral) or airway obstruction (bilateral); external branch of superior laryngeal nerve injury causes loss of high pitch. Post-thyroidectomy haematoma is an airway emergency requiring bedside suture removal and re-intubation.

Pancreatitis: diagnosis needs two of - characteristic epigastric pain radiating to back, serum lipase/amylase >3 times upper limit, or imaging findings. Mild cases: early oral or enteral feeding; severe: aggressive fluids, analgesia, and CT if deterioration or infection suspected.

Pre-eclampsia: hypertension after 20 weeks plus proteinuria or maternal organ dysfunction (renal, hepatic, neurological, haematological) or fetal growth restriction. Treatment is delivery; magnesium sulphate for seizure prophylaxis in severe disease.

Postpartum haemorrhage: >500 mL after vaginal or >1000 mL after caesarean birth, or any bleeding causing haemodynamic compromise. Sequence - uterine massage and oxytocin, then ergometrine, carboprost, misoprostol; tranexamic acid within 3 hours; balloon tamponade or surgery if refractory.

Ectopic pregnancy: assess with transvaginal ultrasound and serial beta-hCG. A discriminatory zone around 1500-3500 IU/L (assay dependent) with empty uterus raises concern; haemodynamically unstable or ruptured cases need immediate laparotomy.

Gestational diabetes screening: 75 g oral glucose tolerance test at 24-28 weeks. Thresholds vary by guideline; a fasting value ≥5.1 mmol/L, 1-hour ≥10.0, or 2-hour ≥8.5 mmol/L meets common criteria.

Fetal heart rate interpretation: baseline 110-160 bpm; late decelerations suggest uteroplacental insufficiency; variable decelerations suggest cord compression; prolonged deceleration >3 minutes requires escalation and consideration of expedited delivery.

Ovarian torsion: sudden severe unilateral pelvic pain with nausea and vomiting; ultrasound may show enlarged oedematous ovary with reduced Doppler flow. Urgent laparoscopy for detorsion and ovarian preservation.

Menorrhagia: structural causes (fibroids, polyps, adenomyosis, malignancy) versus non-structural (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic). First-line medical therapy is the levonorgestrel intrauterine system where no structural cause is found.

Shoulder dystocia: call for help, McRoberts manoeuvre with suprapubic pressure first; then internal rotational manoeuvres, posterior arm delivery, and all-fours position. Avoid fundal pressure and excessive traction, which increase brachial plexus and clavicle injury.

Paediatric assessment: use age-specific normal ranges - respiratory rate falls from ~40-60/min in neonates to 12-20/min in adolescents; tachycardia and tachypnoea are early compensations, and hypotension is a late sign of shock in children.

Bronchiolitis: coryza, cough, tachypnoea, wheeze, and crackles in infants under 2 years, most commonly respiratory syncytial virus. Management is supportive - oxygen for saturations <90-92%, fluids, and feeding support; bronchodilators and corticosteroids are not routinely indicated.

Croup: barking cough, stridor, hoarse voice; dexamethasone is first-line for all severities, nebulised adrenaline for moderate-severe stridor at rest, with observation for rebound after adrenaline.

Febrile child: use age-based risk. Infants under 3 months with fever ≥38°C need full sepsis workup and empirical IV antibiotics. Red flags include non-blanching rash, lethargy, poor perfusion, and reduced consciousness.

Dehydration in gastroenteritis: clinical signs correlate poorly with percentage loss. Use weight change where available; oral rehydration solution is first-line, with nasogastric or IV fluids if oral fails or shock is present.

Neonatal jaundice: measure bilirubin and plot against age-specific treatment thresholds. Jaundice within 24 hours is always pathological. Kernicterus risk rises with rapidly rising bilirubin, prematurity, haemolysis, and sepsis.

Kawasaki disease: fever ≥5 days plus four of five features (rash, conjunctivitis, oral changes, cervical lymphadenopathy, extremity changes); treat with IV immunoglobulin and aspirin to reduce coronary artery aneurysm risk.

Child development milestones: social smile at 6 weeks, sits unsupported at 6-8 months, walks at 12-18 months, two-word phrases at 18-24 months. Loss of previously acquired skills warrants urgent developmental assessment.

Depression: core symptoms are low mood and anhedonia for at least 2 weeks, with sleep, appetite, energy, concentration, guilt, psychomotor, and suicidal changes. Mild-moderate: psychological therapy first-line; severe: antidepressant plus psychological therapy.

Serotonin syndrome: triggered by serotonergic agents, presenting with clonus, hyperreflexia, agitation, hyperthermia, and autonomic instability. Stop the offending agent; benzodiazepines and supportive care; avoid antipsychotics and antipyretics alone.

Neuroleptic malignant syndrome: lead-pipe rigidity, fever, autonomic instability, and raised creatine kinase after dopamine antagonists. Stop the drug, give supportive care, and consider dantrolene or bromocriptine in severe cases.

Acute behavioural disturbance: verbal de-escalation first, with environmental modification and offering oral medication. Rapid tranquillisation (benzodiazepine or antipsychotic, or both) only when de-escalation fails and risk to self or others is high; monitor vitals and ECG.

Alcohol withdrawal: tremor, sweating, anxiety, and seizures within 6-48 hours; delirium tremens at 48-96 hours with confusion, hallucination, and autonomic instability. Use a benzodiazepine regimen, thiamine before glucose, and monitor for Wernicke encephalopathy.

Mental Capacity Act (England and Wales) five principles: presumption of capacity, support to decide, unwise decisions do not prove incapacity, best interests when lacking capacity, and least restrictive option. Assess decision-specific capacity.

First-episode psychosis: urgent referral to early intervention services; baseline physical investigations include bloods, ECG (QTc), weight, and prolactin before antipsychotic initiation. Offer family intervention and psychological therapy alongside medication.

Eating disorders: anorexia nervosa has low body mass index, fear of weight gain, and body image distortion; medical risk rises with rapid weight loss, bradycardia, hypothermia, and electrolyte disturbance. Refeeding syndrome risk requires cautious calorie advancement and electrolyte monitoring.