General

Chest Pain

If your symptoms return, typically with significant chest pain usually triggered by strenuous activity/stress, usually associated with excessive sweating, nausea, vomiting, spreading to your left arm or jaw , and shortness of breath - or you suffer collapse/loss of consciousness - please seek urgent medical attention.

You have been referred to the Atrial Fibrillation Clinic, a nurse-led cardiology service specialising in outpatient management of AF.

The clinic will contact you directly with an appointment and may provide specific instructions (e.g., fasting prior to attendance). Please check any instructions carefully before your appointment.

You have been given an information sheet with further details.

You have been referred for an Exercise Tolerance Test (ETT) with the cardiology team.

This is a treadmill-based test that gradually increases cardiac workload to help assess how your heart responds to physical stress.

The cardiology department will contact you directly with an appointment and may provide pre-test instructions (e.g., withholding beta-blockers such as metoprolol or sotalol beforehand).

Please review any instructions carefully before attending.

Cough/Shortness of Breath

We have advised you to return if your cough worsens, if you develop significant shortness of breath especially if you have difficulty walking, talking in full sentences, develop a fever, nausea or vomiting, your sputum changes colour (usually green/yellow), palpitations, or chest pain—please seek urgent medical attention.

Conservative management with the mainstays of good hydration and trial of honey stressed, as well as home remedies such as vapour rubs, humidifiers, steam baths, ginger/eucalyptus remedies.

Note that honey is not recommended for the ages under 1yo. Adult Vicks remedies with camphor are not suitable for under 2yo. 

We have advised that you may benefit from a review of chronic cough with your GP at 4-6 weeks duration of your symptoms. 

You have been diagnosed with a lower respiratory tract infection by chest X-ray. All patients with such findings are advised to have a repeat X-ray in 4-6 weeks, we have asked your GP to arrange this but if you do not hear back please speak to your GP directly.

For GPs

Thank you for your ongoing care, this patient has been diagnosed with an LRTI. They would benefit from community follow-up of the formal CXR report with actioning of recommendations for ongoing care, and a repeat CXR in 4-6 weeks to ensure resolution of consolidative changes as standard. 

Gastrooesphageal Reflux

We have strongly advised you to take medication to reduce reflux (omeprazole and famotidine) to improve your symptoms but also reduce the risk of damage to your stomach and bowels. This can take several days-weeks to work and should be taken regularly.

Other general advice includes having small but regular meals (up to 4-5/day) as possible. Bland foods such as but not limited to bananas, rice, apple-sauce, and toast may help. Fruits are usually good but try to avoid excessively acidic fruits such as citrus and pineapple. 

You have strongly been advised to avoid common reflux triggers. This includes 

- Fatty/fried food

- Spicy food

- Acidic food such as citrus

- Caffeine/alcohol

- Carbonated fizzy drinks

- Chocolate

- Large meals or meals/food close to bedtime

- Onions/Garlic

- Generalised stress/anxiety

- Smoking

If your symptoms do not improve after a few weeks, please see your GP for review. 

Blood Pressure Monitoring

We have advised you on specific instructions for monitoring your blood pressure (BP) at home. The general target for most individuals is 140/90, but this is whilst at rest, and your GP will analyse the trend over weeks rather than specific days.

- Take your BP at the same time every day

- Perform whilst sitting or semi-recumbent

- Ideally not whilst in pain/stressed and not after strenuous activity

- Take the best of three measurements

- Record your measurements and review with your GP 

Soft Tissue Injury - PEACE and LOVE

Advice for soft tissue injuries as per PEACE and LOVE principles.

*For the first 48hrs*

- Protect -> avoid excessive aggravating injury and causing excessive pain

- Elevate -> to reduce excessive swelling

- Avoid anti-inflammatories -> avoiding ice and NSAIDs like ibuprofen, promotes long term healing

- Compress - to reduce swelling, but should still allow full movement 

*After the first 48hrs*

- Load -> Normal activities should continue as soon as symptoms allow to promote repair and remodeling

- Optimism -> Stay realistic, but encourage optimism to improve the chances of optimal recovery

- Vascularisation -> Early mobilisation and cardiovascular physical activity boosts blood flow and function in injuries

- Exercise -> Reduces risk of recurring injury, improves strength and sensation. Use pain as a guide to progress exercises gradually to increased levels of difficulty 

Sinus Precautions 

You have been strongly advised *not to blow your nose over the next four weeks*. 

Do not smoke, blow your nose or sneeze holding your nose. Sneeze with your mouth open. Do not sniffle, drink with straws, spit or do anything which might create pressure in the sinus cavity. 

Scuba diving and flying in pressurized aircraft may also increase sinus pressure and should be avoided. Avoid “bearing down”—as when lifting heavy objects, blowing up balloons, playing musical instruments that require a blowing action.

Epistaxis / Nasal Fracture

To prevent return of nosebleeds, we have strongly advised you to avoid the following for the next two weeks:

- Blowing your nose

- Consuming hot food/drinks without allowing them to cool adequately first

- Excessively hot baths/showers

Do not pick your nose. General advice usually also includes avoiding strenuous exercise as a precaution. We have advised you to return if you have uncontrolled bleeding despite the following first-aid instructions:

1. Sit upright, lean slightly forward to avoid swallowing blood

2. Pinch the soft part of your nose (below the bony bit) for at least 10-15 minutes - constant pressure without releasing

3. You may use cold packs to the bridge of your nose

4. Do not insert anything into your nose afterwards as this may open up the bleeding again. 

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We have given you our letter for traumatic nasal fracture with a list of local ENT surgeons who will be able to reduce this fracture for you under ACC. This can be done in a few days once the swelling has decreased and with adequate pain-relief on board. We have advised you to contact them with your ACC number.  

Steristrip / Suture / Glue Advice

Steristrips

Keep the wound clean and dry for approximately 3 to 5 days. Keep the wounds completely dry for the first 24 hours and avoid getting it wet when showering for the remainder of the time as water will loosen the steristrips too quickly. Do not remove the steristrips. The steristrips will gradually peel away and drop off.

We have advised you to seek urgent medical attention if the wound opens up again, you develop a fever or significant pain/swelling/tenderness/pus-like discharge. It is normal for clear yellow fluid to drain from the cut in the first few days.

Absorbable Sutures

As you have absorbable sutures (vicryl rapide) in, these should be kept dry for a total of 7-10 days - this is the duration for which they provide strength to your healing wound. Keep the wound clean and dry during this time, completely dry for the first 24 hours and avoid getting it wet when showering for the remainder

We have advised you to seek urgent medical attention if the wound opens up again, you develop a fever or significant pain/swelling/tenderness/pus-like discharge. It is normal for clear yellow fluid to drain from the cut in the first few days.

Non-absorbable Sutures

Keep the wound clean and dry for approximately 3 to 5 days. Keep the wounds completely dry for the first 24 hours and avoid getting it wet when showering for the remainder of the time. You will need to see your GP doctor/nurse to have your wound checked and sutures removed based on the time below - excessive time may worsen scarring.

We have advised you to seek urgent medical attention if the wound opens up again, you develop a fever or significant pain/swelling/tenderness/pus-like discharge. It is normal for clear yellow fluid to drain from the cut in the first few days.

Suture removal — The timing of nonabsorbable suture removal varies with the anatomic site, according to the expected rate of healing :

●Face – 5 days

●Eyelids – 5 days (3 days for low-tension wounds and up to 7 days for high-tension wounds)

●Neck – 5 days

●Scalp – 7 to 10 days

●Trunk and upper extremities – 7 days

●Lower extremities – 8 to 10 days

●Digits, palm, and sole – 10 to 14 days

https://www.uptodate.com/contents/skin-laceration-repair-with-sutures#H36

Tissue Adhesives (Glue)

Wounds repaired by tissue adhesives (glue) do not require external bandages; the adhesive itself acts as a water-resistant bandage. Antibiotic ointment should not be used because it can break down the adhesive prematurely. General advice is to keep wound sites completely dry for 24-48 hours - but patients may shower while the adhesive is on the skin. Take care not to soak or scrub the area for 7 to 10 days. Wet skin should be gently patted dry. Children should not take baths if bathing would result in submersion of the affected area.

The adhesive will peel off when the epithelial layer sloughs off, usually by 5 to 10 days. No follow-up visit is required unless there are signs of infection or non-healing. We have advised you to seek urgent medical attention if your sutures fall out/the wound opens up again, you develop a fever or significant pain/swelling/tenderness/pus-like discharge. It is normal for clear yellow fluid to drain from the cut in the first few days.

Cast Care

(After putting on a cast, especially a full plaster)

• Keep the plaster cast clean and dry at all times.

• The cast usually dries completely in 48 hours. Allow it to dry naturally and keep it away from direct heat.

• Avoid bumping or hitting the cast.

• Do not paint the cast. This will close the pores of the plaster. Having friends decorate the cast using markers is OK.

Elevating the affected area or loose wrapping with ice covered in a thin towel can reduce swelling and tight sensations. Seek urgent medical attention if you feel any tingling or numbness, if you lose sensation, can’t move your fingers or are in significant pain, or if your fingers turn pale or blue. Casts are designed to provide structure and support but you may need your cast urgently cut to relieve excessive pressure.

We have referred you to the Orthopaedic Fracture clinic for follow-up, usually in 1-2 weeks. The clinic will contact you directly with an appointment which may involve further XRs to assess healing, replacing your cast, and guide your next steps for recovery. 

Constipation

We have discussed how constipation can take weeks, sometimes months, to fully resolve. The aim is for x1 soft stool/day. 

You should:

(1) Drink well, good hydration is important. The typical target is 1.5-2L/day for a healthy adult, you may require the higher end of this whilst constipated. 

(2) Ensure a varied diet with fibre. Vegetables generally are recommended. Kiwifruit, ripe bananas, and prunes may also aid constipation

(3) Improve your mobility as you can. Walking and moving the legs promotes good bowel movement.

(4) Take regular pain-relief. Treating constipation can make things worst before they get better - moving hard tough stool can be painful. Paracetamol is a safe option. Other medications may prolong your constipation.

(5) Take laxatives. These include several different types of medication which may soften your stools, add water to your bowel, or physically stimulate your bowel to push out stool. We have advised you to titrate your medication, the aim is x1 soft stool a day.

Docusate Sodium 120mg tablet  Take 1 tablet twice a day. This is a stool softener. If you have excessively loose stools, beyond x1 soft stool a day, you can reduce this dose. The aim is x1 soft stool a day. 

macrogol-3350 13.12 g + sodium chloride 350.7 mg + potassium chloride 46.6 mg + sodium bicarbonate 178.5 mg oral liquid: powder Dissolve each sachet in 125ml of water. Take 1 sachet twice a day. The aim is to pass x1 soft stool a day. Increase your dose by 1 sachet a day to a maximum of 4 sachets twice a day. If you have loose stools, reduce your dose.

paracetamol 500 mg tablet Take 2 tablets (1g) every 4-6 hours for pain/fever as needed. Maximum four times a day. You would likely benefit from taking this regularly for the first few days (i.e. breakfast, lunch, dinner, before bed) 

diclofenac sodium 50 mg tablet: dispersible Take 1 tablet for severe pain up to twice a day. This should be taken with food. If taken regularly you may need to start stomach protection.

Head Injury

We have advised you to return if your headache significantly worsens despite painkillers, and/or you develop new symptoms such as repeated fainting/loss of consciousness, persistent vomiting (typically defined as 3+ episodes in 24hrs), loss or impaired vision, muscle weakness or loss of sensation (particularly of one side of the body), complete neck stiffness, excessive sensitivity to light, or seizure activity. 

Concussion is relatively common after head injuries and can cause temporary generally mild effects. These typically improve over days to short weeks. Recurring headaches, tiredness, difficulty concentrating, mild difficulties with balance, and mood changes are possible during this time but improve with gradual return to activity. 

You may find NZRugby's 21 day guide to return to play useful as a rough guide. https://www.nzrugby.co.nz/player-safety-and-concussion-management/for-players/recover-and-return-2

Do not drive if you do not have full control of your vehicle at all times (i.e. unable to stop in an emergency). General advice is typically not within 24-48hrs of the initial injury. We strongly advise you to avoid further head injuries during your recovery period.

We have referred you to ACC - if you are concerned for more lasting symptoms (typically approaching 2 weeks), you may benefit from referring yourself directly to a local concussion service provider if/once your ACC claim is processed. They will contact your directly regarding this.

https://www.acc.co.nz/for-providers/treatment-recovery/referring-to-rehabilitation/concussion-service-providers 

If you need help arranging this, your GP typically is the best place to start - they can review you as needed, and maybe able to make the referral for you. 

Syncope/Collapse

We have advised you to return if you have further episodes of repeated fainting/loss of consciousness and/or you develop new symptoms such as significant headache despite painkillers, persistent vomiting (typically defined as 3+ episodes in 24hrs), loss or impaired vision, muscle weakness or loss of sensation (particularly of one side of the body), seizure activity, or concerning chest pains and palpitations. 

Ensure you remain hydrated, typically target for fluid intake is approximately 1.5L-2L for a healthy adult. 

Abdominal Pain

We have advised you to return if you have significant worsening of your abdominal pain despite painkillers, or you develop new symptoms such as uncontrolled persistent vomiting, complete inability to tolerate any food or drink, blood in the urine or stools, fevers, or you have other concerns not addressed above. Ensure you remain hydrated, typically target for fluid intake is approximately 1.5L-2L for a healthy adult. 

Mechnical Back Pain

If your symptoms significantly worsen—such as uncontrolled back pain despite painkillers, new weakness, numbness, or tingling in your legs (especially both legs), difficulty walking, loss of control of your bladder or bowels (incontinence or retention), numbness around your groin or inner thighs (“saddle area”), fever (usually above 37.8°C), or if you have other concerns not addressed above—please seek urgent medical attention.

Most back pain settles with time and simple measures. Stay as active as you comfortably can—gentle, regular movement is better than bed rest. Use pain relief as advised; regular paracetamol and ibuprofen are often more effective than opiates (such as morphine, codeine, or tramadol which may have significant side-effects) for this type of pain. Avoid excessive strain, such as lifting heavy objects or sudden twisting, until your symptoms improve. If you are not improving after a few weeks, you may benefit from physiotherapy to help strengthen your back muscles. If you are unsure how to manage your pain at home, or if things are not improving after a few weeks, please arrange follow-up with your GP

Urinary Retention/Urinary Tract Obstruction

We have advised you to return if you have uncontrolled abdominal pain, significant blood in the urine, high fevers, loss of sensation or power particularly to your legs. Ensure you remain hydrated, typically target for fluid intake is approximately 1.5L-2L for a healthy adult. 

Constipation and alcohol use can worsen or cause sudden urinary retention. 

We have referred you to the urology/catheter clinic. If you are not able to access the clinic in the next 2 weeks or so, please contact your GP to see if you can have a 'Trial of Removal of Catheter' with the GP. 

Do not remove the catheter yourself. There is an inflated balloon in your bladder to keep the catheter in place. This can cause significant trauma if pulled out through the urethra. There is a risk that you suffer further urinary retention and require another catheter after early/unsupervised removal. 

Doxazosin - Benign prostatic hyperplasia

Adult initially 1 mg daily; dose may be doubled at intervals of 1–2 weeks according to response, up to maximum 8 mg daily; usual maintenance 2–4 mg daily

Tamsulosin - Benign prostatic hyperplasia 

(Special Authority)

Oral, modified release

Adult 400 micrograms daily

Haemorrhoids Advice

The WASH regimen (Warm water, Analgesics, Stool softeners, and a High-fiber diet with/without fiber supplements) can provide relief from non-thrombosed external hemorrhoids. 

A sitz bath is a warm water bath you sit in to relieve discomfort in your perineal region. Soaking this area in warm water relaxes your anal sphincter, which helps increase blood flow through your anal tissues. This promotes healing and reduces the pain, itching and irritation felt due to various health conditions. You can take a sitz bath in your bathtub or using a small plastic tub that fits over your toilet. 

Sitz baths should be administered 15-20 minutes at a time, 3 times per day. It is vital to dry the skin afterward, either with a towel or blow dryer.

Please follow-up with your GP if you have ongoing issues with your haemorrhoids, you may benefit from an outpatient referral to a specialist team if worsening.

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Ultraproct - cinchocaine 0.5% (5 mg/g) + fluocortolone hexanoate 0.095% (945 microgram/g) + fluocortolone pivalate 0.092% (918 microgram/g) ointment 

Apply a small amount to external haemorrhoids/anus up to 4 times daily on the first day, then twice daily for at least 1 week; continue for up to a maximum of 4 weeks 

docusate sodium 120 mg tablet 

Take 1 tablet twice a day, this is a stool softener and should be used to prevent straining and worsening of haemorrhoids. Aim x1 soft stool a day, titrate down if frequent loose stools. 

Renal Colic / Stones

We have advised you to return if you have worsening of your symptoms i.e. (1) uncontrolled abdominal pain despite painkillers, or (2) fevers, persistent vomiting, with concern for possible infection. 

General advice is to sieve your urine and catch the stone - if brought to your GP/urology team, it can be tested to work out the type and composition. General advice is also to drink plenty whilst you have symptoms/until you pass your stone - this may be up to 3-4L water/day if possible.

If your pain does not settle after 2-4 weeks please contact your GP for follow-up, you may benefit from GP review/urology referral to ensure you do not need intervention to help pass the stone.

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diclofenac sodium 100 mg suppository 

Take 1 suppository, for renal colic pain as needed. To be taken rectally. Maximum x1/day. 

doxazosin 4 mg tablet (as per UpToDate)

4 mg once daily in the evening until stone passage or for up to 4 weeks

Cannabis/Cannabinoid Hyperemesis

We have discussed a possible diagnosis related to your cannabis use known as Cannabinoid Hyperemesis Syndrome. This diagnosis is only suggested for episodic vomiting when there is no other clear cause for your vomiting, and is only proven by stopping cannabis use. 

Symptoms may include:

• ongoing nausea (feeling sick)

• repeated episodes of vomiting 

• tummy pain

• reduced food intake and weight loss

• dehydration

During this phase, vomiting may often be intense and overwhelming. Many people will take a lot of hot showers during the day to ease their nausea. The hyperemetic (vomiting) phase will continue until you stop using marijuana. The recovery phase will begin once you stop using marijuana. During this phase, the symptoms will go away and you will be able to eat normally again. 

Most people see some improvement in 1-2 days but this phase can last days or months. If you try marijuana again, your symptoms are likely to return. The most severe of consequences if you do not stop/keep vomiting include kidney failure and seizures because of electrolyte/nutritional losses.

You should return to the ED particularly if you have persistent uncontrolled vomiting even with antisickness/stopping cannabis, uncontrolled abdominal pain despite painkillers, if you have repeated loss of consciousness/fainting, if you stop passing urine (at least x1-2/day), or you are worried for something else not discussed above.

Small traces of blood after lots of vomiting is common, but if your vomit is mostly/only blood, you should seek urgent medical attention. 

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ECG [ ] 

MAILER-DAEMON@smtp.strato.c

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prochlorperazine tablet: maleate 5mg            Nausafix (3-5 days)

Take 1 tablet up to three times a day for nausea/vomiting

This medicine may make you sleepy. If this happens, do not drive or use tools or machines. Do not drink alcohol. Frequent use may increase your skin's sensitivity to sunburn.

Shoulder Dislocation

Standard advice for all injuries for this type is to return to normal activity as soon as able, though evidence suggests shoulder dislocations may benefit from a short period of rest in the first few days. We place the arm in a sling for comfort rather than to aid recovery specifically - it can be taken off if needed (e.g. at night). Immobilisation should be absolutely no longer than 3-4 weeks to avoid freezing or locking up of the shoulder (i.e. adhesive capsulitis). All patients should avoid impact activities. 

We have referred you to ACC, you may benefit from physiotherapy to guide your recovery particularly if you have ongoing issues with mobility or pain. We have included common principles of physiotherapy for this type of injury below -but you can refer yourself to local physiotherapy providers for further support. If you have problems, you can speak to your GP who may be able to help make that referral for you.