SYMPTOM-BASED INTEGRATED APPROACH TO THE ADULT IN PRIMARY CARE

EMERGENCIES
SYMPTOMS
TB
HIV
COVID-19
ASTHMA/COPD
CARDIOVASCULAR DISEASE
DIABETES
MENTAL HEALTH CONDITIONS
EPILEPSY
MUSCULOSKELETAL DISORDERS

2023
WOMEN’S HEALTH
PALLIATIVE CARE
 PREFACE
ADULT PRIMARY CARE (APC) 2023
Commissioned and published by: The South African National Department of Health.
What is APC? How to use APC? • All medications have been colour coded in either
The Adult Primary Care (APC) clinical tool is a comprehensive APC is designed to reflect the process of conducting a clinical orange, blue or purple to indicate prescriber level for
approach to the primary care of the adult 18 years or older. consultation with an adult patient in primary care: that particular indication and at that dose:
APC has been developed using approved clinical policies and - Orange-highlighted medications may be prescribed
guidelines issued by the National Department of Health and is It is divided into three main sections: by a doctor or a nurse according to his/her scope of
intended for use by all health care practitioners working at primary 1. Address the patient's general health practice.
care level in South Africa as a clinical 2. Symptoms - Purple-highlighted medications are doctor-initiated
decision-making tool. 3. Chronic Conditions. medications. This means a doctor needs to start the
• In the stable patient start by addressing the patient's medication and a nurse can continue it according to
Along with guiding the delivery of sound clinical care, APC aims to his/her scope of practice.
general health then address the patient's symptom/s and/or
uphold its key values: - Blue-highlighted medications are doctor-prescribed
chronic conditions.
• Acknowledgement of each patient’s uniqueness and multiple medications. This means that these medications may
• In the patient presenting with one or more symptoms, start
roles within a family and community only be prescribed by a doctor.
by identifying the patient’s main symptom. Use the Symptoms
• Respect for a patient’s concerns and choices
contents page to find the relevant symptom page in the clinical • Refer to the Health for All health promotion tool when
• The development of a trusting relationship with a patient
tool. Decide if the patient needs urgent attention (indicated you see the icon below.
• Communication with a patient should be effective, courteous
in the red box) and if not, follow the algorithm to either a
and empathic
management plan or to consider a chronic condition in the
• The delivery of follow-up care especially for patients with chronic
chronic condition section of the clinical tool.
conditions
• In the patient known with a chronic condition, use the Chronic
• Linking the patient to community-based resources and support
Conditions contents page to find that condition in the clinical
• Ensuring continuity of care, where possible.
tool. Go to the colour-coded Routine Care pages for that APC and its preceding versions have been developed,
A training package that consists of simulated case scenarios condition to manage the patient’s chronic condition using the tested and refined by the Knowledge Translation Unit in
accompanies this tool. ‘Assess, Advise and Treat’ framework. consultation with the South African National Department
APC is being implemented as part of the Integrated Clinical • Arrows refer you to another page in the clinical tool: of Health, particularly the National Essential Medicines
Services Management (ICSM), a key focus within the Ideal Clinic - The return arrow () indicates that you need to consult another List Committee and Clinical Programmes, and a wide
Realisation and Maintenance (ICRM) initiative to improve the page once you have completed the current page. We suggest range of clinicians, policy makers and end-users. For any
quality of care delivered, and is complemented by the Health for you make a note of additional pages to consult. queries contact The Knowledge Translation Unit, email
All health promotion tool to promote healthy lifestyles and health - The direct arrow () guides you to leave the current page and [email protected] or visit www.knowledgetranslation.co.za
education. continue on another page.
An APC eBook for easy electronic viewing is available for download • The assessment tables on the Routine Care pages are arranged in NEMLC/Affordable Medicines Directorates endorse all
from the Knowledge Hub. 3 tones to reflect those aspects of the history, examination and recommendations in APC approved through the NEMLC
investigations to consider. process as published in the STGs and EML.

DISCLAIMER:The content of this document has been developed specifically for health care professionals practising in South Africa, and which content, at the date of first publication, is reasonably believed to represent best practice in the relevant fields of healthcare.
This information is provided on an "as is" basis and neither the Health Foundation of South Africa (NPC) or any of its affiliates make any representations, conditions, warranties or guarantees, whether express or implied, regarding accuracy, relevance, usefulness or fitness
for purpose. Accordingly, you use this information at your sole risk. To the fullest extent permitted by law, the Health Foundation of South Africa (NPC), all its affiliates (including but not limited to the Knowledge Translation Unit) shall not be held liable or responsible for
any aspect of healthcare administered in reliance upon, or with the aid of, this information or any other use of this information, including any use which is not in accordance with any guidelines or (mis-)use outside South Africa. Users of the content are strongly advised
to independently verify any interpretation of the information, consult a variety of sources and use their own professional judgment when treating patients using this information. It is the responsibility of users to ensure that the information contained in this document is
appropriate to the care required for each of their patients within their respective geographical regions. The information contained in this document does not constitute a substitute for such professional judgment.
 What is new in ADULT PRIMARY CARE (APC) 2023.
APC 2023 aligns with the following National Department of Health policies and What are the APC 2023 updates?
clinical protocols: New pages and extensively revised sections include:
• Standard Treatment Guidelines and Essential Medicines List for South Africa. Primary Healthcare • The HIV section has been revised to include the transitioning of all patients to a dolutegravir-
Level, 2020 Edition (v3). based ART regimen with updates to the clinic visit and blood test monitoring schedules. Pages
• TB Screening and Testing Standard Operating Procedure, June 2022. that have been extensively revised include: Start or re-start ART, Switch ART, manage the
• National Guidelines on the Treatment of Latent TB Infection, February 2023. unsuppressed VL pages.
• NDOH. National HIV Testing Services Policy, April 2023. (Updated August 2023). • The TB section has been updated to include a new page "Assess and manage TB infection"
• NDOH: 2023 ART Clinical Guidelines for the Management of HIV in Adults, Pregnancy and
which provides guidance on managing TB exposures in TB contacts and treating latent TB
Breastfeeding, Adolescents, Children, Infants and Neonates, June 2023.
• NDOH: Guideline for Vertical Transmission Prevention of Communicable Infections 2023, infection. Updated recommendations regarding increased active TB screening and testing have
August 2023. also been included.
• National Clinical guidelines of Post-Exposure Prophylaxis in occupational and non-occupational • The contraception section has been revised to include a new pregnancy diagnosis page as well
exposures. NDOH. Approved 2019. Published 2020. as recommendations around the newly available intrauterine device: LNG-IUD.
• 2021 Updated guidelines for the provision of Pre-Exposure Prophylaxis (PrEP) to persons at • COVID-19 content has been integrated into existing pages and new pages have been added:
substantial risk of HIV infection. NDOH. October 2021. Screen all patients for COVID-19, COVID-19 diagnosis, Acute COVID-19, Ongoing COVID
• National guidelines for the management of Viral Hepatitis. NDOH. December 2019. symptoms, Long COVID: routine care
• Management of Rifampicin-Resistant Tuberculosis: A Clinical Reference Guide. November 2019 • A new section has been added on preventing HIV with pre-exposure prophylaxis (PrEP).
• Guidance document on the use of lateral flow lipoarabinomannan assay for the diagnosis of • Other new pages in this update include: Chronic pain, Skin ulcer or non-healing wound: routine
active tuberculosis in people living with HIV. NDOH. December 2020. care, Support the patient taking chronic medication, Observation post vaccination.
• Comprehensive STI Clinical Management Guidelines. NDOH. 2021-2025.
• Maternal, Perinatal, and Neonatal Health Policy. NDOH. 21 June 2021. • For more details, find a full ‘Summary of Changes’ document on the Knowledge Hub.
• National Contraception clinical guidelines. NDOH. 2019
• Clinical Guidelines for Breast Cancer Control and Management. NDOH. 2019. Keep up to date with expected changes in clinical guidance
• National User Guide on the Prevention and Treatment of Hypertension in Adults at PHC level.
Clinical guidance and policies are continuously being updated as new evidence becomes
NDOH. 2021.
• National guidelines for the treatment of Malaria, South Africa, 2019 available and clinicians are urged to be aware of expected changes in clinical practice.
• COVID-19 Clinical Management Guidelines – version 5 Clinical guidance updates expected in 2023/2024 include:
• Guide to Antigen Testing for SARS-COV-2 in South Africa. NDOH. 2023.
• COVID-19 Disease: Infection Prevention and control Guidelines. Version 3. July 2021 • Clinical Management of RR-TB - 6-month BPaLL regimen
• Maternity Care Guidelines
Check regularly for new NDOH circulars, notices or memorandums indicating updates as per
standard practice in government.

Any distribution of the APC publication must remain unaltered. Users are strictly prohibited from reproducing, selling, reselling, or exploiting the APC publication or information contained therein for any commercial purposes.

APC is revised and improved based on feedback from end-users. Send your feedback to [email protected]
 CONTENTS
SYMPTOMS

A E Lump, skin 67 Sexually transmitted infections 49

Abused patient 88 Ear symptoms 33 Lymphadenopathy 25 Skin symptowms 67
44 14 Sleeping difficulty 87
Abdominal pain
Aggressive patient 84
Emergency patient
Eye symptoms 31
M Smoking 141
Menstrual symptoms 56
Anaemia 27 Stings 22
Anal symptoms 48
F Miserable patient 86
Stress 86
Face symptoms 32 Mouth symptoms 35
Anaphylaxis 20 Suicidal patient 83
28
Anxiety 86
Faint
Falls 28
N Syphilis 53
64
Arm symptoms
Fatigue 26
Nail symptoms 82 T
Nausea 45
B Fever 24
Neck pain 64
Tasting difficulty 35
Back pain 63 Fits 19 Teeth symptoms 36
Needlestick injury 108
Bites 22 Foot symptoms 66 Throat symptoms 35
Nose symptoms 34
Blackheads 67 Foot care 66 Tiredness 26
Blackout 28 Fracture 18 O Traumatised patient 88
60
Body pain
Breast symptoms 43
G Overweight patient 127 U
Breathing difficulty 38
Genital symptoms 49 P Ulcer, genital 49
Glucose 17 Pain, back 63 Ulcer, skin 67
Burns 21
Gum symptoms 36 Pain, body/general 60 Unconscious patient 16
C Pain, chest 37 Urinary symptoms 59
14
H
Cardiac arrest
Cervical screening 55
Hair loss 81
Pain, chronic 61 V
Pain, neck 64
Hand symptoms 64 Vaginal bleeding 57
Chest pain 37 Pallor 27
Headache 30 Vaginal discharge 49
Cholera 47 Period problems 56
Hearing symptoms 33 Violent patient 84
Collapse 28 Pimples 67
Heartburn 44 Vision symptoms 31
Coma 16
Condom broken 154 I R Vomiting 45
Confused patient 85 Injured patient 18
Rape 88 W
Constipation 48 Rash 67
Itch 67 Warts, genital 49
Convulsion 19 Respiratory arrest 14
Weakness 26
Cough 38 J S Weight loss 23
Jaundice 79 Wheeze 39
D Joint symptoms 62
Scalp symptoms 80
Wound, acute 18
Dental symptoms 36 Scrotal symptoms 49
Diarrhoea 46 L Seizures 19 Wound, chronic 76
Discharge, genital 49 Leg symptoms 65 Self-harm 83
Disruptive patient 84 Lump, neck/axilla/groin 25 Sexual problems 58
Dizziness 29
 CHRONIC CONDITIONS

TB CARDIOMETABOLIC CONDITIONS EPILEPSY 149

Assess and manage TB infection 89 Cardiovascular disease risk: diagnosis 127

How to collect a good sputum specimen for TB 91 Cardiovascular disease risk: routine care 129 MUSCULOSKELETAL DISORDERS
TB: diagnosis 92 Diabetes: diagnosis 17 Chronic arthritis 151
Drug-sensitive TB (DS-TB): routine care 94 Diabetes: routine care 130 Gout 152
INH mono-resistant TB: routine care 95 Hypertension: diagnosis 132 Fibromyalgia 153
Rifampicin-resistant TB (RR-TB): routine care 99 Hypertension: routine care 133
Heart failure 135
WOMEN’S HEALTH
HIV Stroke 136
Ischaemic heart disease: initial assessment 137 Cervical Screening 55
HIV: pre-exposure prophylaxis (PrEP) 106
Ischaemic heart disease: routine care 138 Contraception 154
HIV: post-exposure prophylaxis (PEP) 108
Peripheral vascular disease 139 Pregnancy 157
HIV: diagnosis 110
Routine antenatal care 159
HIV: routine care 111
MENTAL HEALTH Routine postnatal care 164
Manage the pregnant/breastfeeding mother with an 166
HEPATITIS B (HBV) 120 The mentally ill patient needing treatment or admission 140 unsuppressed VL (≥ 50)
Tobacco smoking 141 Prevent communicable infections in the newborn 167
LONG COVID 121 Alcohol/drug use 142 Prevent vertical transmission of HIV 168
Depression: diagnosis 143 Menopause 169
Depression and/or anxiety: routine care 144
CHRONIC RESPIRATORY DISEASE Schizophrenia 146 PALLIATIVE CARE
Asthma and COPD: diagnosis 123 Dementia 148
Routine palliative care 170
Using inhalers and spacers 123
Address the dying patient's needs 172
Asthma: routine care 125
COPD: routine care 126

OTHER PAGES

Glossary 6 COVID-19 diagnosis 40 Protect yourself from occupational infection 174

Prescribe rationally 7 Acute COVID-19 41 Protect yourself from occupational stress 175
Screen all patients for COVID-19 and TB 8 Ongoing COVID-19 symptoms 42 Communicate effectively 176
Initial assessment of the patient 9 Prevent communicable infections in the newborn 167 Support the patient to make a change 177
Address the patient's general health 10 Support the patient taking long-term medication 173 Helpline numbers 178
 GLOSSARY
3TC lamivudine E L R
A ECG
EDD
electrocardiogram
estimated date of delivery
LAM
LAP
lipoarabinomannan (urine TB test)
lower abdominal pain
Respiratory rate
RPCs
measured in breaths per minute
repeat prescription collection strategies
ABC abacavir
EDR.web electronic drug-resistant TB register LLETZ large loop excision of the RPR rapid plasmin reagin
ADR adverse drug reaction transformation zone
EFV efavirenz RR-TB rifampicin-resistant tuberculosis
AHR abacavir hypersensitivity reaction LP lumbar puncture
eGFR estimated glomerular filtration rate RtHB road to health booklet
ALP alkaline phosphatase LPVr lopinavir/ritonavir
EGK electronic gate keeper
ALT alanine aminotransferase S
ART antiretroviral therapy
ELISA enzyme-linked immunosorbent
assay
M SAMF South African Medicines Formulary
ATVr atazanavir/ritonavir MCS microscopy, culture and sensitivity SBP systolic blood pressure
EX-PUP external pick-up point
AZT zidovudine MCV mean cell volume SFH symphysis-fundal height
F MHCA mental health care act
B FAC-PUP facility pick-up point MIC Medicines Information Centre
SSW
STI
scrotal swelling
sexually transmitted infection
BAL balanitis/balanoposthitis FBC full blood count MTB mycobacterium tuberculosis
BMI body mass index FT4 free thyroxine MU million units T
BP blood pressure measured in FTC emtricitabine MUAC mid upper arm circumference TB tuberculosis
millimeters of mercury [mmHg] TB NAAT tuberculosis nucleic acid amplification
MUS male urethritis syndrome
C G test
CCMDD central chronic medicine dispensing
GCS Glasgow Coma Scale N TBSA total body surface area
and delivery GUS genital ulcer syndrome NCAC national clinical advisory committee Td tetanus and diphtheria vaccine
NDoH National Department of Health TDF tenovofir
CD4 CD4 count of the lymphocytes with H NSAIDs non-steroidal anti-inflammatory TEE tenofvir + emtricitabine + efavirenz
a CD4 surface marker
Hb haemoglobin drugs
CHW community health worker TIA transient ischaemic attack
HbA1c glycated haemoglobin NVP nevirapine
CNS central nervous system TIER.net Three Interlinked Electronic Registers
HBsAb hepatitis B surface antibody
COPD chronic obstructive pulmonary
HBsAg hepatitis B surface antigen P TLD
TOP
tenofvir + lamivudine + dolutegravir
termination of pregnancy
disease
HIV human immunodeficiency virus PCAC provincial clinical advisory
CPR cardiopulmonary resuscitation committee TPT TB preventive treatment
HPV human papillomavirus
CPT co-trimoxazole preventive therapy PCR polymerase chain reaction TSH thyroid stimulating hormone
CrAg cryptococcal antigen I PEFR peak expiratory flow rate U
CrCl creatinine clearance IM intramuscular PEP post-exposure prophylaxis UTI urinary tract infection
CRP c-reactive protein IMCI Integrated Management of PJP pneumocystis jiroveci pneumonia
CVD cardiovascular disease Childhood Illness POP progestogen-only pill V
INH isoniazid
D INR international normalized ratio
PPE papular pruritic eruption VDS
VL
vaginal discharge syndrome
viral load
DBP diastolic blood pressure PROM prelabour rupture of membranes
IU international units PTB pulmonary tuberculosis VTP vertical transmission prevention
DMPA depot medroxyprogesterone acetate
IUD intrauterine device Pulse rate measured in beats per minute
DS-TB drug-sensitive tuberculosis
IV intravenous PVD peripheral vascular disease
DST drug susceptibility testing
DTG dolutegravir
DVT deep vein thrombosis
 PRESCRIBE RATIONALLY Scan QR code
to download
Medsafety App to
report medication
Assess the patient needing a prescription
adverse events.
Assess Note
Diagnosis Confirm the patient's diagnosis, that the medication is necessary and that its benefits outweigh the risks.
Other conditions If necessary adjust the dose (e.g. simvastatin, hydrochlorothiazide in liver disease; tenofovir in kidney disease) or change medication (e.g. avoid ibuprofen in hypertension, asthma).
Other medications Check all medication (prescribed, over-the-counter, herbal) is necessary and for possible interactions especially if on hormonal contraceptive or treatment for TB, HIV, epilepsy.
Allergies If known allergy or previous bad reaction to medication, record in patient's notes and discuss alternative with doctor.
Age If > 65 years consider lowering the dose or frequency of medication. Discuss with doctor if patient on amitriptyline, theophylline, ibuprofen, amlodipine or fluoxetine or is using > 5 medications.
Pregnant/breastfeeding If pregnant or breastfeeding check if the medication is safe. Ensure patient receives routine antenatal care  161.
Response to treatment • If the patient's condition does not improve, first exclude poor adherence, then consider changing the treatment or an alternative diagnosis.
• Check for side effects and report medication reactions via: the MedSafety App (scan the QR code for download) or the reporting website https://primaryreporting.who-umc.org/ZA or using an
Adverse reporting form1. Email this to [email protected].

Advise the patient needing a prescription

• Explain to the patient when and how to take the medication and what to do if side effects occur. Ask the patient to repeat your explanation to ensure s/he understands how to take the medication.
• Ensure patient knows the generic name of all his/her medication and advise to ask prescriber/pharmacist if s/he does not understand a change to regular medication.
• Educate the patient on the importance of adherence and that not adhering to medication may lead to relapse or worsening of the condition and in some instances, resistance to the medication.
• Over-the counter medications and herbal treatments may interfere with prescribed medication. Encourage patient to discuss with prescriber before using them.

Treat the patient needing a prescription

• Ensure that the appropriate prescriber writes the prescription: orange-highlighted medications may be prescribed by a doctor or a nurse according to his/her scope of practice. Purple-highlighted
medications may be initiated by a doctor and continued by a nurse according to his/her scope of practice. Blue-highlighted medications may be prescribed by a doctor only.
• Consult the South African Medicines Formulary (SAMF) or MIC helpline (021) 406 6829 if unsure about your medicine choice and dosing, side-effects or drug interactions.
• If medications listed in APC are not available, check Therapeutic Class list2 and local formulary to identify specific medicine that has been approved for use in your facility.
• Once patient stable on chronic medication and agrees to be registered for Central Chronic Medicines Dispensing and Distribution (CCMDD) programme, help patient select a pick up point (PuP).
Then create 6-month repeat prescription (see below). Write neatly. Patient will collect first supply at facility, then next 5 months from chosen PuP. Patient to return to facility every 6 months.
PRESCRIPTION Patient’s age
PATIENT'S NAME AND SURNAME
Patient’s name and surname ID Age
Patient’s ID or
ALLERGIES passport number
Prescription date
DATE DETAILS OF PRESCRIPTION REPEATS
Generic name of Print the name of the drugs in the blocks below 1 of 6 Patient’s allergies
NOTE ONE ITEM PER BOX 2 of 6 3 of 6 4 of 6 5 of 6 6 of 6
medication in full (INITIAL)
Dose, strength, frequency Date Number of repeats
Number of repeats (maximum for 6 months)
Quantity
(maximum for 6 months) Delete those boxes where repeat
or equivalent Batch No not needed
Dispenser
Prescriber’s name, qualifications
Signature Date of issue
and signature
Prescriber name, signature & qualifications Print Name
Name and
signature of dispenser

1
Adverse drug reaction report forms available from clinic pharmacy or may be accessed via website: www.sahpra.org.za. 2 Primary Health Care Essential Medicines List, 2020 edition: Therapeutic classes and members list can be accessed via:
https://www.knowledgehub.org.za/elibrary/primary-health-care-phc-essential-medicines-list-eml-2020
7
 SCREEN ALL PATIENTS FOR COVID-19 AND TB
• Health care workers need to wear a surgical or N95 mask. Patients need to wear cloth or surgical masks and keep 1-2m apart from each other. Ensure queues are distanced.
• Have 70% alcohol-based hand sanitiser or soap and water handwashing stations available for all patients entering facility.
• Ensure a separate patient pathway for patients suspected of having COVID-19. All waiting areas need to be well-ventilated (open doors and all windows) or outside.
• Ensure triage station has a supply of surgical masks to give to symptomatic patients and patient information leaflets for close contacts1.

If patient known with COVID-19 and returning with worsening symptoms, fast track this patient:
Give surgical mask and send patient to separate area identified for emergency care of COVID-19 patients for urgent attention  40.

If patient is not known to be COVID-19 positive, screen for the following symptoms:
Ask each patient if s/he has had new onset of any of the following in the last 14 days:
• Shortness of breath or difficulty breathing • Sore throat • Loss of sense of smell or change in sense of taste
• Cough • Headache with blocked/runny nose or sneezing • Is/he is known with asthma or COPD with chronic symptoms: worsening of cough or breathing

Yes to any No to all

Consider as patient with suspected COVID-19 • Send patient to attend normal waiting area.
• Give patient a surgical mask to wear. • Ask patients to sit 1-2m apart if possible.
• Does patient have shortness of breath or difficulty breathing?
• If TB symptoms other than cough (unexplained weight loss > 1.5kg in a month, drenching
Yes No night sweats or fever), arrange to collect 1 sputum sample for TB NAAT  92.
• If no TB symptoms, assess for TB preventive treatment (TPT)  89 if any of:
- TB contact2 (repeat course of TPT for each new TB contact)
Send patient to separate • Ensure patients sit 1-2m apart.
- HIV positive (if not had TPT before), including HIV positive pregnant patient
area identified for • Advise on cough and hand hygiene, and if available,
- Silicosis
emergency care of patient to have a rapid antigen test  40.
COVID-19 patients for • If cough present, arrange to collect 1 sputum sample
urgent attention 40. for TB NAAT to exclude TB  92.
Manage symptoms as on symptom pages.

1
Close COVID-19 contact is when a person has had face-to-face (within 1 metre) contact with someone with COVID-19, or has been in a closed environment (like room or vehicle) with someone with COVID-19 for at least 15 minutes. 2A TB contact refers to
a patient who shared an enclosed space (at work, socially, in a hostel, or in a household setting), for ≥ 1 night or for frequent/extended daytime periods, with an adult/adolescent with pulmonary TB ("index patient"), during the 3-month period before the
index patient started their TB treatment.
8
 INITIAL ASSESSMENT OF THE PATIENT
Give urgent attention to the patient with any of:
• Decreased consciousness • Bleeding
• Fitting • Burn
• Difficulty breathing or breathless while talking • Eye injury
• Respiratory rate ≥ 30 breaths/minute • Severe pain
• Chest pain • Suspected fracture or joint dislocation
• Headache and vomiting • Recent sudden onset weakness, numbness or visual disturbance
• Aggressive, confused or agitated • Unable to pass urine
• Overdose of drugs/medication • Sudden facial swelling
• Recent sexual assault • Pregnant with abdominal pain/vaginal bleeding
• Vomiting or coughing blood • Purple/red rash that does not disappear with gentle pressure
Management:
• Check and record BP, pulse, respiratory rate and temperature and ensure patient is urgently seen by nurse or doctor.
• If decreased consciousness, fitting, confused, unable to sit up or known diabetic, also check glucose.

Do routine prep room tests on the patient not needing urgent attention
• Routinely check and record weight, BP, pulse and temperature.
• If coughing/difficulty breathing, also check respiratory rate.
• If known diabetic and feeling unwell, also check glucose.

Ensure the patient with any of the following is seen promptly by nurse or doctor:
• BP ≥ 180/110 or BP < 90/60 • Pulse irregular, ≥ 100 or < 50 • Respiratory rate ≥ 30 • Oxygen saturation < 92% at rest
• Pregnant with BP ≥ 140/90 • Temperature ≥ 38°C • Glucose < 3 (or < 4 if diabetic) or ≥ 11.1 • Oxygen saturation drop to < 87% on exertion (walking 15-20m)

Continue to assess the pregnant patient and the patient with hypertension and/or diabetes:

Patient is pregnant Patient has hypertension Patient has diabetes

Check at booking visit: Check at every visit: Check at every visit:

• Mid Upper Arm Circumference (MUAC) • BP • BP
• Height to calculate BMI1 • At first visit also check height to calculate BMI1. • Fingerprick glucose (only if unwell or not yet stable
• Hb on medications)
• Rapid rhesus Check once a year: • Urine dipstick only if fingerprick glucose ≥ 11.1
• Syphilis • Weight, waist circumference (also check 3 monthly if trying
to lose weight) At first visit also check height to calculate BMI1.
Check at every visit: • Urine dipstick Check once a year:
• BP • Fingerprick glucose (also check if glucose on urine dipstick) • Weight, waist circumference (also check 3 monthly
• Urine dipstick if trying to lose weight)
• Fingerprick glucose only if glucose on urine dipstick • Urine dipstick
• HIV • Visual acuity

1
BMI = weight (kg) ÷ height (m) ÷ height (m).
9
 ADDRESS THE PATIENT'S GENERAL HEALTH
Assess the patient’s general health at every visit.
Assess When to assess Note
Symptoms Every visit Manage symptoms as on symptom pages.
TB Every visit If current cough (any duration), weight loss, night sweats or fever, exclude TB  92. Also assess need for TB preventive treatment (TPT)  89.
Family planning Every visit • Assess patient’s contraceptive needs  154 and pregnancy plans. If pregnant, give antenatal care  161.
• If HIV positive and planning pregnancy, advise patient to use contraception until viral load lower is suppressed1.
Sexual health Every visit • Ask about genital symptoms  49 and sexual problems  58.
• If risky sexual behaviour: new or multiple partner/s, uses condoms unreliably, has sex under influence of alcohol/drugs, give safe sex advice.
Depression Every visit In the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either  143.
Alcohol/drug use Every visit In the past year, has patient: 1) drunk ≥ 4 drinks2/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to
any  142.
Smoking Every visit If patient smokes, encourage to stop  141.
Older person risk If > 65 years: at every visit • If patient has a change in function, check for symptoms suggesting a cause: fever  24, urinary symptoms  59, confusion  85.
• Consider using lower medication doses (give full doses of antibiotics and ART). Avoid unnecessary medications. Discuss with doctor if patient on
diazepam, amitriptyline, theophylline, codeine, ibuprofen, amlodipine or fluoxetine or is using ≥ 5 medications.
• If memory problems and disorientation for at least 6 months, consider dementia  148.
Weight (BMI) Yearly • BMI = weight (kg) ÷ height (m) ÷ height (m).
• If BMI > 25  127. If BMI < 18.5, refer for nutritional support.
BP First visit, then depending on result Check BP: if ≥ 140/90  132. If pregnant and BP ≥ 140/90  159.
CVD risk If ≥ 40 years or ≥ 2 risk factors • Assess CVD risk  127 at first visit, then depending on risk.
• Risk factors: smoking, BMI > 25, waist circumference > 80cm (woman) or 94cm (man), hypertension, diabetes, cholesterol > 5.2, parent/sibling with
early onset CVD3 (man < 55 years or woman < 65 years).
Diabetes risk At first visit if: • If not known diabetic, check glucose  17.
• If ≥ 45 years or • Risk factors: physical inactivity, hypertension, parent or sibling with diabetes, polycystic ovarian disease, Indian ethnicity, cardiovascular disease,
• If BMI ≥ 25 and ≥ 1 other risk factor diabetes during pregnancy or previous big baby > 4000g, previous impaired glucose tolerance or impaired fasting glucose or TB in past year.
HIV • If status unknown Test for HIV  110.
• If sexually active: 6-12 monthly
• If pregnant: every antenatal visit
• If breastfeeding: 3 monthly
Cervical screen When needed • HIV negative: do 3 cervical screens, each 10 years apart from age 30  55.
(if woman) • HIV positive: do cervical screen at HIV diagnosis (regardless of age), then 3-yearly  55.
Breast check • First visit • Check for lumps in breasts  43 and axillae  25.
(if woman) • On contraceptive or hormone therapy: yearly • If on hormone therapy, refer for mammogram at initiation if available.
• If > 40 years: 6 monthly
Continue to manage the patient's general health 11.

1
Viral load < 50. 2One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer. 3Cardiovascular disease (CVD) includes ischaemic heart disease, peripheral vascular disease and stroke/TIA.
10
  14
Advise the patient about his/her general health
• Ask the patient about his/her concerns and expectations from this visit, and try to address these.
• Educate patient that not all tests, treatments and procedures help prevent or treat disease. Some provide little or no benefit and may even cause harm (like doing x-rays or giving antibiotics unnecessarily).
• Help the patient to choose lifestyle changes to improve and maintain his/her general health. Support the patient to change  177.
Smoking Stress Be sun safe Have safe sex Road safety
Alert patient to the risks and Assess and manage • Avoid sun exposure, especially • Have only 1 partnership at a time. • Use pedestrian crossings
encourage to stop  141. stress  86. between 10h00 and 15h00. • If HIV negative, test for HIV to cross the road.
• Use sunscreen and protective between partners and consider • Use a seat belt.
clothing (e.g. hat) when male medical circumcision.
outdoors. • Advise partner/s and children to
• If albinism  79. test for HIV.
• Use condoms.

Physical activity Avoid alcohol/drug use Breast self-awareness Diet

• Aim for at least 30 minutes In the past year, has patient: • Educate that breast cancer is common in women and • Eat a variety of foods in moderation.
of moderate exercise (e.g. 1) drunk ≥ 4 treatable if found early. Although uncommon, men can still Reduce portion sizes.
brisk walking) on most drinks1/session, get breast cancer. • Increase fruit, vegetables, nuts
days of the week. 2) used illegal • Advise woman to be aware of changes in her and legumes.
• Increase activities of daily drugs or breast that are not normal for her. • Choose whole grain bread/rice
living like gardening, 3) misused • Encourage patient to look and feel for changes: or potatoes rather than white
housework, walking prescription or - Check in mirror, when washing, and when lying bread/rice.
instead of taking over-the-counter on back. • Replace brick margarine/butter with vegetable oil or soft
transport, using stairs medications? - Check skin, under arms, each breast and nipples. tub margarine. Remove skin and fat from meat.
instead of lifts. If yes to any • Advise to seek care if: painless hard lump in • Reduce salty processed foods like gravies, stock cubes,
• Exercise with arms if  142. breast/under arm, nipple discharge, nipple retraction packet soup. Avoid adding salt to food.
unable to use legs. (pulled in), skin changes (rash, dimpling). • Avoid/use less sugar.

Treat preventively to maintain the patient’s general health

• If woman planning pregnancy:
- Give folic acid 5mg daily up to 13 weeks gestation. If on anticonvulsants, family history or previous baby with neural tube defect, continue folic acid throughout pregnancy.
- If on valproate, refer to doctor to consider switching medications before patient falls pregnant (risk of birth defects).
• Review the patient’s immunisation history and give if needed:
Vaccine When Note
COVID-19 • All patients, especially if high risk. • Vaccinate against severe COVID-19.
• If booster needed. • High risk: elderly, diabetes, obesity (BMI2 ≥ 30), hypertension or heart disease, HIV (if not on ARVs), TB, chronic kidney disease,
chronic lung disease (like asthma, COPD), cancer.
Influenza • > 65 years • Give influenza vaccine 0.5mL IM yearly.
• HIV positive • Avoid if HIV positive with CD4 < 100.
• Chronic heart or lung disease
• Pregnant woman at time of annual campaign
Hepatitis B If working in a health care facility (medical and non-medical staff ) If not given before, give 3 doses of hepatitis B vaccine 1mL IM immediately, at 4 weeks and 6 months.
Tetanus toxoid If pregnant If not already given, give 1 dose of tetanus toxoid (TT) or tetanus, diphtheria (Td) vaccine 0.5mL IM into arm and record in
maternity case record.

Observe patient for adverse events following vaccination 12.

1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer. 2BMI = weight (kg) ÷ height (m) ÷ height (m).
11
GENERAL
HEALTH
 OBSERVATION POST VACCINATION
• Observe patient for at least 15 minutes after vaccination. If patient known with severe allergies: observe for longer (30 minutes).
• Check for signs or symptoms that may indicate an adverse reaction:

Feeling faint/cardiovascular symptoms Skin/mucosal symptoms Respiratory symptoms Gastrointestinal

• Light-headedness or dizziness symptoms
• Feeling warm or cold
• Sweating
• Palpitations
• Nausea
Collapse 13. • Visual ‘blurring’ (darkening or white-out of vision)
• Reduced hearing (‘whooshing’ noise)
• Pallor reported by onlookers
• Wheeze or cough
• Itchiness • Throat tightness • Nausea
• Ask patient to lean forward and his/her head between knees, • Skin rash (hives) • Stridor • Vomiting
or lie down flat, for several minutes until feeling better. • Swelling of eyes, lips, • Shortness of breath • Diarrhoea
• Loosen tight clothing – undo buttons around neck, loosen tongue, face, or hands/feet) • Hoarseness • Cramps
tie/belt. • Nasal congestion • Oxygen sats < 92%
• Apply a cool cloth to his/her face or neck. • Trouble swallowing
• Calmly reassure patient. • Drooling

Do symptom/s improve quickly (minutes)?

Yes No

Faintness likely Decide when to treat for anaphylaxis

Observe until Are signs or symptoms generalised: are 2 or more body systems involved?
symptoms resolve.
Yes No. Does patient have generalised urticaria (raised red rash/hives) involving the whole body?

Yes No. Are signs or symptoms serious or life-threatening, even if only single body system (hypotension,
respiratory distress, or significant swelling of the tongue or lips)?

Yes No
• If isolated rash (raised, red rash in patient who is otherwise well without other symptoms):
- Monitor for at least 30 minutes to pick up any other symptoms:
Treat as anaphylaxis 20. • If no other associated symptoms and patient remains well, pseudoallergic self-
limiting rash likely: reassure patient and advise to take oral antihistamines.
• Advise to seek urgent health care if any of the following develop: swelling of face, lips or
tongue; difficulty breathing, abdominal pain, nausea or vomiting.
• If other symptoms: discuss with doctor/specialist urgently.
• If in doubt, treat as anaphylaxis  20.

12
 COLLAPSE FOLLOWING VACCINATION
Collapse

• Call for help.

• Lie patient on his/her back and raise legs.
• Check response: if unresponsive, check circulation, airway and breathing.
- If no pulse/not breathing, start CPR  14.
- If breathing and pulse present: assess timing of collapse and duration of loss of consciousness and check breathing, pulse and BP:

• Collapse occurred suddenly, at the time of injection (before, during or immediately after). • Collapse occurred 5-10 minutes after the injection (could
• Loss of consciousness usually lasts 20 seconds to 1 minute and is relieved by lying occur up to 1 hour after).
patient down and raising legs. • Loss of consciousness is not brief and not relieved by lying
• BP: briefly low but rapidly normal again. patient down and raising legs.
• Pulse may be slow. • BP < 90/60 and remains low
• Breathing usually normal but may be rapid, deep (hyperventilation). • Pulse > 120
• No other signs or symptoms present. • Breathing: may have wheeze, stridor, cough
• Other signs and symptoms (like swelling or rash) present.
Fainting episode likely
Treat as anaphylaxis 20.
Management:
• If not already done, lie patient flat and raise legs.
• Loosen any tight clothing: undo buttons around the neck, loosen tie/or tight belt.
• Apply cool cloth to face/neck.
• Calmly reassure patient – explain what happened and assure them that they will be alright.
• Check for any other injuries they may have sustained falling.
• Stay with the patient until they are fully recovered. Patient should remain lying with legs up until
feeling better.

Refer if:
• Head injury.
• Known with a heart condition or other serious illness.
• Patient has unusual symptoms, such as chest pain, shortness of breath, confusion,
blurred vision, or difficulty talking.

Report:
• Report electronically using the Med Safety app or complete NDoH Case Reporting Form (CRF)
for Adverse Events Following Immunisation (AEFI) and report to sub-district or district office and
provincial EPI manager within 24 hours.
• Replace all medications/equipment used and seal emergency kit.

13
 THE EMERGENCY PATIENT
Give urgent attention to the emergency patient:
Does the patient respond to voice or physical stimulation?

Yes No

• Call for help and an automated external defibrillator (AED) or defibrillator.

• Feel for carotid pulse for maximum of 10 seconds.

Pulse felt No pulse felt or unsure

Check breathing: Start CPR1 15.

Patient breathing well Patient gasping or not breathing

• Check airway clear.

• Give 1 breath with bag valve mask attached to oxygen every 6 seconds.
• Recheck pulse every 2 minutes. If no pulse, start CPR1 15.

Assess and manage airway, breathing, circulation and level of consciousness

Airway Breathing Circulation Level of consciousness

• If airway obstructed • If difficulty breathing or oxygen • Establish IV access. • Assess Glasgow Coma Score (GCS):
(snoring, gurgling, noisy saturation < 94%, give face mask • If pulse < 50 and unstable (BP < 90/60,
breathing), open with head- oxygen. decreased consciousness, chest pain or Best motor response Best verbal response Eye opening
tilt and chin-lift. If injured, • If respiratory rate < 9 or blue lips/ acute heart failure2): give atropine 0.5mg 6 Obeys commands 5 Orientated 4 Spontaneous
use jaw-thrust instead, tongue, connect bag valve mask to IV. Repeat every 3 minutes, up to a total 5 Localises to pain 4 Confused 3 To voice
keeping neck stable. oxygen and slowly deliver each breath of 3mg. 4 Withdraws from pain 3 Inappropriate 2 To pain
• Remove foreign bodies from with the patient. • If BP < 90/60, pulse ≥ 100 or heavy 3 Abnormal flexion to words 1 None
mouth and suction fluids. • Intubate if using bag valve mask and still bleeding, give sodium chloride 0.9% pain 2 Incomprehensible
• If unconscious, insert difficulty breathing, oxygen saturation 1L IV rapidly, repeat until systolic BP > 2 Extends to pain sounds
oropharyngeal airway. < 94% or blue lips/tongue. 90. If known heart problem or severe 1 None 1 None
If patient resists, gags or • If sudden breathlessness, more infection suspected, give instead sodium
vomits, use lubricated resonant/decreased breath sounds/ chloride 0.9% 500mL IV over 30 minutes,
• Add scores to give a single score out of 15:
nasopharyngeal airway pain on 1 side, deviated trachea: tension repeat until systolic BP > 90. Continue 1L
- If GCS ≤ 8, intubate patient.
instead. pneumothorax likely: 6 hourly. Stop if breathing worsens.
• Intubate if unable to - Insert large bore cannula above 3rd rib • Stop bleeding: apply pressure and
maintain airway with oro- or in mid-clavicular line. elevate limb. If bleeding still severe,
nasopharyngeal airway. - Arrange urgent chest tube. apply tourniquet above injury.
Manage further and refer urgently:
• While awaiting transport, continue to assess and manage airway, breathing, circulation and level of consciousness.
• If decreased consciousness or vomiting, place in left lateral lying (recovery) position.
• If injured 18, if fitting/just had fit 19, if decreased consciousness 16, if burns 21, if bite/sting 22, if fever 24, if rash 67, if anaphylaxis 20.
• If other symptom, manage as on symptom page.
1
If the patient has a life-limiting illness, consider whether or not to proceed. If CPR not needed in the palliative care patient, address the dying patient's needs 172. 2Leg swelling, difficulty breathing which worsens on lying down/with effort.
14
 CARDIOPULMONARY RESUSCITATION (CPR)
In the patient with no pulse, record the time and start chest compressions:
• Give continuous cycles of 30 chest compressions and 2 breaths with bag-valve-mask attached to 100% oxygen at 10-15L/min.
• Attach monitor/defibrillator and pause compressions to check initial heart rhythm:

Ventricular fibrillation (VF) Pulseless ventricular tachycardia (pVT) Asystole Any other rhythm:
Pulseless electrical activity (PEA)

Give shock of 120-150J.

If monophasic defibrillator, give instead shock of 360J.

• Immediately restart CPR, starting with compressions.

• After 2 minutes of CPR, pause compressions and recheck heart rhythm:

VF pVT Asystole Other rhythm

Give shock of 120-150J (increase joules with each shock given). Feel for carotid pulse for up to 10 seconds.
If monophasic defibrillator, give instead shock of 360J.
No pulse felt Unsure Pulse felt

PEA Stop CPR

and check
• Immediately restart CPR, starting with compressions. breathing
• Give adrenaline1 1mL (1:1000 solution) IV, followed by 5mL sterile water or sodium chloride 0.9%. Repeat adrenaline every 2 cycles (every 3-5 minutes). 14.
• After every 2 minutes of CPR, pause compressions, recheck heart rhythm and manage as above.

While giving continuous CPR:

• If VF or pVT: after 3rd shock, give amiodarone 300mg IV, followed by 10mL sodium chloride 0.9%.
- If VF or pVT persists after next shock or recurs, give further amiodarone 150mg IV.
• Doctor to consider intubation. If intubated, give 1 breath every 6 seconds and continuous chest compressions.
• Look for and manage possible cause:
- If trauma, diarrhoea/vomiting or dehydration, give sodium chloride 0.9% 1L IV rapidly. Repeat if needed. If unsure, discuss with doctor.
- If glucose < 3 or unable to measure  17. If temperature ≤ 35°C  16. If overdose/poisoning, discuss with specialist or local poison helpline  178.
- If more resonant/decreased breath sounds on 1 side or deviated trachea, tension pneumothorax likely: insert large bore cannula above 3rd rib in mid-clavicular line.

Decide when to stop CPR:

How to give chest compressions
• If no pulse after 30 minutes of continuous CPR:
• Ensure patient is lying on firm surface. If on bed, use backboard or move patient onto floor.
- If ongoing VF/pVT, temperature ≤ 35°C or overdose/poisoning,
• Place heel of one hand over lower half of sternum. Place heel of second hand on top of first hand.
continue CPR and discuss/transfer urgently.
• Push down quickly, hard (depth of 5-6cm) and fast (100-120 per minute).
- If none of above, stop CPR and pronounce dead. Arrange
• Allow chest to return to normal shape between compressions.
bereavement counselling for family.
• Do not interrupt compressions unless giving ventilations or checking heart rhythm.
• Swop with colleague every 2 minutes to avoid fatigue.

1
Adrenaline is also known as epinephrine.
15
EMERGENCIES
 DECREASED CONSCIOUSNESS
Give urgent attention to the patient with decreased consciousness:
• First assess and manage airway, breathing, circulation and level of consciousness  14.
• Identify all injuries and look for cause: undress patient and assess front and back. If injured, use log-roll to turn. Then cover and keep warm.
• If fits, injuries or burns, also manage on symptom pages.
• If sudden decreased consciousness and any of: generalised itch/rash, face/tongue swelling, wheeze, difficulty breathing, abdominal pain, vomiting or exposure to possible allergen1, check for
anaphylaxis  20.
• Check glucose, temperature and pupils:
Glucose Temperature Pupils

< 3 or unable ≥ 11.1 ≤ 35°C ≥ 38°C Pinpoint Both Unequal

to measure equally or respond
• Give sodium • Remove cold/ • Give ceftriaxone 2g IV4/IM to Illegal drug use and/or Excessive secretions or dilated poorly to
• Give dextrose chloride 0.9% wet clothing cover for possible meningitis. respiratory rate < 12 muscle twitching light:
10%2 5mL/kg IV. 15-20mL/kg and cover Avoid injecting > 1g IM at one Stimulant • Raise
If known alcohol IV over the with warm injection site. Opioid overdose likely Organophosphate poisoning or other head by
user, give first hour, blankets. • If patient was in malaria area • Give 100% face mask likely drug 30 degrees.
thiamine 100mg then 10mL/ • Warm IV and malaria test5 positive, also oxygen. • Give atropine 2mg IV overdose • If injured,
IM/IV before kg/ hour fluids to 40°C give artesunate 2.4mg/kg IM. • Give naloxone 0.4mg immediately. likely keep body
dextrose. thereafter. (avoid cold Notify. Refer urgently within IV/IM7 immediately. • Reassess every 5 minutes: if no straight and
• Recheck glucose • Stop if fluids). 6 hours. Record artesunate • Reassess every response (still has excessive tilt to raise
after 15 minutes: breathing • If no dose in referral letter. 2 minutes: if secretions, persistently low BP head (avoid
if still < 3, give worsens. response or - If artesunate unavailable, respiratory rate < 12, or pulse), give repeated doses bending
further dextrose • If known temperature give quinine: dilute quinine give increasing doses of atropine every 5 minutes, spine).
10%2 2mL/kg IV. diabetes and ≤ 32°C, 20mg/kg in dextrose 5% naloxone (0.8mg, 2mg, doubling the dose each time:
• Once glucose referral delay also use a 5-10mL/kg. Give as slow IV 4mg) every 2 minutes, 4mg, 8mg, 16mg, 32mg. If some
≥ 3, continue > 2 hours: warming infusion over 4 hours. If IV up to a total of 10mg. response, give the same or
dextrose 5% give short- device. not possible, give in 2 IM6 Naloxone wears off reduced dose. Continue until
1L IV 6 hourly. acting insulin doses diluted in sodium quickly, monitor secretions controlled.
0.1 unit/kg chloride 0.9%. closely and give • Suction secretions often.
IM (not IV)3. • If temperature > 40°C: further doses later if • Wear PPE - carefully remove
- Remove clothing. needed. contaminated clothes and
- Use fan and water spray to wash skin.
cool patient.
- Apply ice-packs to axillae, If no response or overdose/poisoning with other or unknown substance,
groin and neck. discuss with specialist or local poison helpline  178.
• Refer urgently.
• While awaiting transport:
- Check BP, pulse, respiratory rate, oxygen saturation and GCS every 15 minutes. Insert urinary catheter.
- If BP < 90/60, pulse > 100 or < 50, respiratory rate > 20 or < 9, oxygen saturation < 94% or drop in GCS, reassess and manage airway, breathing, circulation and level of consciousness  14.

1
Common allergens include medication, food or insect bite/sting within the past few hours. 2If dextrose 10% unavailable: mix 1 part dextrose 50% to 4 parts water for injection to make dextrose 10% solution. 3Avoid IV insulin as it may cause low
potassium and heart dysrhythmia. Avoid using an insulin needle to give IM insulin. 4Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. 5Test for malaria with rapid diagnostic test if
available, and parasite slide microscopy. 6To give IM quinine: first calculate volume of sodium chloride 0.9% in mL: weight x 20 ÷ 100. Then add this volume of sodium chloride 0.9% to quinine 20mg/kg and inject half the volume into each thigh. 7Give
naloxone IM only if IV not possible.
16
 ASSESS AND MANAGE GLUCOSE
If known diabetes 130.

Interpret and manage random fingerprick glucose:

Glucose < 3 Glucose 3-6.0 Glucose 6.1-11 Glucose ≥ 11.1

Patient has hypoglycaemia.
Does patient have BMI3 ≥ 25 and ≥ 1 of: Check if patient needs urgent attention:
Give urgent attention • Physical inactivity • Decreased consciousness 16 • Nausea or vomiting
• Hypertension • Chest pain 37 • Abdominal pain
Is patient alert? • Parent or sibling with diabetes • Fits  19 • Rapid deep breathing
• Polycystic ovarian disease • Drowsiness • Temperature ≥ 38°C
Yes No • Indian ethnicity • Confusion • Dehydration5
• Cardiovascular disease
• Give glucose1 • If known alcohol • Diabetes during pregnancy
5mL/kg orally. user, give • Previous big baby > 4000g No Yes
• If unable to thiamine 100mg • Previous impaired fasting glucose Check urine for ketones.
take orally, give IM/IV. • TB in past year
instead glucose1 • Give dextrose
or dextrose 10%2 5mL/kg IV. No ketones Ketones
10%2 5mL/kg via • If decreased No Yes Has patient had weight loss, thirst present
nasogastric tube consciousness (especially at night) or been passing
(NGT). 16. Recheck excessive amounts of urine often?
• Give sodium
• Check glucose • If fits  19. glucose chloride 0.9%
after 15 minutes: • Check glucose 3 yearly No Yes 20mL/kg IV over
after 15 minutes: once over the first hour, then
<3 45 years. Check fasting plasma glucose after an 8-hour overnight fast. 10mL/kg/hour
≥3 <3 thereafter. Stop if
Give further breathing worsens.
glucose1 or Look for • Give < 6.1 6.1-6.9 ≥7
• Patient has impaired fasting glucose. • If referral delay
dextrose cause. dextrose > 2 hours: give
10%2 2mL/ Return to 10%2 Repeat fasting • Repeat fasting plasma glucose after 1 week.
short-acting
kg orally/ symptom 2mL/kg IV. plasma insulin 0.1units/kg
via NGT and page. • Then give glucose <7 ≥7 IM (not IV)6. Avoid
discuss/ dextrose after 3 years using insulin
refer. 5% 1L IV or 1 year Repeat fasting plasma glucose 1 week later. needle to give IM
6 hourly. if CVD4 or insulin. Use 22-25
• Refer. hypertension. gauge needle
<7 ≥7
depending on
weight of patient.
Repeat fasting glucose after 1 year. Diagnose diabetes • Refer urgently.
• If < 35 years, type 1 diabetes likely. Refer.
• If ≥ 35 years, give routine diabetes care 130.
Assess CVD risk  127.

1
Three teaspoons sugar (15g) in 1 cup (200mL) water. 2If dextrose 10% unavailable: mix 1 part dextrose 50% to 4 parts water for injection to make dextrose 10% solution. 3BMI = weight (kg) ÷ height (m) ÷ height (m). 4Cardiovascular disease (CVD)
includes ischaemic heart disease, peripheral vascular disease and stroke/TIA. 5Thirst, dry mouth, poor skin turgor, BP < 90/60, pulse ≥ 100. 6Avoid IV insulin as may cause low potassium and heart dysrhythmia. Monitoring needed.
17
 THE INJURED PATIENT
Give urgent attention to the injured patient:
• First assess and manage airway, breathing, circulation and level of consciousness  14.
• Identify all injuries and look for cause: undress patient and assess front and back. If head or spine injury, use log-roll to turn. Then cover and keep warm.
Bruising and Wound and any of: Fracture and any of: Head injury and any of:
blood in urine • Poor perfusion (cold, pale, • Poor perfusion (cold, pale, numb, • Weak/numb below • Any loss of consciousness • Blood or clear fluid leaking
numb, no pulse) below injury no pulse) below fracture fracture • Seizure/fit from nose or ear
Give sodium • Excessive or pulsatile bleeding • Increasing pain, muscle tightness, • Open fracture • Severe headache • Pupils unequal or respond
chloride 0.9% • Penetrating wound to head/ numbness in limb • > 2 rib fractures • Amnesia poorly to light
1L IV hourly neck/chest/abdomen • Suspected femur, pelvis or spine • Severe deformity • Suspected skull fracture • Weak/numb limb/s
for 2 hours, fracture • Bruising around eyes or • Vomiting ≥ 2 times
then 500mL • If BP < 90/60, give sodium behind ears • ≥ 1 other injury
hourly. Aim for chloride 0.9% 1L IV rapidly, repeat • If pain severe, give morphine 10mg IM or 3-10mg slow IV1. • Blood behind eardrum • Drug or alcohol intoxication
urine output until systolic BP > 90. Continue Avoid if severe head injury.
> 200mL/hour. 1L 6 hourly. Stop if breathing • If poor perfusion, weakness/numbness below fracture: • If GCS < 15, neck/spine tenderness, weak/numb limb or abnormal
Stop if worsens. gently re-align into normal position. pupils, apply rigid neck collar and sandbags/ blocks on either side
breathing • If excessive or pulsatile • If open fracture: remove foreign material, irrigate with of head.
worsens. bleeding, apply direct pressure sodium chloride 0.9% and cover with saline-soaked gauze. • If pupils unequal or respond poorly to light, keep body straight and
and elevate limb. Give ceftriaxone 1g IV2/IM. tilt to raise head (avoid bending spine).
• If bleeding severe and persists, • Splint limb to immobilise joint above and below fracture. • If fits, avoid diazepam/midazolam, give phenytoin3 20mg/kg IV in
apply tourniquet above injury. • If pelvic fracture, tie sheet tightly around hips to immobilise. 200mL of sodium chloride 0.9% (not dextrose) over 60 minutes.

• Refer urgently. While awaiting transport, check BP, pulse, respiratory rate, oxygen saturation and GCS every 15 minutes. If open wound, give tetanus toxoid 0.5mL IM if none in past 5 years.
• If BP < 90/60, pulse > 100 or < 50, respiratory rate > 20 or < 9, oxygen saturation < 94% or drop in GCS, reassess airway, breathing, circulation, level of consciousness  14.

Approach to the injured patient not needing urgent attention:

• Refer same day if pregnant, known bleeding disorder, on anticoagulant, involved in high-speed collision, ejected from or hit by vehicle or fell > 3 metres. If assault or abuse  88.
• If open wound, give tetanus toxoid 0.5mL IM if none in past 5 years.

Wound Fracture Head injury

• Apply direct pressure to stop bleeding. Remove foreign material, loose/dead skin. Wash well with chlorhexidine 0.05% • Splint limb to • Observe for 2 hours before discharging.
aqueous solution under running water for 5 minutes. Apply povidone iodine 10% solution if dirty. immobilise joint above • If mild headache, dizziness or mental fogginess,
• If sutures needed: inject lidocaine 1% or 2% 3mg/kg5 around wound to numb area. Apply non-adherent dressing for 24 hours. and below fracture. concussion likely:
• Avoid suturing if > 12 hours (body), > 24 hours (head/neck), remaining foreign material, infected, gunshot or deep puncture: • Give paracetamol 1g - Advise complete rest for 2 days. If no symptoms
- If not suitable for suturing: pack wound with saline-soaked gauze and give cefalexin6 500mg 6 hourly for 5 days. 4-6 hourly (up to 4g ≥ 3 days, gradually increase exertion.
- Review in 2 days. Suture if needed and no infection unless gunshot/deep puncture (irrigate and dress every 2 days instead). in 24 hours) and add - Advise that recovery can take > 1 month.
• Give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) as needed for up to 5 days. ibuprofen7 400mg - Give paracetamol 1g 4-6 hourly (up to 4g in
• Advise patient to return if signs of infection (red, warm, painful, swollen, foul-smell or pus). 8 hourly with food for 24 hours) as needed for up to 5 days.
• Remove sutures after 5 days (face), 4 days (neck), 10 days (leg) or 7 days (rest of body). up to 5 days if needed. • Advise to return immediately if any of above
• Refer if unable to close wound easily, weakness/numbness below injury or cosmetic concerns. • Do x-ray and refer to symptoms of severity develop.
• If not healed completely after 3 months or heals by < 50% after 6 weeks on treatment 76. doctor same day.
1
Dilute 10mg morphine with 9mL of sodium chloride 0.9%. Give diluted morphine 3mL IV over 3 minutes (1mL/minute). If needed, give another 1mL/min until pain improved, up to 10mL. Stop if BP drops < 90/60. 2Do not mix Ringer's lactate and IV
ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. 3IV phenytoin can cause low blood pressure and heart dysrhythmia: maximum infusion rate is 50mg/minute; monitor ECG and BP. If IV phenytoin unavailable, give face
mask oxygen and refer urgently. 4One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer. 5To calculate volume to inject, use 0.15mL/kg of lidocaine 2% and 0.3mL/kg of lidocaine 1%. 6If cefalexin unavailable, use instead
flucloxacillin 500mg 6 hourly for 5 days. If severe penicillin allergy (history of anaphylaxis, urticaria or angioedema), give azithromycin 500mg daily for 3 days instead. 7Avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure, kidney disease.
18
 SEIZURES/FITS
Give urgent attention to the patient who is unconscious and fitting:
• If current head injury  18.
• Place in left lateral lying (recovery) position and give 100% face mask oxygen.
• Establish IV access.
• If glucose <3 or unable to measure, give dextrose 10%1 5mL/kg IV. If known alcohol user, give thiamine 100mg IM/IV before dextrose. Recheck glucose after 15 minutes: if still < 3, give further
dextrose 10%1 2mL/kg IV. Once glucose ≥ 3, continue dextrose 5% 1L 6 hourly.
• If ≥ 20 weeks pregnant up to 1 week postpartum 159.
• If not pregnant or < 20 weeks pregnant, give diazepam 10mg IV over at least 2 minutes or midazolam 10mg IM/buccal2. If still fitting after 5 minutes, repeat diazepam/midazolam dose.
• If still fitting 5 minutes after second dose of diazepam/midazolam or patient does not recover consciousness between fits, refer urgently. If available, doctor to give phenytoin 20mg/kg IV in 200mL
sodium chloride 0.9% (not dextrose) in a different line to diazepam, over 60 minutes with BP and ECG monitoring. If dysrhythmia develops, interrupt infusion and restart slowly. Refer urgently.

Approach to the patient who is not fitting now

Confirm that patient indeed had a fit: jerking movements of part of or the whole body, usually lasting < 3 minutes. May have had tongue biting, incontinence, post-fit drowsiness and confusion.

Yes No

Refer patient same day if any of: New sudden Collapse with
• Temperature ≥ 38°C, headache, neck stiffness or purple/red rash, meningitis likely: give ceftriaxone 2g IV3/IM. Avoid injecting > 1g IM at asymmetric twitching lasting
one injection site. weakness or < 15 seconds
• If patient was in malaria area and malaria test4 positive, also give artesunate 2.4mg/kg IM. If artesunate unavailable, give quinine as slow numbness of face, following flushing,
IV infusion over 4 hours: dilute quinine 20mg/kg in dextrose 5% 5-10mL/kg. If IV not possible, give IM5 diluted in sodium chloride 0.9%. arm or leg; difficulty dizziness, nausea,
• New/different headache or headache getting worse/more frequent speaking or visual sweating and with
• Patient with HIV and no known epilepsy disturbance rapid recovery
• Decreased consciousness > 1 hour after fit
• Glucose < 4 one hour after treatment or patient on glimepiride/insulin Stroke or TIA Common faint
• Glucose ≥ 11.1 17 likely 136. likely 28.
• New sudden asymmetric weakness or numbness, difficulty speaking or visual disturbance
• BP ≥ 180/130 more than 1 hour after fit has stopped If diagnosis uncertain, refer.
• Alcohol/drug use: overdose or withdrawal
• Recent head injury
• Pregnant or up to 1 week postpartum. If ≥ 20 weeks pregnant and just had fit 159.

Approach to the patient who had a fit but does not need same day referral
Is the patient known with epilepsy?

Yes No
Give routine • Doctor to check full blood count, creatinine (eGFR), urea, sodium, calcium and review results.
epilepsy care 149. • If focal seizures or new fits after meningitis, stroke or head injury, discuss with specialist.
• If patient had ≥ 2 definite fits with no identifiable cause, doctor to consider epilepsy and give routine care 149.

1
If dextrose 10% unavailable: mix 1 part dextrose 50% to 4 parts water for injection to make dextrose 10% solution. 2Buccal: use 5mL syringe to draw up correct dose, remove needle and give midazolam between the cheek and gum. 3Do not mix
Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. 4Test for malaria with rapid diagnostic test if available, and parasite slide microscopy. 5To give IM quinine: first calculate volume of sodium chloride
0.9% in mL: weight x 20 ÷ 100. Then add this volume of sodium chloride 0.9% to quinine 20mg/kg and inject half the volume into each thigh.
19
 ANAPHYLAXIS
Give urgent attention to the patient with possible anaphylaxis:
In the few hours before symptoms started, was patient exposed to any medication, food1 or insect bite/sting which has caused anaphylaxis before?

Yes No
In the few hours before symptoms started, was patient exposed to any medication, food1 or insect bite/sting?

Yes No

Is there sudden onset of ≥ 2 of: 1) Generalised itch/rash or face/tongue swelling Is there sudden onset generalised itch/rash or face/tongue swelling and
2) Difficulty breathing 3) BP < 90/60 or dizziness/collapse 4) Abdominal pain or vomiting any of: difficulty breathing, BP < 90/60 or dizziness/collapse?

Yes No No Yes

Treat for anaphylaxis. Anaphylaxis unlikely. Treat symptoms as on symptom pages. If unsure, discuss. Treat for anaphylaxis.

Manage anaphylaxis and refer urgently:

• Give immediately adrenaline2 0.5mL (1:1000 solution) IM into mid outer thigh. Repeat every 5 minutes if needed.
• Raise legs and give 100% face mask oxygen.
• Give sodium chloride 0.9% 1-2L IV rapidly regardless of BP. Then, if BP < 90/60, also give sodium chloride 0.9% 500mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if
breathing worsens.
• If persistent wheeze or difficulty breathing despite adrenaline2, also give 1mL salbutamol 0.5% solution and 2mL ipratropium bromide solution in 4mL sodium chloride 0.9% via nebuliser every
20 minutes for 3 doses. If needed, assess and further manage airway  14.
• Give hydrocortisone 200mg IM/slow IV immediately and promethazine 50mg IM/slow IV.

Assess the patient with previous anaphylaxis

Assess When to assess Note
Trigger At diagnosis Ensure a specialist has reviewed the patient with anaphylaxis to confirm trigger/s. Common triggers include medications, food1 and insect bites/stings.
Other allergy At diagnosis • If recurrent cough, wheeze, tight chest or difficulty breathing, exclude asthma  123. If known asthma, give routine asthma care  125.
• If patches of dry, scaly, itchy skin on wrists, ankles, inside elbows or behind knees, eczema likely  69.
• If itchy, red, raised wheals that appear suddenly and usually disappear within 24 hours, urticaria likely  69.
• If recurrent sneezing or itchy/runny/blocked nose most days for > 4 weeks, allergic rhinitis likely  34.
• If both eyes watery and itchy, allergic conjunctivitis likely  31.

Advise the patient with previous anaphylaxis

• Advise to avoid identified trigger/s and if trigger is a medication, to always inform health worker.
• Ensure patient has a plan in case of anaphylaxis: ambulance telephone number, nearest hospital and reliable transport plan.
• If adrenaline2 auto-injector device (like EpiPen®) prescribed, ensure patient knows when and how to use it:
- If exposed to trigger, use immediately if any of: itch/rash, face/tongue swelling, itchy/tight throat, cough, wheeze, difficulty breathing, dizziness/collapse, abdominal pain or vomiting. After use,
immediately phone for ambulance.
- Advise to read instructions found in packaging.
• Arrange a MedicAlert® bracelet  178 and advise patient to always wear it.
1
Common foods causing anaphylaxis include peanuts, tree nuts, egg, milk and fish. 2Adrenaline is also known as epinephrine.
20
 BURNS
Calculate the percentage total body surface area (% TBSA) burnt using the figure below.

Give urgent attention to the patient with burn/s and any of:
• Drowsy or confused • Circumferential burn of chest/limbs
• Electric/chemical burn • Burn to face, hand/foot, genitals, joint How to calculate %TBSA of burn
• Full-thickness burn (white/black, painless, leathery, dry) • Oxygen saturation < 94% Front Back
• Partial thickness burn (pink/red, blisters, painful, wet) > 10% TBSA • Temperature ≥ 38°C
• Inhalation injury likely (burns to face/neck, difficulty breathing, • BP < 90/60
hoarse, stridor or black sputum) • Other injury 4.5% 4.5%

Management:
• Remove clothing. Cool burn with cool tap water or wet towel/s for 30 minutes. Keep warm with clean, dry sheet.
• Give face mask oxygen if burn > 10% TBSA, inhalation injury, oxygen saturation < 94% or drowsy/confused. Front Back
18% 18%
Doctor to consider intubation.
• If > 10% TBSA:
- Insert a large-bore IV line. If % TBSA burnt > 40% or if transport to hospital likely to take more than 45 minutes, 4.5% 4.5% 4.5% 4.5%
insert a second IV line.
- Give sodium chloride 0.9% IV 4mL x weight (kg) x % TBSA over 24 hours. Give half this volume in first 8 hours
from time of burn. Calculate the hourly volume (mL) = total volume (mL) ÷ 2 ÷ 8. 1%
- Insert a urine catheter and document urine output every hour.
9% 9% 9% 9%
• Give paracetamol 1g orally 4-6 hourly (up to 4g in 24 hours).
• If pain severe, give morphine 3-10mg slow IV . 1

• If other injuries, manage  18.

• Clean and dress burn gently:
- Remove loose/dead skin and clean burn with sodium chloride 0.9%.
- If full thickness or > 10% TBSA burn, apply paraffin gauze and cover with plastic wrap.
- If hospital transfer delayed > 12 hours, apply paraffin gauze and cover with dry gauze and bandage.
- If none of above, apply Burnshield® and cover with bandage. If not available, use a non-adherent dressing or
wrap in clean, dry sheet and blanket.
• Give tetanus toxoid 0.5mL IM if none in past 5 years. The patient's open palm (including fingers) represents 1% TBSA.
• Monitor hourly while awaiting transport: BP, pulse, respiratory rate, oxygen saturation, level of consciousness Exclude simple redness from calculation.
and urine output.
• Refer urgently.

Approach to the patient with burn/s not needing urgent attention

• Cool burn < 3 hours old with cool tap water or wet towel/s for 30 minutes.
• Give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) as needed for up to 5 days.
• Remove loose/dead skin and gently clean burn with sodium chloride 0.9%. Then cover with paraffin gauze dressing.
• Give tetanus toxoid 0.5mL IM if none in past 5 years.
• If cigarette burns, burn with specific shape of object (e.g. iron, grid, knife/fork, car cigarette lighter, light bulb), repeated/unexplained burns or other unexplained injuries, consider abuse  88 and
self-harm  83.
• Review daily until burn healed:
- Dress burn with paraffin gauze dressing. If signs of infection (redness, swelling), apply povidone iodine 5% cream daily.
- If severe infection (extensive redness or swelling, foul-smell, pus or temperature ≥ 38°C), pain despite medication or burn not healed within 2 weeks, refer
1
Dilute 10mg morphine with 9mL of sodium chloride 0.9%. Give diluted morphine 3mL IV over 3 minutes (1mL/minute). If needed, give another 1mL/min until pain improved, up to 10mL. Stop if BP drops < 90/60.
21
 BITES AND STINGS
Give urgent attention to the patient with a bite/sting and any of:
• Snake bite (even if bite marks not seen) or venom in eyes
• If sudden generalised itch/rash, face/tongue swelling, wheeze, difficulty breathing, BP < 90/60, dizziness/collapse, abdominal pain or vomiting, check for anaphylaxis  20.
• Weakness, drooping eyelids, difficulty swallowing and speaking, double vision
• Animal/human bite with any of: multiple bites, deep/large wound, loss of tissue, involving joint/bone, temperature ≥ 38°C or pus
• BP < 90/60
• Excessive or pulsatile bleeding
Manage and refer:
• If snake bite or venom in eyes:
- Keep patient calm and still. Remove jewellery and immobilise bitten limb.
- If venom in eyes: irrigate eye thoroughly for at least 20 minutes with water or sodium chloride 0.9%. If available, instil 1 drop tetracaine 1% eye drops before irrigating.
- Clean bite with chlorhexidine 0.05% solution. Avoid applying tourniquet or sucking out venom.
- Discuss pain management and need for antivenom with local poison helpline  178.
• If excessive or pulsatile bleeding, apply direct pressure and elevate limb. If bleeding severe and persists, apply tourniquet above injury.
• If BP < 90/60, give sodium chloride 0.9% 1L IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens.
• Remove loose/dead skin. Clean wound with chlorhexidine 0.05% or povidone iodine 10% solution and irrigate under running water for 10 minutes. Avoid suturing the wound.
• Give tetanus toxoid 0.5mL IM if none in past 5 years.

Approach to the patient with a bite/sting not needing urgent attention

Human or animal bite/s Insect/spider/scorpion sting or bite/s

• Remove loose/dead skin. Clean wound with chlorhexidine 0.05% or povidone iodine 10% solution and • Remove stinger. Clean wound with soap and water. Apply ice pack for pain/swelling.
irrigate under running water for 10 minutes. • If severe pain, redness, swelling or itch:
• Avoid suturing puncture wounds. - Give chlorphenamine 4mg 6-8 hourly for up to 5 days.
• If animal bite, consider rabies post-exposure prophylaxis: - Apply calamine lotion as needed.
- If bite/scratch with visible blood, licking of eyes/mouth/broken skin by a dog, cat, mongoose, jackal, - Give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) as needed for up to
cattle or goat; or any contact with a bat: 5 days.
• Inject rabies immunoglobulin 20IU/kg at the site of the bite and • If spider bite, advise patient to return if signs of infection (skin red, warm, painful)
• Inject rabies vaccine 1 ampoule IM into deltoid muscle (not buttock). Repeat vaccine on days 3, 7 and and give flucloxacillin 500mg 6 hourly for 5 days. If severe penicillin allergy2, give
14 (if impaired immunity1, also give a 5th dose on day 28). instead azithromycin 500mg daily for 3 days.
- If scratch with no visible blood, give rabies vaccine only as above. • If very painful scorpion sting, inject lignocaine 2% 2mL around site.
- If rabies immunoglobulin or vaccine unavailable, refer. If unsure, contact rabies hotline for advice  178.
• Give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) as needed for up to 5 days. • If hypersensitivity response to insect bites - red raised bump/s that blister and
• If bite punctured the skin with visible bleeding, bite to hand or from human or bat: give amoxicillin/ heal with hyperpigmentation (darkened skin), papular urticaria likely: apply
clavulanic acid 875/125mg 12 hourly for 5 days. If severe penicillin allergy2, give instead azithromycin hydrocortisone 1% daily for 5 days.
500mg daily for 3 days and metronidazole3 400mg 8 hourly for 5 days. • If long-term itch, give cetirizine 10mg once daily.
• If human bite, severe enough to cause bleeding, also assess need for hepatitis B post-exposure prophylaxis • Advise to reduce exposure to insects:
(PEP)  108. Risk of HIV transmission through biting is negligible and HIV PEP not needed. - Treat pets, use bed nets, wash bedding, use insect repellents.
• If bite infected and no response to antibiotics within 48 hours, refer. - Clear away puddles of water around house.

If human/animal/spider bite or scorpion sting, give tetanus toxoid 0.5mL IM if none in past 5 years.

1
Known with HIV, diabetes or cancer, pregnant or receiving chemotherapy or corticosteroids. 2History of angioedema, anaphylaxis or urticaria. 3Advise no alcohol until 24 hours after last dose of metronidazole.
22
 WEIGHT LOSS
• Check that the patient that says s/he has unintentionally lost weight has indeed done so. Compare current weight with previous records and ask if clothes still fit.
• Investigate unintentional weight loss of > 5% of body weight.
• Calculate % weight loss = (previous weight - current weight) ÷ previous weight x 100

STEP 1. Check for TB, HIV and diabetes

Exclude TB Test for HIV Check for diabetes

• Start workup for TB  92. Test for HIV  110. If HIV positive, give routine care  111. Check glucose
• At the same time, test for HIV and diabetes (see adjacent) and consider other causes below.  17.

STEP 2. Then ask about symptoms of common cancers

Abnormal vaginal Breast lump/s or nipple discharge Urinary symptoms in man Change in bowel habit Cough ≥ 2 weeks, blood-stained
discharge/bleeding sputum, long smoking history
Consider breast cancer. Consider prostate cancer. Consider bowel cancer.
Consider cervical cancer. Examine breasts and axillae Do rectal examination. If hard, If mass on abdominal or Consider lung cancer.
Do a speculum examination and a for lumps 43. nodular prostate, refer same week. rectal examination or stool occult Do chest x-ray.
cervical screen if needed 55. blood positive, refer same week. If suspicious, refer same week.

STEP 3. Ask if food intake is adequate: if inadequate look for reason:

Nausea or Loss of appetite If stress No money for food The patient has a Sore mouth or
vomiting or anxiety life-limiting illness. difficulty swallowing
• Eat small frequent meals.  86. Refer to social worker to help
45. • Drink high energy drinks (milk, maas, mageu, soup). organise nutritional support. Consider giving Oral/oesophageal
• Increase energy value of food by adding milk powder, palliative care candida likely 35.
peanut butter, oil or margarine.  170.

STEP 4. Screen for thyroid problem, depression, substance misuse and neglect:
• Ask about other symptoms and manage as on symptom pages: if abdominal pain  44, if diarrhoea  46, if constipation  48.
• If pulse ≥ 100, palpitations, tremor, dislike of hot weather or thyroid enlargement, check TSH. If abnormal, refer to doctor.
• Review medication: anticonvulsants, antidepressants, diabetes medications and levothyroxine can cause unintentional weight loss. Discuss with doctor.
• Screen for depression: in the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either  143.
• Screen for alcohol/drug use: in the past year, has patient: 1) drunk ≥ 4 drinks1/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.
• Ask about neglect in the older or ill patient needing care. If yes, refer to social worker.

Review in one month. If no better or no cause found, discuss/refer.

1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer.
23
 FEVER
A patient with a fever has a temperature ≥ 38°C now or in past 3 days.

Give urgent attention to the patient with a fever and any of:
• Fits or just had a fit  19. • Respiratory rate > 30 or difficulty breathing • Severe abdominal or back pain
• Decreased consciousness  16 • BP < 90/60 • Jaundice
• Neck stiffness, drowsy/confused or purple/red rash, meningitis likely • Tender in right lower abdomen, appendicitis likely • Easy bleeding or bruising
Management:
• If BP < 90/60, give sodium chloride 0.9% 500mL IV over 30 minutes, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens.
• If likely meningitis, decreased consciousness, fits or respiratory rate > 30/difficulty breathing: give ceftriaxone 2g IV1/IM. Avoid injecting > 1g IM at one injection site.
• If patient was in a malaria area in past 3 months and malaria test2 positive: give artesunate 2.4mg/kg IM and notify. Refer urgently within 6 hours. Record artesunate dose in referral letter. If artesunate
unavailable, give quinine as slow IV infusion over 4 hours: dilute quinine 20mg/kg in dextrose 5% 5-10mL/kg. If IV not possible, give IM3 diluted in sodium chloride 0.9%.
• If glucose < 3 or ≥ 11.1  17.
• Refer urgently.

Approach to the patient with a fever not needing urgent attention

• If on abacavir, check for abacavir hypersensitivity reaction (AHR)  116.
• Has patient been in a malaria area in past 3 months?

Yes: arrange same day malaria test2. If not available same day, refer. No

Malaria test positive Malaria test negative

Malaria likely Consider other cause of fever:

• Notify and give artemether/ Does patient have a tick bite (small dark brown/black scab) or tick present?
lumefantrine 80/480mg with food/
milk: immediately, then after 8 hours, Yes No
then 12 hourly for 2 days (total of
6 doses). If patient vomits within the
1st hour of taking treatment, give the Tick bite fever likely: • Ask about other symptoms: assess and manage on symptom page.
same dose again. • May also have headache, body pain, rash or localised • Acute viral infection likely (such as influenza or COVID-19) if any of: cough,
• Also consider other cause of fever lymphadenopathy. sore throat, loss of taste or smell, nose symptoms, headache, body pain. If the
(see adjacent). • If tick present, grip tick close to skin using forceps and remove. current prevalence of COVID-19 is high, consider COVID-19  40.
• Check Hb and glucose. • Give doxycycline 100mg 12 hourly for 7 days. If pregnant,
• Give urgent attention and refer same give instead azithromycin 500mg 12 hourly for 3 days. If none of above:
day if: Hb < 7, glucose < 3, unable to • Give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) as • Check urine dipstick: if blood, leucocytes or nitrites 59.
take orally or symptoms worsen. needed for 5 days. • Exclude TB  92.
• Refer same day if: > 65 years old, • If severe headache or no better after 3 days, refer. • Test for HIV  110.
pregnant, known HIV/diabetes or • Advise patient to return if other symptoms develop.
malaria treatment not available. • If previous malaria test negative and fever persists after 2 days, repeat malaria test2.
• If fever persists for > 5 days and cause still uncertain, discuss/refer.
1
Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. 2Test for malaria with rapid diagnostic test if available, and parasite slide microscopy. 3To give IM quinine: first calculate volume of
sodium chloride 0.9% in mL: weight x 20 ÷ 100. Then add this volume of sodium chloride 0.9% to quinine 20mg/kg and inject half the volume into each thigh.
24
 LUMP/SWELLING IN NECK, AXILLA OR GROIN
Give urgent attention to the patient with lump/swelling in groin and any of:
• Lump in groin that gets bigger when standing/coughing/passing stool and any of: severe pain, vomiting, no stools or flatus/wind for past 24 hours, or lump
cannot be reduced: incarcerated/strangulated inguinal hernia likely
• Pulsating lump: aneurysm likely
Refer urgently.

Approach to the patient with lump/swelling in neck, axilla or groin not needing urgent attention:
• If lump is in the skin 67.
• If lump is beneath the skin, first exclude thyroid mass and hernia:
- Lump in neck that moves up when patient swallows, thyroid mass likely: check TSH and refer same week for further investigation.
- Lump in groin that gets bigger when standing/coughing/passing stool, inguinal hernia likely: refer.
• If none of the above, a lump in neck, axilla or groin is likely an enlarged lymph node (lymphadenopathy). If unsure, refer.

Is lymphadenopathy localised (neck or axilla or groin) or generalised (≥ 2 areas)?

Generalised Localised lymphadenopathy: ask about other symptoms and look for cause (infection, rash, bite):
lymphadenopathy
Neck Axilla Groin
Check scalp, face, • Check arms, breasts, chest, Is the groin lymph node hot and tender?
eyes, ears, nose, upper abdomen and back.
mouth and throat. • If lump in breast 43. No: check lower abdomen, legs, Yes: treat for bubo:
buttocks, genitals, anal region. • First assess and advise the patient  49.
• Give azithromycin 1g weekly for 3 weeks.
Has a cause been found? • If fluctuant lymph node, aspirate pus through healthy skin in
sterile manner every 3 days as needed.
• If pain, give ibuprofen1 400mg 8 hourly with food for up to 5 days.
No Yes • Give partner notification slip/s with code: Bubo.
• Review in 14 days: if no better, refer.
• Test for HIV  110 and syphilis. If HIV positive, give routine care  111. If syphilis positive  53. • Manage as on
• If cough, weight loss, night sweats or fever, exclude TB  92. Also aspirate lymph node symptom page.
for TB microscopy and cytology (see adjacent). If no TB found, aspirate does not confirm • Reassure patient How to aspirate lymph node for TB microscopy and cytology:
diagnosis and symptoms persist, refer same week. lymphadenopathy • Clean skin over largest node with alcohol or povidone iodine.
• Check full blood count. If abnormal, discuss with doctor. should resolve • Hold node in fixed position with one hand so that it will not move. Insert
• Review medication: atenolol, allopurinol, co-trimoxazole, antibiotics and phenytoin can with treatment. 22 gauge needle into node, draw back plunger 2-3mL to create vacuum.
cause lymphadenopathy. Discuss with doctor. • If lymph node • Partially withdraw and reinsert needle at different angles several times
• If none of above, decide how to manage further: persists > 4 weeks, (avoid withdrawing needle completely, maintain continuous vacuum).
refer. • Release vacuum pressure before withdrawing needle completely.
• Remove syringe from needle, pull 2-3mL air into syringe, re-attach needle
Localised lymphadenopathy and well • Generalised lymphadenopathy or and gently spray contents of needle onto a glass slide.
• Unwell or • Lay another slide on top and pull the slides apart to spread the material.
• Reassure patient. • Lymph node/s getting bigger quickly • Allow one slide to air dry and spray other slide with cytology fixative
• Advise to return if symptoms develop. spray. Send slides for TB microscopy and cytology. If enough aspirate,
• If lymph node persists > 4 weeks, refer. Refer same week. also send in sputum bottle for TB NAAT, TB culture and DST.
1
Avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure, kidney disease.
25
 WEAKNESS OR TIREDNESS
Give urgent attention to the patient with weakness or tiredness and any of:
• New sudden asymmetric weakness or numbness of face, arm or leg; difficulty speaking • Glucose < 3 (or < 4 if diabetes)
or visual disturbance: consider stroke or TIA 136 • Glucose ≥ 11.1
• Chest pain 37 • Dehydration: thirst, dry mouth, poor skin turgor, drowsiness/confusion, BP < 90/60, pulse ≥ 100
• Difficulty breathing or respiratory rate ≥ 30 38 • Hb < 6 27
• Difficulty breathing worse on lying flat and leg swelling, heart failure likely 137. • Worsening weakness of leg/s
• Temperature ≥ 38°C now or in past few days 24
Management:
• If dehydrated, give oral rehydration solution (ORS) and observe. If unable to drink or BP < 90/60, give sodium chloride 0.9% 500mL IV over 30 minutes, repeat until systolic BP > 90. Continue 1L
6 hourly. Stop if breathing worsens. If IV rehydration needed or no better with oral rehydration after 2 hours, refer.
• If glucose < 3 or ≥ 11.1  17 or if diabetes and glucose < 4  130.
• If worsening weakness of leg/s, refer urgently.

Approach to patient with tiredness not needing urgent attention:

• Look for a cause for tiredness when it persists so that the patient is unable to complete routine tasks and it disrupts work, social and family life.
• First check symptoms, medications, mental health and for chronic conditions:

Check symptoms Check chronic conditions Check medications Check mental health
• If fever now or in past 3 days  24. • Test for HIV  110. If HIV positive, give • If on abacavir or zidovudine, check • In the past month, has patient: 1) felt down,
• If cough, weight loss, night sweats or fever, routine care  111. for urgent side effects  116. depressed, hopeless or 2) felt little interest or
exclude TB  92. • Exclude pregnancy  157. • Chlorphenamine, enalapril, pleasure in doing things? If yes to either  143.
• If difficulty breathing worse on lying flat and • Exclude anaemia: check Hb. If < 12 (woman) amlodipine, fluoxetine, • In the past year, has patient: 1) drunk ≥ 4 drinks1/
leg swelling, heart failure likely 135. or < 13 (man), anaemia likely  27. amitriptyline, metoclopramide, session, 2) used illegal drugs or 3) misused
• If patient has difficulty sleeping  87. • Exclude diabetes: check glucose  17. sodium valproate, phenytoin and prescription or over-the-counter medications? If yes
• If weight gain, low mood, dry skin, • If ongoing symptoms following acute spironolactone can cause weakness to any  142.
constipation or cold intolerance, check TSH. COVID-19, assess for Long COVID  42. or tiredness. Discuss with doctor. • If none of the above, assess for stress and anxiety  86.
If abnormal, refer to doctor. • If patient has a life-limiting illness, also
consider giving palliative care  170.

Is there muscle weakness on examination2?

No Yes

Ask about duration of tiredness: • If available, refer to

doctor. Doctor to confirm
< 1 month ≥ 1 month weakness and:
- Check potassium,
sodium, calcium,
• If any other symptoms managed above, reassure • Check FBC, differential count, sodium, calcium, creatinine and ALT. If abnormal, discuss with doctor. phosphate, TSH.
that tiredness should resolve with treatment. • If likely cause found, reassure that tiredness should resolve with treatment. If tiredness persists - Discuss/refer to specialist.
• Advise to return if no better in 1 month. despite treatment, discuss/refer. • If no doctor available, refer.
• If no cause found, review in 1 month. If tiredness persists and cause still not found, discuss/refer.
1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer. 2If unsure how to examine for muscle weakness, discuss with doctor.
26
 PALLOR AND ANAEMIA
• Patient has pallor if s/he has pale conjunctiva or palms. Compare patient’s palms to your own.
• Check Hb: anaemia likely if:
- Non pregnant woman has Hb < 12.
- Pregnant woman has Hb < 11 160.
- Man has Hb < 13.

Give urgent attention to the patient with pallor/anaemia and any of:
• Hb < 6 • BP < 90/60 • Swollen legs • Widespread/easy bruising
• Pulse ≥ 100 • Dizzy/faint • Jaundice • Purple/red rash that does not
• Respiratory rate ≥ 30 • Chest pain or palpitations • Black1 or bloody stools disappear with pressure
Manage and refer urgently:
• If respiratory rate increased, give face mask oxygen.
• If BP < 90/60, give sodium chloride 0.9% 500mL IV over 30 minutes, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens.

Approach to the patient with pallor/anaemia not needing urgent attention

• Test for HIV  110 and TB  92.
• Exclude pregnancy  157.
• If fever now or in past 3 days, and in a malaria area in past 3 months, arrange same day malaria test2. If positive, malaria likely 24.
• If not pregnant, send full blood count (FBC) and manage further according to mean cell volume (MCV)3 result:

MCV3 low MCV3 normal MCV3 high

Iron deficiency anaemia likely Systemic Macrocytic anaemia likely

Is patient a man or a woman who no longer has periods? disease Patient postpartum or known to misuse alcohol4?
or chronic
Yes No condition likely Yes No

Discuss/ • Ask about abnormal vaginal bleeding: if abnormal  57. • If HIV, TB and Folate deficiency likely Refer to
refer to • Give ferrous sulphate compound BPC 170mg or ferrous fumarate 200mg 12 hourly with pregnancy • Review medication: if on zidovudine or investigate for
look for food. If not tolerated (abdominal pain, nausea, vomiting, constipation), give instead ferrous excluded, anticonvulsants, discuss with doctor. vitamin B12
hidden sulphate compound BPC 340mg or ferrous fumarate 400mg once weekly with food discuss/refer. • Give folate 5mg daily until Hb normal. deficiency.
blood loss. - Repeat Hb monthly on treatment: if Hb decreases or if no better after 4 weeks, refer. • If pateint is • Repeat Hb monthly on treatment: if Hb
- Continue treatment until 3 months after Hb reaches normal value. known with decreases or if no better after 4 weeks, refer.
• Advise: life-limiting • Advise:
- To eat foods rich in iron: liver, kidney, meat, eggs, spinach, beans, peas, lentils, nuts, dried illness, also - To eat foods rich in folic acid: liver, eggs,
fruit and fortified cereals. Foods rich in vitamin C help iron absorption: guavas, peppers, consider fortified cereals, citrus fruit, spinach,
oranges, strawberries, broccoli, cauliflower. giving other green vegetables, lentils, dry beans,
- Avoid drinking tea/coffee with meals as these interfere with iron absorption. Also avoid palliative care peanuts.
taking iron tablets with milk or calcium tablets.  170. - Avoid alcohol  142.
- Warn that stools may become black with treatment, reassure this is normal. • If chronic diarrhoea, refer.
1
Black stools may be caused by iron tablets. Only refer if black stools started before iron treatment. 2Test for malaria with rapid diagnostic test if available, and parasite slide microscopy. 3Mean cell volume (MCV) helps identify cause of anaemia. Check on
FBC result sheet if MCV low, normal or high compared to reference range. 4Drinks > 14 drinks/week or ≥ 4 drinks/session. One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer.
27
 COLLAPSE/FALLS
Give urgent attention to the patient who has collapsed and any of:
• Collapse following vaccination 13 • Systolic BP < 90
• New sudden asymmetric weakness or numbness of face, arm or leg; difficulty speaking or visual • Pulse < 50 or irregular
disturbance: consider stroke or TIA 136 • Palpitations
• Decreased consciousness 16 • Family history of collapse or sudden death
• Fit 19 • Abnormal ECG
• Chest pain 37 • Known heart problem
• Difficulty breathing 38 • Collapse with exercise
• Glucose < 3 (or < 4 if diabetes)  17 • Vomited blood or blood in stool
• Sudden collapse and any of: generalised itch/rash, face/tongue swelling, wheeze, difficulty breathing, • Pregnant or missed/overdue period with abdominal pain and vaginal bleeding
abdominal pain, vomiting or exposure to possible allergen1, check for anaphylaxis  20 • Severe back or abdominal pain
• Recent injury
Manage and refer urgently:
• If BP < 90/60, give sodium chloride 0.9% 500mL IV over 30 minutes, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens.

Approach to the patient who has collapsed not needing urgent attention:
• Ensure patient has had an ECG. If abnormal, refer same day.
• Check Hb: if <12 (woman) or < 13 (man), anaemia likely  27.
• Screen for alcohol/drug use. In the past year, has patient: 1) drunk ≥ 4 drinks2/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.
• Check BP: if ≥ 140/90  132. Then measure BP after lying for 5 minutes and repeat after standing for 3 minutes. Does systolic BP drop by ≥ 20 or diastolic BP drop by ≥ 10?

Yes No

Orthostatic hypotension likely Was patient breathing very quickly or deeply immediately before or during the collapse?
• This is common in the elderly.
• Review medications: e.g. fluoxetine, amitriptyline, amlodipine,
No Yes
enalapril, furosemide, hydrochlorothiazide, isosorbide dinitrate
can cause syncope. Discuss with doctor.
• If diarrhoea  46, if vomiting  45, if fever  24, if poor Did patient have dizziness, light-headedness, nausea, sweating, weakness or vision changes before the collapse? Hyperventilation
fluid intake, encourage fluids and give oral rehydration solution. likely
• Advise patient to sit first before standing up from lying down. • Reassure and
• Refer if: Yes No
encourage patient
- Diabetes to breathe at a
- Peripheral neuropathy (pain/numbness of feet) Common faint likely • If collapse associated with normal rate.
- Tremor, slow movements or stiffness • Advise to avoid triggers like overheating, dehydration and coughing, swallowing, head • Assess for stress and
- History of constipation or erection problems prolonged standing. turning, refer. anxiety  86.
• Advise to lie flat with legs raised as soon as symptoms occur. • If known diabetes  130.

• If none of the above, look for and manage likely cause: if vision problems  31, joint problems  62, foot problems  66, leg problems  65, dementia  148.
• Refer if patient > 65 years with possible heart disease, patient collapses/falls repeatedly or cause for collapse/falls is uncertain.

1
Common allergens include medication, food or insect bite/sting within the past few hours. 2One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer.
28
 DIZZINESS
Give urgent attention to the patient with dizziness and any of:
• New sudden asymmetric weakness or numbness of face, arm or leg; difficulty • Difficulty breathing, especially on lying flat with leg swelling 135
speaking or visual disturbance: consider stroke or TIA 136. • Recent head injury
• BP < 90/60 • Unable to stand without support
• Pulse < 50 or irregular • New sudden severe dizziness with nausea/vomiting, abnormal eye
• Glucose < 3 (or < 4 if diabetes)  17 movements or walk
• Chest pain 37
Manage and refer urgently:
• If BP < 90/60, give sodium chloride 0.9% 500mL IV over 30 minutes, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens.

Approach to the patient with dizziness not needing urgent attention:

• Ask about ear symptoms. If present  33. If hearing loss, refer same week.
• Ask about fainting/collapse attacks. If present, do ECG. If ECG abnormal, refer same day.
• Screen for alcohol/drug use: in the past year, has patient: 1) drunk ≥ 4 drinks1/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.
• Review medication: antidepressants, hypertension and epilepsy treatment, furosemide and efavirenz can cause dizziness. Discuss with doctor.
• Check Hb: if < 12 (woman) or < 13 (man), anaemia likely  27.
• Check BP: if ≥ 140/90  132. Measure BP after lying for 5 minutes and repeat after standing for 3 minutes. Does systolic BP drop by ≥ 20 or diastolic BP drop by ≥ 10?

Yes No

Orthostatic Was patient breathing very quickly or deeply immediately before or during the collapse?
hypotension likely
• This is common in Yes No
the elderly.
• If diarrhoea  46,
if vomiting  45, Hyperventilation likely Ask about associated symptoms and length of dizziness. Is there hearing loss or tinnitus (ringing/buzzing in ear/s)?
if fever  24, if • Usually associated with
poor fluid intake, emotional stress. May also No Yes
encourage fluids and have light-headedness,
give oral rehydration chest tightness, tingling
of hands/feet and visual Sudden dizziness lasting seconds, precipitated by head movements Sudden dizziness lasting hours/days Refer.
solution. with nausea/vomiting. May have
• Advise patient to sit changes.
• Encourage to breathe at a Positional vertigo likely preceding flu-like illness.
first before standing
up from lying down. normal rate and depth. • Reassure patient that dizziness is self-limiting and usually resolves within 6 months.
• Assess for stress and • If no neck or heart problems, doctor to perform particle repositioning (Epley) manoeuvre. Vestibular neuronitis likely
anxiety  86. • If headaches, visual symptoms or hearing loss/tinnitus develop, refer. • Mobilise as soon as possible.
• If recurrent episodes, refer • If hearing loss/tinnitus develop or
to psychologist. no better after 2 weeks, refer.

• If none of the above, check TSH. If abnormal, refer to doctor.

• Refer if no cause is found, dizziness persists despite above treatment or uncertain of diagnosis.

1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer.
29
 HEADACHE
Give urgent attention to the patient with headache and any of:
• Decreased consciousness 16 • Sudden severe headache or dizziness • Persistent headache since
• BP ≥ 180/110 and not pregnant 132 • Headache that is getting worse and more frequent starting ART
• Pregnant or 1 week postpartum, and BP ≥ 140/90 159 • Headache that wakes patient or is worse in the morning • Following a first seizure
• Sudden weakness/numbness of face/arm/leg or speech problem 136 • Neck stiffness, drowsy/confused or purple/red rash: meningitis likely • Recent head injury
• New vision problems or eye pain 31 • Persistent nausea/vomiting • Unequal pupils
Manage and refer urgently:
• If temperature ≥ 38°C or meningitis likely: give ceftriaxone 2g IV1/IM. Avoid injecting > 1g IM at one injection site.
• If in a malaria area in past 3 months and malaria test2 positive: give artesunate 2.4mg/kg IM. If artesunate unavailable, give quinine as slow IV infusion over 4 hours: dilute quinine 20mg/kg in 5%
dextrose 5-10mL/kg. If IV not possible, give IM3 diluted in sodium chloride 0.9%.

Approach to the patient with headache not needing urgent attention

Does patient have fever and body pain or recent common cold?

Yes No
Has patient had recent common cold and now any of: thick nasal/postnasal discharge, Does patient get recurrent headaches that are throbbing, disabling with
pain when pushing on forehead/cheeks, headache worse on bending forward? nausea or light/noise sensitivity, that resolve completely within 72 hours?

Yes No Yes No
Sinusitis likely • If in a malaria area in past 3 months, arrange Migraine likely • Check BP. If ≥ 140/90  132.
• Give paracetamol 1g 4-6 hourly (up same day malaria test2. If positive, malaria • Give paracetamol 1g 4-6 hourly (up to • Ask about type and site of pain:
to 4g in 24 hours) for up to 5 days. likely 24. 4g in 24 hours) or ibuprofen5 400mg
• Give sodium chloride 0.9% nose • If patient has a tick bite (small dark brown/ 8 hourly with food for up to 5 days. Tightness around Constant Patient > 50 years,
drops as needed. black scab) or tick present, tick bite fever likely • If nausea, also give metoclopramide head or generalised aching pain over temples
• Give oxymetazoline 0.05% 2 drops 24. 10mg 8 hourly up to 3 doses. pressure-like pain pain,
in each nostril 8 hourly for up to 5 • If none of above, treat as acute viral infection: • Advise to recognise and treat migraine tender
days. Advise against overuse which - Consider COVID-19  40. Advise patient to early, rest in dark, quiet room. Giant cell arteritis
Tension headache neck likely
may worsen blocked nose. isolate at home for 7 days from start of • Advise regular meals, keep hydrated, muscles
• If symptoms ≥ 10 days, fever ≥ 38°C, his/her symptoms. regular exercise, good sleep hygiene. likely • Check CRP.
purulent nasal discharge, facial pain - Advise to wear mask indoors and social distance. • Keep a headache diary to identify triggers • Give paracetamol 1g • Give paracetamol
≥ 3 days, or symptoms worsen after While unwell, avoid contact with elderly/those like lack of sleep, hunger, stress, caffeine, 6 hourly as needed Muscular 1g 4-6 hourly (up to
initial improvement, give amoxicillin with chronic diseases/groups, wash hands. chocolate, cheese. Avoid if possible. for up to 5 days. neck 4g in 24 hours) for
500mg 8 hourly for 5 days. If severe - Give paracetamol 1g 4-6 hourly (up to 4g in • Avoid oestrogen-containing • Assess for stress and pain up to 5 days.
penicillin allergy4, give instead 24 hours) as needed for up to 5 days. Explain contraceptives  154. anxiety  86. likely • Review next day: if
azithromycin 500mg daily for 3 days. antibiotics are not needed. Advise to rest and • If ≥ 2 attacks/month, refer/discuss for • Advise regular 64. CRP > 5, discuss with
• If recurrent, test for HIV  110. maintain hydration. medication to prevent migraines. exercise. specialist same day.
• If tooth infection or swelling over - Advise to return if worsening symptoms: if
sinus/around eye, refer same day. cough/difficulty breathing 38, if face pain Advise to use analgesia only when necessary. Overuse may cause headaches: if using analgesia > 2 days/week
32, if ear pain 33. for ≥ 3 months, advise to reduce amount used. Headache should improve within 2 months of decreased use.

If diagnosis uncertain or poor response to treatment, discuss/refer.

1
Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. 2Test for malaria with rapid diagnostic test if available, and parasite slide microscopy. 3To give IM quinine: first calculate volume of
sodium chloride 0.9% in mL: weight x 20 ÷ 100. Then add this volume of sodium chloride 0.9% to quinine 20mg/kg and inject half the volume into each thigh. 4History of anaphylaxis, urticaria or angioedema. 5Avoid ibuprofen if peptic ulcer, asthma,
hypertension, heart failure, kidney disease.
30
 EYE/VISION SYMPTOMS
Give urgent attention to the patient with eye or vision symptoms and any of:
• New sudden asymmetric weakness or numbness of face, arm or leg; difficulty speaking or • One painful red eye • Penetrating or metallic foreign body
visual disturbance: consider stroke or TIA 136. • Sudden loss or change in vision • Chemical burn
• BP ≥ 180/110 and not pregnant 132. (including blurred or reduced vision) • Corneal ulcer
• Pregnant or up to 1 week post-partum, and BP ≥ 140/90: treat as severe pre-eclampsia 159. • Shingles involving eye or nose • Hazy cornea
• Yellow eyes: jaundice likely 79. • Penetrating injury • Sudden drooping of eyelid
• Whole eyelid swollen, red and painful: orbital cellulitis likely • Eyelid laceration
Manage and refer urgently:
• If painful eye with redness, blurred vision, haloes around light, dilated unreactive pupil, headache or nausea/vomiting, acute glaucoma likely. Give acetazolamide orally 500mg, then 250mg 6 hourly.
• If orbital cellulitis likely, give ceftriaxone 2g IV1/IM. Avoid injecting > 1g IM at one injection site.
• If chemical burn: irrigate eye for at least 20 minutes with sodium chloride 0.9% or water. If pain, instil 1 drop tetracaine 1% eye drops to affected eye. Apply chloramphenicol 1% ointment 6 hourly.
• If penetrating or metallic foreign body: avoid removing. Cover gently. Avoid lying flat. If deep corneal/scleral injury and delay in transfer, instil 1 drop atropine 1% and chloramphenicol 1% ointment.
• If pain, give paracetamol 1g 4 hourly.

Approach to patient with eye/vision symptoms not needing urgent attention

Eyes discharging or watery. Red or swollen Superficial foreign body (FB) Poor vision
Is there a prominent itch? eyelid/s
• Wash out eye with clean water • Check vision
Yes No • Wash lid/s twice or sodium chloride 0.9%. using Snellen E
• If both eyes involved or patient has eczema, hayfever Is the discharge clear or pus? a day with warm • If FB not visible, use fluoroscein chart and pinhole
or asthma, treat for likely allergic conjunctivitis: water. stain and ultraviolet light. test:
- Help to identify and advise to avoid triggers2. Clear Pus • Give • Instil 1 drop tetracaine 1% eye - If vision
- Give oxymetazoline 0.025% eye drops 1-2 drops in chloramphenicol drops3 and gently remove FB improves when
each eye 6 hourly up to 7 days and advise to apply 1% ointment with moist cotton bud. looking through
cold compresses. If no better after 7 days: give instead Viral conjunctivitis likely Bacterial conjunctivitis likely 6 hourly for 7 days. • If under eyelid, pull top eyelid pinhole and
anti-allergy eye drops (e.g. olopatidine 0.1% 1 drop • Apply cold compresses. • Wipe eyes gently from inside • If yellow lump over bottom eyelid and service available,
12 hourly) for 1-3 months or long-term. • Give oxymetazoline to outside with clean cotton on eyelid, apply release. refer for glasses.
- If symptoms > 1 month, add cetirizine 10mg once 0.025% eye drops wool soaked in sodium frequent warm • Apply eye shield until - If vision no
daily until itch controlled. 1-2 drops 6 hourly up chloride 0.9% until pus clears. compresses. tetracaine has worn off. better with
- If recurrent nose problem, exclude allergic rhinitis to 7 days. • Give chloramphenicol 1% • Refer to eye OPD • Refer same day if: pinhole, service
 34. If recurrent skin problem, exclude urticaria • Infectious: only return ointment 6 hourly in each eye if: - Removal unsuccessful not available or
and eczema  67. If recurrent cough or wheeze, to work once better/no for 7 days. - Lump no better - Damage to eye unsure, refer for
exclude asthma  112. discharge. • Return to work after 2 days of with warm - Abnormal vision or eye full assessment.
• If one eye involved and no eczema, hayfever or treatment and no pus. compresses movement • Exclude diabetes
asthma, localised cause likely: wash eye with - Eyelashes - No better 24 hours after  17 and
clean water and try to identify and remove cause. • Avoid sharing towels/bedding. Wash hands often. touching cornea removal hypertension
Give oxymetazoline 0.025% eye drops 1-2 drops 6 • Give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) as - Eyelids bent  132.
hourly for 3 days. If no better after 24 hours, advise to needed for up to 5 days. in/out. • Test for HIV  110.
return: refer. • If no better after 5 days or one red eye for >1 day, refer.

1
Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. 2Common triggers include pollens, household pets, house dust mite, cockroaches and moulds. 3Strictly avoid giving tetracaine eye
drops to patient to take home as they can cause blindness if used too often.
31
 FACE SYMPTOMS
Give urgent attention to the patient with face symptoms and any of:
• New sudden asymmetric weakness or numbness of face (with no/minimal forehead involvement), arm or leg; difficulty speaking or visual disturbance: consider stroke or TIA 136.
• Sudden face/tongue swelling and any of: difficulty breathing, BP < 90/60, dizziness/collapse, abdominal pain, vomiting or exposure to possible allergen1, check for anaphylaxis  20.
• Painful red facial swelling and temperature ≥ 38°C: facial cellulitis likely
• New swelling of face and blood/protein in urine: kidney disease likely
Manage and refer urgently:
• If likely facial cellulitis with if whole eyelid swollen, red and painful, orbital cellulitis likely: give ceftriaxone 2g IV2/IM. Avoid injecting > 1g IM at one injection site.
• If kidney disease likely: if pulse > 100 or respiratory rate > 30, give face mask oxygen and furosemide 80mg slow IV, avoid IV fluids. If BP > 150/100, give amlodipine 5mg and furosemide 40mg orally.

Approach to patient with face symptoms not needing urgent attention

• If rash on face 67.
• If gum or tooth problem  36.
• Manage according to face symptom/s:

Face pain Sudden progressive weakness Swelling of face

of one side of face and unable
to wrinkle forehead or close eye.
Pain on one side of face Pain when pushing on forehead/cheeks, headache Painless swelling of lips/eyes Painful swelling of
May have impaired taste
worse on bending forward. Thick nasal/postnasal one/both sides of face
or dry eye.
discharge, recent common cold. with fever, headache,
Recurrent Previous shingles on Angioedema likely
body pain.
intense, same side of face • If airway obstruction, assess
Bell’s palsy likely
superficial, Sinusitis likely and manage airway  14
• Give prednisone as soon as
stabbing • Give paracetamol 1g 4-6 hourly (up to 4g in and manage for anaphylaxis Mumps likely
Post-herpetic possible (within 48 hours
pain 24 hours) as needed for up to 5 days.  20. • Give paracetamol
neuralgia likely of onset): give 60mg daily
• Give sodium chloride 0.9% nose drops as needed. • If no airway obstruction: 1g 4-6 hourly (up
• Give amitriptyline3 for 7 days. If no better after
• Give oxymetazoline 0.05% 2 drops in each nostril if urticaria or itch present, to 4g in 24 hours)
Trigeminal 25mg (or 10mg if ≥ 10 days, refer.
8 hourly as needed for a maximum of 5 days. Advise give cetirizine 10mg or as needed for up to
neuralgia likely 65 years) at night. If • Protect eye:
against overuse which may worsen blocked nose. promethazine 25-50mg IM. 5 days.
• Give no response, increase - Advise patient not to rub eye.
• If symptoms ≥ 10 days, fever ≥ 38°C, purulent nasal • If on enalapril: stop enalapril, • Advise patient
paracetamol by 25mg every - Keep eye moist with drops.
discharge, face pain ≥ 3 days, or symptoms worsen never restart and educate s/he can return to
1g 4-6 hourly 2 weeks, up to 75mg - Cover eye with transparent
after initial improvement of common cold, give patient to avoid it in future. work after 5 days
as needed. if needed. eye shield during the day, if
amoxicillin 500mg 8 hourly for 5 days. If severe Doctor to review medication. and that symptoms
• If needed, • f pain ≥ 4 weeks, available.
penicillin allergy4, give instead azithromycin • Help to identify and advise to usually resolve
add tramadol assess and advise - Tape eyelid closed at night.
500mg daily for 3 days. avoid triggers5. within 2 weeks.
50mg 6 hourly.  61. • Refer same day if:
• If recurrent, test for HIV  110. • Monitor until swelling resolves. • Refer if:
• Refer. • If poor response, refer. - Otitis media
• Refer if: • If swelling not resolving or no - Neck stiffness
- Change in hearing
- Tooth infection obvious cause, refer same day. - Painful scrotal
- Recent head injury
- Swelling over sinus or around eye • Record in patient’s notes. swelling
- Damage to cornea
- Neck stiffness • Advise to return urgently - Loss of hearing
- Unsure of diagnosis
- Poor response to treatment if difficulty breathing or - Abdominal pain
symptoms worsen.
1
Common allergens include medication, food or insect bite/sting within the past few hours. 2Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. 3Avoid if on bedaquiline. 4History of
anaphylaxis, urticaria or angioedema. 5Common triggers include foods (milk, eggs, nuts, wheat, seafood), medications, insect bites/stings and latex.
32
 EAR/HEARING SYMPTOMS
Ask about ear itch, discharge from ear, ear pain or difficulty hearing/tinnitus (ringing/buzzing in ear/s). Then look in ear.

Itchy ear Discharge from ear Painful ear Difficulty hearing or tinnitus

Redness, swelling Symptoms ≥ 2 weeks, Symptoms • If ear also itchy, consider otitis externa (see adjacent). • If on amikacin, discuss with TB doctor.
and/or pus in ear canal hole in eardrum for • Able to view eardrum? • If itchy/painful ear or discharge from ear,
< 2 weeks see adjacent column/s.
Yes No • Look in ear for foreign body and wax:

• If normal looking ear, Any of: Foreign Wax Normal looking ear
referred pain likely, check • Pain > 2 days body
mouth and face: • Pain that wakes patient at night
- If gum or tooth problem • Temperature ≥ 38°C in past 2 days • Syringe ear/s with
36. warm water.
©University of Cape Town - If painful swelling of • Avoid syringing and
©University of Cape Town Yes No
one/both sides of face, refer instead if:
Chronic suppurative mumps likely 32. - Hole in eardrum
Otitis externa likely - If pain in temporo- Treat for • Give paracetamol - Chronic suppurative ©University of Cape Town
otitis media likely
• Clean ear.1 mandibular joint, check acute 1g 4-6 hourly (up otitis media
• Clean ear1 repeatedly.
• After cleaning, instil for joint problem 62. otitis to 4g in 24 hours) • If unsuccessful after
• If poor response to • Arrange hearing test.
acetic acid 2% in • If red bulging eardrum, media: as needed for up 3 attempts or causes
treatment, test for • Look for cause: Ask about
alcohol 4 drops in ear acute otitis media likely: to 5 days. pain, stop and refer/
HIV  110 and TB prolonged exposure to
6 hourly for 5 days. • If no better in discuss with doctor.
 92. loud noise.
• Give paracetamol 1g 2 days, advise • If hearing no better
• Refer if: • Review medication: aspirin,
4-6 hourly (up to 4g in to return: treat after foreign body/
- No better after NSAIDs and furosemide.
24 hours) as needed for acute otitis wax removal, refer for
4 weeks • Refer if :
for up to 5 days. media: hearing test.
- Hole in eardrum - Sudden onset
• If severe pain, firm
large, not getting - One-sided
red swelling or
smaller after - Dizziness/vertigo
temperature ≥ 38°C,
3 months, or persists ©University of Cape Town - Patient taking amikacin
give flucloxacillin2
> 6 months.
500mg or cefalexin
- Difficulty hearing
500mg 6 hourly for 5 Acute otitis media likely How to syringe an ear
- Yellow/white
days. • Give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) as needed for up to 5 days. Fill a large syringe (50-200mL)
deposit on eardrum,
• Refer if: • Give amoxicillin2 1.5g 12 hourly for 5 days. If patient has had amoxicillin in last with warm water. Ask patient to
cholesteatoma
- No better after 30 days: give instead amoxicillin/clavulanic acid2 875/125mg 12 hourly for 5 days. hold container under ear against
likely.
5 days • If nose symptoms, consider and treat for allergic rhinitis  34. neck to catch water. Gently pull
• Refer same day if:
- Blisters on ear, • If discharge, clean ear1 and avoid getting ear wet. ear upwards and backwards to
- Painful swelling
herpes zoster likely • If recurrent episodes, test for HIV  110 and refer. straighten ear canal. Place tip of
behind ear,
- Red swollen painful • If no response to treatment after 3 days, refer. syringe at ear canal opening (no
mastoiditis likely
ear lobe, cellulitis • Refer same day if: neck stiffness or painful swelling behind ear, mastoiditis likely
- Neck stiffness further than 8mm into canal) and direct water spray
likely
upwards in ear canal.
1
Cleaning the ear (dry mopping): roll a piece of clean soft tissue into a wick. Carefully insert wick into ear with twisting action. Remove wick and replace with clean dry wick. Repeat until wick is dry when removed. Never leave wick or other object inside
ear. The ear can only heal if dry. 2If severe penicillin allergy (history of anaphylaxis, urticaria or angioedema), give instead azithromycin 500mg daily for 3 days.
33
 NOSE SYMPTOMS
Give urgent attention to the patient with nose symptoms and:
• Head injury with clear watery discharge from nose 18.
Refer urgently.

Approach to the patient with nose symptoms not needing urgent attention
Manage according to nose symptom/s:

Blocked/runny nose Bleeding nose

Ask about duration and associated symptoms:
• Firmly pinch nostrils together
Sore throat or fever Pain when pushing on forehead/ Recurrent sneezing or itchy/runny/blocked Runny nose for 10 minutes with patient
cheeks, headache worse on bending nose most days for > 4 weeks. May have with persistent sitting and leaning forward.
forward, recent common cold itchy eyes, ears or throat. cough, and/or • Check BP:
Acute viral infection likely
frequent throat - If < 90/60, give sodium
(like common cold, influenza or COVID-19)
clearing chloride 0.9% 1L IV rapidly,
• If temperature ≥ 38°C, chills or body pain, Sinusitis likely Allergic rhinitis likely
repeat until systolic BP > 90.
influenza or COVID-19 more likely. • Give paracetamol 1g 4-6 hourly • Help to identify and advise to avoid
Continue 1L 6 hourly. Stop if
- Assess for COVID-19  40. (up to 4g in 24 hours) as needed triggers2. Upper airway
breathing worsens.
• Advise to wear mask indoors and social for up to 5 days. • Give fluticasone3 nasal spray 100mcg cough
- If ≥ 140/90  132.
distance. While unwell, avoid contact with • Give sodium chloride 0.9% nose (1 spray) in each nostril twice a day. Advise syndrome
• If still bleeding, insert
elderly/those with chronic diseases/groups, drops as needed. patient to aim nozzle outwards and (postnasal drip)
bismuth iodoform paraffin
wash hands. • Give oxymetazoline 0.05% 2 upwards and avoid sniffing vigorously. likely
paste (BIPP) soaked ribbon
• Give paracetamol 1g 4-6 hourly (up to 4g in 24 drops in each nostril 8 hourly as • Give chlorphenamine 4mg 6-8 hourly • Check throat:
gauze into nostril/s:
hours) as needed for up to 5 days. needed for a maximum of 5 days. as needed for up to 5 days only when secretions or
- If bleeding stops, advise to
• Explain antibiotics are not needed. Advise to Advise against overuse which may symptoms worsen (side effect is sedation). cobblestone
return next day to remove
rest and maintain hydration. worsen blocked nose. • If nose very blocked at night, give appearance
BIPP gauze.
• Advise to return if worsening symptoms: if • If symptoms ≥ 10 days, fever oxymetazoline 0.05% 2 drops in each may be seen at
- If bleeding persists, refer
cough/difficulty breathing  38, if face pain ≥ 38°C, purulent discharge, face nostril at night for a maximum of 5 days. back of throat.
urgently.
 32, if ear pain  33. pain ≥ 3 days, or symptoms Advise against overuse which may worsen • Treat as for
• If patient on aspirin or
worsen after initial improvement, blocked nose. allergic
warfarin, doctor to review
give amoxicillin 500mg 8 hourly • If recurrent eye problem, exclude allergic rhinitis (see
medication and if on warfarin,
for 5 days. If severe penicillin conjunctivitis  31. adjacent
check INR.
allergy1, give instead azithromycin • If recurrent skin problem, exclude urticaria column).
• Advise to avoid nose-picking
500mg daily for 3 days. and eczema  67. • If no
and contact sport if recurrent
• If recurrent, test for HIV  110. • If recurrent cough or wheeze, exclude improvement
bleeds.
• If poor response to antibiotic, refer. asthma  123. after 2 weeks,
• If continually rubbing or itchy
• Refer same day if: • Review after 3 months: if symptoms still refer/discuss.
nose, consider allergic rhinitis
- Tooth infection not controlled despite good adherence to
(see adjacent).
- Swelling over sinus or around eye nasal spray, add cetirizine 10mg at night.
• If recurrent bleeds and no
- Neck stiffness • If symptoms severe and persist despite
improvement with above
treatment, refer.
management, refer.

1
History of anaphylaxis, urticaria or angioedema. 2Common triggers include pollens, household pets, house dust mite, cockroaches and moulds. 3If on lopinavir/ritonavir or atazanavir/ritonavir, avoid fluticasone, discuss/refer instead.
34
 MOUTH/THROAT SYMPTOMS
Give urgent attention to the patient with mouth/throat symptoms and any of:
• Red swelling blocking airway • If sudden face/tongue swelling and any of: wheeze, difficulty breathing, BP < 90/60,
• Unable to open mouth dizziness/collapse, abdominal pain, vomiting or exposure to possible allergen1, check
• Unable to swallow at all for anaphylaxis  20.
Refer urgently.

Approach to the patient with mouth/throat symptoms not needing urgent attention
• If on abacavir, check for abacavir hypersensitivity reaction (AHR)  116. If swelling of lips 32. If gum or tooth problem 36.
• Ask about dry mouth and swallowing problems. If food/liquid gets stuck with swallowing, refer.
• Wear a mask while examining the mouth and throat. Check for redness, white patches, blisters, ulcers or cracks:

Sore/red throat White patches on cheeks, Painful blisters Painful Red, cracked corners Dry mouth
gums, tongue, palate. on lips/mouth ulcer/s with of mouth
• Consider for COVID-19  40 if not already done. central white • If thirst, urinary
• Examine the patient's throat. Does patient have either of: Oral candida likely Herpes simplex patch Angular cheilitis/stomatitis frequency, weight
- Enlarged tonsils with pus/white patches on tonsils or • Give nystatin suspension likely likely loss, exclude diabetes
- Enlarged tonsils without cough or runny nose 100 000IU/mL (1mL) • Test for HIV Aphthous • Apply zinc and castor oil  17.
6 hourly after meal for  110. ulcer/s likely ointment 8 hourly. • If runny or blocked
No to both Yes to either 7 days. Keep inside mouth • Advise to rinse • Apply • If patient also has oral candida, nose  34.
for as long as possible. mouth with salt tetracaine treat as in adjacent column • Look for and treat
Continue for 2 days after water2 for one 0.5% gel and apply clotrimazole cream oral candida (see
Viral pharyngitis Bacterial pharyngitis/tonsillitis white patches resolved. minute twice a day. on ulcers 12 hourly for 2 weeks. adjacent).
likely likely • If on inhaled corticosteroids, • Apply petroleum 6 hourly. • If crusts and blisters around • Review medication:
Explain that • If ≤ 21 years old, give single dose advise to rinse mouth with jelly to blisters on • Refer if: mouth, impetigo likely  78. furosemide,
antibiotics are not benzathine benzylpenicillin 1.2MU water after use. lips. - Ulcer • If very itchy, contact amitriptyline,
necessary. IM3 or phenoxymethylpenicillin4 • Test for HIV  110 and • For pain, give > 1cm dermatitis likely. Identify and chlorphenamine,
500mg 12 hourly for 10 days. If diabetes  17. paracetamol 1g - Not healed remove irritant. antipsychotics and
penicillin allergy5, give instead • If patient has a life-limiting 6 hourly as needed within • If dentures, ensure good fit and morphine can cause
azithromycin 500mg daily for 3 days. illness, also consider giving for up to 5 days. 10 days advise to clean every night. dry mouth. Discuss
• If > 21 years old, advise to return if palliative care  170. • If extensive, apply • If on inhaled corticosteroids, with doctor.
symptoms persist/worsen: tetracaine 0.5% advise to rinse mouth after use. • Advise to sip fluids
discuss/refer. gel to blisters • If no better or uncertain of frequently. Sucking on
• If ≥ 6 episodes per year, refer for If difficulty or pain on
swallowing, oesophageal 6 hourly. cause: oranges, pineapple,
ENT assessment. • If HIV, give - Check Hb. If < 12g/dL lemon or passion fruit
candida likely:
• Give fluconazole 200mg aciclovir 400mg (woman) or < 13g/dL (man), may help.
• Give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) as daily for 14 days. 8 hourly for 7 days. anaemia likely  27. • If patient has a life-
needed for up to 5 days. • If HIV positive, start ART  111. • If severe or no - Test for HIV  110 and limiting illness, also
• Advise to gargle with salt water2 for 1 minute twice a day. • If no better, refer. better after 1 week diabetes  17. consider giving
of treatment, refer. - If still uncertain, refer. palliative care  170.

 137
Advise the patient with a sore mouth/throat to avoid spicy, hot, sticky, dry or acidic food and to eat soft, moist food. Keep mouth and teeth clean by brushing and rinsing regularly.
1
Common allergens include medication, food or insect bite/sting within the past few hours. 2Add 2.5mL (½ teaspoon) of table salt to 200mL lukewarm water. 3For benzathine benzylpenicillin 1.2MU injection: dissolve benzathine benzylpenicillin 1.2MU
in 3.2mL lidocaine 1% without epinephrine (adrenaline). 4If phenoxymethylpenicillin not available, give instead amoxicillin 1g 12 hourly for 10 days. 5History of anaphylaxis, urticaria or angioedema.
35
 GUM/TEETH SYMPTOMS
Give urgent attention to the patient with gum/teeth symptoms and any of:
• Temperature ≥ 38°C and swelling of face/jaw/next to tooth
• Unable to eat or drink
• Tooth pain that is felt without touching tooth/gum or that wakes patient at night
Refer urgently. © BMJ Best Practice

Approach to the patient with gum/teeth symptoms not needing urgent attention:
• Is there tooth pain, red or bleeding/enlarged gums?
• Look in mouth: lift lips to look at teeth and gums:

Brown/black staining of teeth at gumline, Gums red/bleeding or enlarged Previous/current tooth pain with pus in mouth,
holes, pits or missing teeth. May have tooth swelling next to tooth
pain with hot or cold food/drink.

© BMJ Best Practice

Gum problem likely

• Advise patient to care for his/her mouth (below).
• Review medication: phenytoin and amlodipine may cause gum
overgrowth. Discuss with doctor.
• Rinse mouth with salt water mouthwash1 for 1 minute twice a day.
• If no better with good mouth care, rinse with chlorhexidine 0.2%
© BMJ Best Practice
mouthwash twice a day for 5 days, after brushing teeth:
© University of Cape Town
- Swirl in mouth but do not swallow.
Dental caries likely - Avoid repeated use as can damage teeth.
• Advise patient to care for his/her mouth (below). - Advise to avoid eating/drinking for 30 minutes after rinsing. Dental abscess likely
• Refer to dentist. • Give as needed for pain paracetamol 1g 4-6 hourly (up to 4g in 24 • Give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) for
hours) for up to 5 days. up to 5 days.
• Refer to dentist if: • Give amoxicillin 500mg 8 hourly for 5 days. If penicillin
- No better after 5 days allergic, give instead azithromycin 500mg daily for 3 days.
- Foul-smelling breath • Give metronidazole2 400mg 8 hourly for 5 days.
- Swollen gums • Refer to dentist.
- Temperature ≥ 38°C • Advise to return and refer urgently if symptoms worsen,
- Mobile teeth temperature ≥ 38°C or no better after 2 days.
- Loss of gum or bone around tooth • Refer same day if > 65 years, alcohol/drug misuse, HIV or
- HIV or diabetes diabetes.

Advise the patient with gum/teeth symptoms to care for his/her mouth
• Advise a healthy diet  11.  136
• Advise to brush and floss teeth twice a day.
• If dentures, advise to clean thoroughly every day. If poorly fitting dentures or discomfort, refer to dentist.
• Ask about smoking and alcohol/drug use. If patient smokes, encourage to stop  141. If alcohol/drug use  142.
1
Mix ½ teaspoon salt in ½ cup lukewarm water. 2Advise no alcohol until 24 hours after last dose of metronidazole.
36
 CHEST PAIN
Give urgent attention to the patient with chest pain and any of:
• Respiratory rate ≥ 30 or difficulty breathing • Severe pain • Nausea or vomiting • At risk of heart attack (diabetes,
• BP ≥ 180/110 or < 90/60 • New pain or discomfort in centre or left side of chest • Pallor or sweating smoker, hypertension, high cholesterol,
• Pulse irregular, > 100 or < 50 • Pain radiates to neck, jaw, shoulder/s or arm/s • Known with ischaemic heart disease known CVD risk > 20%, family history)
Do an ECG.

ECG abnormal ECG normal/other abnormalities or unavailable or uncertain

(ST elevation, ST
depression or left Is chest pain worse on lying down, palpation or breathing deeply?
bundle branch block )
No Yes

Ischaemic heart disease likely 137. Manage and refer urgently:

• If oxygen saturation < 94%, oxygen saturation not available, respiratory rate ≥ 30 or difficulty breathing, give face mask oxygen.
• If sudden breathlessness, more resonant/decreased breath sounds/pain on one side, deviated trachea: tension pneumothorax likely:
- Doctor to insert large bore cannula above 3rd rib in mid-clavicular line and arrange urgent chest tube.
• If BP < 90/60, give sodium chloride 0.9% 500mL IV over 30 minutes, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens.
• If BP > 180/130, give single dose amlodipine 10mg orally.
• If chest pain worse on breathing deeply, coughing sputum and temperature ≥ 38°C, give ceftriaxone 1g IV1/IM to cover for severe pneumonia.

Approach to the patient with chest pain not needing urgent attention:
• If recurrent episodes of central chest pain, brought on by exertion and relieved by rest, ischaemic heart disease likely 137.
• If cough, fever or pain on breathing deeply  38.
• If ongoing chest pain after an acute COVID-19 infection 42.
• Ask about site of pain and associated symptoms:

Retrosternal or epigastric pain with eating, hunger or lying down/bending forward Tender at costochondral junction, Burning pain
no fever or cough on one side of
body with or
Dyspepsia (heartburn) likely
without rash
• Advise to stop NSAIDS (ibuprofen/aspirin), quit smoking  141, limit alcohol, caffeine, spicy food, fizzy drinks, late night meals. Musculoskeletal problem likely
• If waist circumference > 80cm (woman) or 94cm (man), assess CVD risk  127. • Give ibuprofen 400mg 8 hourly with
• Give lansoprazole2 30mg daily for up to 14 days. food for up to 5 days (avoid if peptic Herpes zoster
• Refer same week if any of: no better after 7 days treatment, symptoms return, painful/difficulty swallowing, persistent ulcer, asthma, hypertension, heart (shingles)
vomiting, abdominal mass, blood in vomit or stool (occult blood positive), weight loss, Hb < 12 (woman) or < 13 (man), new failure or kidney disease). likely 68.
pain and > 50 years, or family history of stomach/oesophageal cancer. • If pain persists > 4 weeks, refer.

If diagnosis uncertain, refer same week.

1
Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. 2Avoid if on atazanavir/ritonavir. Discuss with specialist.
37
 COUGH OR DIFFICULTY BREATHING
Give urgent attention to the patient with cough or difficulty breathing and any of:
• Wheeze/tight chest 39 • BP < 90/60 • Oxygen saturation < 92% at rest, or sats • Sudden breathlessness, more resonant/decreased
• Difficulty breathing worse on lying flat and • Breathless at rest or while talking drop to < 87% on exertion (walking 15-20m) breath sounds/pain on 1 side, deviated trachea,
leg swelling: heart failure likely 135 • Respiratory rate ≥ 30 • Coughs ≥ 1 tablespoon fresh blood BP < 90/60: tension pneumothorax likely
• Confused or agitated • Pulse > 120 • Swelling and pain in one calf
Manage and refer urgently:
• If short of breath or oxygen saturation < 95%, give oxygen: 1-4L/min via nasal prongs or 6-10L/min via facemask (up to 10-15L/min via non-rebreather mask). Aim for oxygen saturation ≥ 90%.
• If tension pneumothorax likely: insert large bore cannula above 3rd rib in mid-clavicular line. Arrange urgent chest tube.
• If BP < 90/60, give sodium chloride 0.9% 500mL IV over 30 minutes, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens.
• If rapid deep breathing, check glucose: if ≥ 11.1 17.
• Check temperature: if referral delay > 2 hours, temperature ≥ 38°C and respiratory rate ≥ 30, give ceftriaxone1 1g IV/IM to treat for possible severe bacterial pneumonia.

Approach to the patient with cough or difficulty breathing not needing urgent attention
• Test for HIV  110. If on abacavir, check for abacavir hypersensitivity reaction (AHR)  116.
• Test for TB: send 1 sputum sample for TB NAAT  92.
• If patient smokes, encourage to stop  141.
• Manage further according to duration and recurrence of cough or difficulty breathing:

Patient has had cough < 2 weeks and it is not recurrent. Patient has had cough/difficulty breathing ≥ 2 weeks or has recurrent episodes

Is patient coughing sputum with any of: pulse rate ≥ 100, respiratory rate ≥ 20 or temperature ≥ 38°C? • If itchy/blocked nose, or or frequent throat clearing, consider underlying nose problems  34.
• Also consider asthma and COPD  123 and other cause for cough or difficulty breathing:
No Yes
Acute viral infection likely Pneumonia likely HIV with CD4 < 200 and dry Persistent Recent upper Smoker or
• If recent cold and now tight/ • Confirm on chest x-ray or with crackles/bronchial breathing cough, shortness of breath. snoring or respiratory tract recently stopped
sore chest or coughing sputum, on auscultation. poor sleep infection, no
acute bronchitis likely. • If poor adherence likely or access to urgent care difficult, refer. Pneumocystis pneumonia (PJP) difficulty breathing • If weight loss,
• If fever, chills or body pain, • Any of: HIV, > 65 years, lung/heart/liver/kidney disease, diabetes likely Obstructive consider lung
influenza or COVID-19 more or alcohol misuse? • Doctor to confirm on sleep apnoea Post-infectious cancer  23.
likely. Assess for COVID-19 chest x-ray. likely cough likely • If coughing
 40. Yes: give amoxicillin/clavulanic acid2 No: give amoxicillin2 • Give co-trimoxazole • If overweight • Reassure cough sputum
• Advise that antibiotics are not 875/125mg 12 hourly for 5 days. 1g 8 hourly for 5 days. 320/1600mg, 6 hourly for  127. should resolve on most days of
needed. If pain/fever: give 3 weeks. If < 56kg, reduce dose3. • Refer if: its own. 3 months for ≥
paracetamol 1g 4-6 hourly (up • Give HIV routine care  111. enlarged tonsils, • Advise to return 2 years, chronic
• If pain/fever: give paracetamol 1g 4-6 hourly (up to 4g in
to 4g in 24 hours) for up to 5 • Refer same day if: x-ray atypical/ stops breathing/ if cough persists bronchitis
24 hours) for up to 5 days. Advise rest and hydration.
days. Advise rest and hydration. unavailable or respiratory chokes/gasps > 8 weeks. likely. Discuss.
• Review in 2 days: if no better, refer. Advise to return if worse.
• Advise to return if symptoms rate >24. while sleeping.
• If > 50 years: repeat chest x-ray after treatment to ensure
worsen, a new fever develops
pneumonia resolved.
or no better after 2 weeks.

If diagnosis uncertain or poor response to treatment, refer. If patient has life-limiting illness, also consider giving palliative care  170.
1
Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. 2If penicillin allergy, give instead moxifloxacin 400mg daily for 5 days. 3If < 40kg, give 160/800mg; if 40-56kg, give 240/1200mg; if ≥ 56
kg, give 320/1600mg.
38
 WHEEZE/TIGHT CHEST
• If sudden wheeze/tight chest and any of: generalised itch/rash, face/tongue swelling, BP < 90/60, dizziness/collapse, abdominal pain, vomiting or exposure to possible allergen1, check for anaphylaxis  20.
• If difficulty breathing worse on lying flat and leg swelling, heart failure likely 135.

Give urgent attention to the patient with wheeze/tight chest:

Assess severity of episode:
Any of: respiratory rate > 30, pulse > 120, unable to talk in full sentences, using accessory muscles, silent chest (tight chest but no wheeze), agitated, drowsy or confused?

No Yes

Mild or moderate Severe

• Give inhaled salbutamol via spacer 400-800mcg (4-8 puffs) or nebulise 1mL salbutamol 0.5% solution in 4mL sodium chloride 0.9%,
with oxygen at flow rate of 8L/minute. If no better, repeat salbutamol every 20 minutes during first hour.
• If known asthma or COPD, give prednisone 40mg orally.
• Monitor response regularly:

Improving or no change after 1 hour of treatment Worsening despite treatment

Check respiratory rate. Can patient talk normally?

Able to talk normally and respiratory rate < 20 Unable to talk normally or has
respiratory rate ≥ 20
Wheeze/tight chest Wheeze/tight chest still present
resolved • Refer urgently.
• Repeat salbutamol every 2-4 hours as needed. • While awaiting transport:
• Is wheeze/tight chest still present after - Give 40% face mask oxygen (if known COPD, give 24-28% face mask oxygen) while preparing
3 hours of treatment? nebuliser and between nebulisations/doses.
- Nebulise 1mL salbutamol 0.5% solution in 4mL sodium chloride 0.9% with oxygen at flow rate of
No Yes 8L/minute, every 20 minutes (or continuously if needed). If nebuliser unavailable, give instead
inhaled salbutamol via spacer 400-800mcg (4-8 puffs) every 20 minutes.
- If not already given, give single dose prednisone 40mg orally. If unable to take oral medication,
• If first episode of wheeze/tight chest, assess Continue salbutamol give single dose hydrocortisone 100mg IM/slow IV.
for asthma and COPD 123. every 2-4 hours as - If poor response to salbutamol, add 2mL (0.5mg) ipratropium bromide solution to salbutamol
• If known asthma/COPD, give routine care: if needed and refer. nebuliser every 20 minutes for 3 doses only. If nebuliser unavailable, add instead inhaled ipratropium
asthma 125, if COPD 126. bromide via spacer 80-160 mcg (2-4 puffs), every 20 minutes as needed for up to 3 hours.

1
Common allergens include medication, food or insect bite/sting within the past few hours.
39
 COVID-19 DIAGNOSIS
• Suspect COVID-19 in the patient with new onset of symptoms in the last 14 days, consistent with COVID-19: fever, cough, shortness of breath (new or worse than before), sore throat, loss of sense of
smell, taste abnormalities, runny/blocked nose, fatigue, chest pain, body aches, headache, diarrhoea.
• COVID-19 is more likely if current prevalence is high and the patient has not yet received a COVID-19 vaccine.

Give urgent attention to the patient with suspected COVID-19 and any of:
• Short of breath at rest or • Oxygen saturation < 92% at rest, or sats • BP < 90/60 • Sudden breathlessness, more resonant/decreased breath sounds/pain
while talking drop to < 87% on exertion (walking 15-20m) • Confused, agitated or on 1 side, deviated trachea, BP < 90/60: tension pneumothorax likely
• Respiratory rate ≥ 30 • Pulse rate > 120 decreased consciousness • Coughing up fresh blood
Manage and refer urgently 38.

Approach to the patient with suspected COVID-19 not needing urgent attention

Check if COVID-19 test should be done.

Testing strategy changes according to burden of infection - decide who is eligible for a test according to current testing strategy at your facility (check latest circular):

Universal testing Limited testing

Test patients Test if in clusters in group settings or at risk of severe COVID-19 - usually during a ‘wave’ of COVID -19 infections, when testing capacity is limited.
with COVID-19
symptoms referred Is patient part of a cluster in group settings such as old age/care homes, hospitals, or prisons?
to hospital -
usually only
available between Yes No
waves of COVID
infection, when Is patient a health care worker or does patient have any of these risk factors for severe COVID-19?
testing capacity is • > 60 years old • Heart disease • Chronic kidney disease
not limited. • Diabetes • HIV (if not on ARVs) • Chronic lung disease (like asthma, COPD)
• Obesity (BMI1 ≥ 30) • TB (current or previous) • Cancer

Yes No

Test for COVID-19. • Explain that capacity for COVID-19

• If possible, collect 2 upper respiratory swabs, preferably nasopharyngeal swabs: one rapid antigen test swab for on- testing is limited and based on his/
site testing and one swab to send to laboratory for PCR testing if rapid antigen test negative. her symptoms, it is likely that s/he
• If symptoms include cough, fever or fatigue, also test for TB: send 1 sputum sample for TB NAAT  92. has COVID-19 infection.
• If symptoms include cough, fever
Rapid antigen test positive Rapid antigen test negative Rapid antigen test or fatigue, also test for TB: send
• Diagnose acute COVID-19 • If currently high number of COVID-19 cases ('wave'): send confirmatory PCR swab. unavailable/inconclusive 1 sputum sample for TB NAAT
 41. No need to send • If currently low number of COVID-19 cases: consider patient COVID-19 negative. Send swab for PCR testing.  92.
PCR swab. • Manage empirically for likely
• Notify. COVID-19 41.
If PCR swab sent, advise to isolate and manage as presumptive COVID-19 until PCR swab result are back 41.
1
BMI = weight (kg) ÷height (m) ÷height (m).
40
 ACUTE COVID-19
Assess the patient with acute COVID-19 infection or likely infection (presumptive COVID-19)
Assess Note
Symptoms Manage symptoms as on symptom pages.
Chronic condition/s • If patient has chronic condition, check that it is well controlled. Specifically ask if patient has diabetes.
• If known diabetes and no HbA1c result in past 3 months: take HbA1c and creatinine today.
Best place for care • If known diabetes and any of: ≥ 60 years, chronic kidney disease, random fingerprick glucose > 11 with ketones present in urine or patient known with very poor glucose control (HbA1c > 10%)
and another risk factor such as: BMI1> 30, hypertension, ischaemic heart disease, peripheral vascular disease, previous stroke/TIA, HIV, TB, cancer, chronic respiratory disease, discuss referral for
early admission.
Diabetes screen If not known with diabetes and any of: BMI1 ≥ 30, hypertension, family history of diabetes (parent/sibling), symptoms suggestive of diabetes2 or diabetes during pregnancy, check glucose  17.

Advise the patient with acute COVID-19 infection or likely infection (presumptive COVID-19)
• Advise patient to inform household members to use strict hygiene and prevention measures and monitor themselves for symptoms. Close contacts no longer need to quarantine or isolate, even if
symptoms develop. Advise to use a mask and avoid indoor social gatherings as much as possible for at least 5 days.
• Advise the patient with known diabetes:
- Explain that s/he is at risk of severe COVID-19. Advise to go to nearest emergency centre if s/he develops shortness of breath, weakness or high fevers/chills.
- Advise to check glucose each morning upon waking and keep a record: if fasting glucose persistently ≥ 8, advise to return for review of insulin doses.
• Check patient understands to monitor symptoms at home (see red box below).
• Check patient understands how to safely isolate. Refer to community-based services for follow up if available.
• Provide medical certificate for sick leave for 7 days from date that symptoms started. This may need to be extended.
• Explain that patient may discontinue isolation 7 days after date that symptoms started. If symptoms have not resolved by 7 days, advise to continue isolating until 10 days completed.

Treat the patient with acute COVID-19 infection or likely infection (presumptive COVID-19)
For fever/pain, advise to take paracetamol 1g 4-6 hourly (up to 4g in 24 hours) orally as needed, rather than NSAIDS4. If using NSAIDS4 for other condition/s, avoid discontinuing.

Review the patient with acute COVID-19 infection or likely infection (presumptive COVID-19)
Advise that there is no need to return to facility unless condition worsens. Advise to return for TB test if cough persists ≥ 2 weeks. Ensure correct contact details. Include a second phone number.

Advise to return urgently to health facility if:

Shortness of breath, difficulty breathing, persistent chest pain/pressure, new confusion or worsening drowsiness.

1
BMI = weight (kg) ÷height (m) ÷height (m). 2Weight loss, thirst (especially at night) or passing excessive amounts of urine often. 3Non-steroidal anti-inflammatory drugs (like ibuprofen).
41
 ONGOING COVID-19 SYMPTOMS
• Manage the patient with COVID-19 symptoms that have lasted for more than 4 weeks.
• Common ongoing symptoms include: tiredness, breathlessness, cough, smell/taste abnormalities, headache, dizziness, cognitive slowing (‘brain fog’), joint/muscle pain and chest pain.
• Confirm that patient had COVID-19: either positive COVID-19 test or a typical history of COVID-19. If no positive test and uncertain about COVID-19 history, discuss with specialist.

Give urgent attention to the patient with ongoing COVID-19 symptoms and any of:
• Respiratory rate ≥ 25 • New sudden asymmetric weakness or numbness of face, arm or leg; difficulty speaking or
• Oxygen saturation < 95% visual disturbance: consider stroke or TIA 136
• Temperature ≥ 38°C • If difficulty breathing worse on lying flat and leg swelling, heart failure likely  135
• Pulse rate > 120 • Decreased consciousness or new onset confusion/agitation
• BP < 90/60 • Coughing up fresh blood
• Headache with vomiting • Swollen painful calf
• Severe or new chest pain  37
Manage and refer urgently  38.

Approach to the patient with ongoing COVID-19 symptoms not needing urgent attention:
• If known with a chronic condition, check control and give routine care.
• Test for TB if current cough, weight loss ≥ 1.5kg, drenching night sweats, fever or fatigue: send 1 sputum sample for TB NAAT  92.
• If stress, anxiety or low mood, assess and manage further  86.

Ask about duration of symptoms:

< 2 months ≥ 2 months

• Reassure that many people have ongoing COVID-19 First check for pregnancy, HIV, diabetes and anaemia:
symptoms, even in mild cases.
• Explain that symptoms usually resolve slowly with time.
Check for pregnancy Check for HIV Check for diabetes Check for anaemia
• Advise to rest and pace activity.
If woman of child bearing age, exclude If HIV status is unknown or Check fingerprick Check fingerprick Hb. If < 12
• Treat pain with paracetamol 1g 4-6 hourly (up to 4g in 24
pregnancy  157. negative, test for HIV  110. glucose and (woman) or < 13 (man),
hours) or ibuprofen 400mg 8 hourly with food as needed for
interpret  17. anaemia likely  27.
up to 5 days.
• Extend sick leave as needed.
If chest pain, joint pain, headache, dizziness, manage as on symptom pages.
• If symptoms persist, advise to return for review.
• Advise when to return urgently: see red box below. If none of above or symptoms persist despite treatment, Long COVID likely, give routine care  121.

Advise to return urgently if breathlessness worsens, new or worsening confusion or unable to wake patient,
chest pain or pressure that won’t go away, new sudden weakness or numbness in face, leg or arm.

42
 BREAST SYMPTOMS
Approach to the patient with a breast symptom who is not breastfeeding

Breast lump/s Breast pain Nipple discharge/retraction Breast enlargement

Any of: patient > 25 years, family history of breast cancer, irregular fixed • Reassure that pain is unlikely due to breast cancer. • Refer to breast clinic/Regional • If only one breast
lump, skin/nipple changes, nipple discharge or axillary lymph node? • If lump/s, see adjacent. Breast Unit same week if any of: enlarging, refer to breast
• Exclude pregnancy  157. - Blood-stained clinic/Regional Breast
Yes No - One-sided discharge Unit.
- Patient ≥ 50 years • Check if this is obesity.
- Male If BMI1 > 25 assess CVD
Refer One breast Both breasts - Skin/nipple changes risk  127.
same - Breast/axillary lump • Review medication:
week to Re-examine Fibrocystic change likely • If pregnant, reassure and give antipsychotics,
a breast breast on day 7 of • Pain usually occurs before period and improves with period. antenatal care  160. antidepressants, efavirenz,
clinic/ menstrual cycle. • Reassure this is common and advise a well-fitting bra. • Review medication: nifedipine, amlodipine can
Regional If lump persists, • If pain, give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) as needed with food for up to 5 days. antipsychotics, antidepressants, cause breast enlargement.
Breast refer to breast • May be a side effect of hormonal contraception. If no better after 3 months on contraception, oral contraceptive and Discuss with doctor.
Unit. clinic/Regional change method  154. metoclopramide can cause nipple If on efavirenz, doctor
Breast Unit within • Advise to return if symptoms change/worsen: refer to breast clinic/Regional Breast Unit within discharge. Discuss with doctor. to consider switching
21 days. 60 days. • If cause uncertain, refer. medication  117.

Approach to the patient with a breast symptom who is breastfeeding

Painful/cracked nipples Painful breast/s without lump Painful breast/s with lump

• Usually due to poor latching: help to latch Temperature ≥ 38°C or body pain? Temperature ≥ 38°C or body pain?
baby properly.
• Avoid using soap on nipples. Yes: mastitis likely No No Yes
• Advise to apply breastmilk to nipples after • Give flucloxacillin3 500mg 6 hourly for 5 days and paracetamol
feeding and expose to air. Apply zinc and 1g 4-6 hourly (up to 4g in 24 hours) as needed for up to 5 days.
castor oil ointment between feeds. Engorgement Blocked duct Breast
• Advise warm compresses. likely likely abscess
• If no better after 2 days or breast lump (abscess) develops, refer. likely
• Advise frequent breastfeeds, warm
• If HIV negative, advise to continue breastfeeding. compresses and to gently massage breast. Refer same
• If HIV positive: if only one breast affected, express and discard milk from this side. Continue breastfeeding from other side. • Advise to return if fever/body pain day.
- If both breasts affected, advise to temporarily stop feeding from breast, express, heat-treat2 milk, and cup-feed baby until cracks/mastitis develops or if breast lump persists:
resolve. If heat treating not possible: explore circumstances at home to assess safety of formula feeding. If barriers to safe formula feeding, consider other causes and discuss/refer.
advise to continue breastfeeding and emphasize importance of strict ART adherence and viral suppression.

Refer to breastfeeding counsellor/lactation consultant or support group. If HIV positive, give routine HIV care  111 and prevent transmission to baby  168.

1
BMI = weight (kg) ÷ height (m) ÷ height (m). 2Heat-treat milk to rid it of HIV and bacteria: place breastmilk in sterilized glass jar. Close lid and place in pot. Fill pot with water 2cm above milk and heat water. Remove jar when water is rapidly boiling. 3If
severe penicillin allergy (history of anaphylaxis, urticaria or angioedema), give instead azithromycin 500mg daily for 3 days.
43
 ABDOMINAL PAIN
Give urgent attention to the patient with abdominal pain and any of:
• Chest pain 37 • Pain in right lower abdomen with nausea/vomiting/fever: appendicitis likely
• Pregnant 159 • Guarding, rigidity or rebound tenderness: peritonitis likely
• Recent delivery/miscarriage/termination of pregnancy 164 • Severe pain in right upper abdomen with nausea/fever/loss of appetite: cholecystitis likely
• Glucose ≥ 11.1 17 • Sudden severe upper abdominal pain spreading to back with nausea/vomiting: pancreatitis likely
• Unable to pass urine 59 • No stools or flatus/wind for past 24 hours
• Jaundice • If sudden abdominal pain and any of: generalised itch/rash, face/tongue swelling, difficulty breathing, BP < 90/60,
• Abdominal or pelvic mass dizziness/collapse or exposure to possible allergen1 check for anaphylaxis  20.
• Pulsatile abdominal mass: abdominal aortic aneurysm likely
Manage and refer urgently:
• If abdominal aortic aneurysm likely: avoid giving IV fluids even if BP < 90/60 (raising blood pressure may worsen rupture).
• If BP < 90/60 or pancreatitis likely, give sodium chloride 0.9% 500mL IV over 30 minutes, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens.
• If pain severe, give morphine 10mg IM or diluted morphine2 3-10mg slow IV: start with 3mL IV over 3 minutes. If needed, give another 1mL/minute until pain improved, up to 10mL. Stop if BP
drops < 90/60.

Approach to the patient with abdominal pain not needing urgent attention:
• If cramping abdominal pain with recent onset vomiting, diarrhoea, loss of appetite, body pain or fever, gastroenteritis likely 45.
• If on ART, check for urgent side effects  116.
• If urinary symptoms (burning/frequency/urgency) or leucocytes/nitrites/blood on dipstick 59.
• Is pain in the lower abdomen and is patient a woman?

Yes No
• Exclude pregnancy  157. If pregnant, refer urgently same day. Does patient have epigastric pain which is worse with eating,
• If crampy lower abdominal pain only during periods, dysmenorrhoea likely 56. hunger or lying down/bending forward?
• Ask about abnormal vaginal discharge and do pelvic examination to check for pain on moving cervix:
No Yes
Abnormal vaginal discharge or pain on moving the cervix No abnormal discharge and
no pain on moving Dyspepsia (heartburn) likely
Treat for lower abdominal pain (LAP) syndrome: the cervix • Advise to stop NSAIDS (e.g. ibuprofen/aspirin), stop smoking  141, limit
• If temperature ≥ 38°C, pulse > 100 or BP < 90/60: give IV fluids as above, alcohol, caffeine, spicy food, fizzy drinks, late night meals.
ceftriaxone 1g IV3/IM and metronidazole4 400mg orally and refer same day. • If weight loss  23. • In past year, has patient: 1) drunk ≥ 4 drinks8/session, 2) used illegal drugs
• Assess and advise patient  49. • If recurrent pain/discomfort and or 3) misused prescription or over-the-counter medications? If yes to any
• Give single dose ceftriaxone 250mg IM5 and azithromycin 1g and ≥2 of: pain relieved with passing stool,  142.
metronidazole4 400mg 12 hourly for 7 days. If severe penicillin allergy6, omit abdominal distension, change in stool • If waist circumference > 80cm (woman) or 94cm (man), assess CVD risk  127.
ceftriaxone and increase azithromycin dose to 2g. frequency/appearance, mucous in stool, • Give lansoprazole9 30mg daily for 14 days.
• For pain, give ibuprofen7 400mg 8 hourly with food for up to 5 days. irritable bowel syndrome (IBS) likely. • Refer same week if any of: Hb < 12 (woman) or < 13 (man), new pain and
• Give partner notification slip/s with code: LAP. Refer to doctor to confirm diagnosis and > 50 years, or family history of stomach/oesophageal cancer.
• Advise to return if no better within 3 days or urgently if worse: refer. dietician for dietary advice. • Advise to return if: no better after 7 days, symptoms return, difficulty
Otherwise, review in 7 days. • If constipated 48. If diarrhoea 46. swallowing, persistent vomiting, blood in vomit or stool, weight loss. Refer.

If no better or diagnosis uncertain, discuss/refer.

1
Common allergens include medication, food or insect bite/sting within the past few hours. 2Dilute 10mg morphine with 9mL of sodium chloride 0.9%. 3Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and
after IV ceftriaxone. 4Advise no alcohol until 24 hours after last dose of metronidazole. 5For ceftriaxone 250mg IM injection: dissolve 250mg in 0.9mL lidocaine 1% without epinephrine (adrenaline). 6History of anaphylaxis, urticaria or angioedema. 7Avoid
if peptic ulcer, asthma, hypertension, heart failure or kidney disease. 8One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer. 9If HIV positive on atazanavir/ritonavir, avoid lansoprazole, discuss/refer.
44
 NAUSEA/VOMITING
Give urgent attention to the patient with nausea/vomiting and any of:
• Headache 30 • Guarding, rigidity or rebound tenderness: • Jaundice
• Chest pain 37 peritonitis likely • Abdominal pain/distention and no stools or flatus/wind
• If patient has watery diarrhoea (with or without • Tender in right lower abdomen: appendicitis likely • Drowsy/confused/rapid deep breathing
vomiting) and has been in cholera outbreak area • Sudden severe upper abdominal pain spreading • If sudden nausea/vomiting and any of: generalised itch/rash, face/tongue
in past 5 days, cholera likely 47 to back: pancreatitis likely swelling, wheeze, difficulty breathing, BP < 90/60, dizziness/collapse or
• Neck stiffness, drowsy/confused or purple/red • BP < 90/60 exposure to possible allergen1, check for anaphylaxis  20.
rash: meningitis likely • Vomiting blood
Manage and refer urgently:
• If BP < 90/60 or pancreatitis likely, give sodium chloride 0.9% 500mL IV over 30 minutes, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens.
• If meningitis likely, give ceftriaxone 2g IV2/IM. Avoid injecting > 1g IM at one injection site.
• If pain severe, give morphine 10mg IM or diluted morphine3 3-10mg slow IV: start with 3mL IV over 3 minutes. If needed, give another 1mL/minute until pain improved, up to 10mL. Stop if BP
drops < 90/60.
• If glucose < 3 or ≥ 11.1  17 or if diabetes and glucose < 4  130.

Approach to the patient with nausea/vomiting not needing urgent attention

• If thirst, dry mouth, poor skin turgor or pulse ≥ 100, dehydration likely, give single dose metoclopramide 10mg orally/IM/IV. Then give oral rehydration solution and observe: encourage small
frequent sips. Aim for 1-2L in first 2 hours. If vomits, wait 10 minutes and try again more slowly.
• If unable to drink or no better after 2 hours, give sodium chloride 0.9% 500mL IV over 30 minutes and refer.
• Exclude pregnancy  157. If pregnant, reassure that nausea/vomiting is common in first trimester. Encourage to eat smaller meals more frequently and drink fluids regularly.
• If associated dizziness  29.
• Review medication: NSAIDs (e.g. ibuprofen), metformin, contraceptives, hormone therapy, chemotherapy and morphine can cause nausea/vomiting. Discuss with doctor. If on DS-TB medication
 96, RR-TB medication  104 or ART  116.
• Screen for alcohol/drug use: in the past year, has patient: 1) drunk ≥ 4 drinks4/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.

Is there recent onset vomiting with cramping abdominal pain, diarrhoea, loss of appetite, body pain or fever?

Yes No

Gastroenteritis likely Does patient have epigastric pain which is worse with eating, hunger or lying down/bending forward?
• If nausea/vomiting, give metoclopramide 10mg
8 hourly as needed for up to 5 days. Yes No
• Give oral rehydration solution. Dyspepsia (heartburn) likely • Assess for stress and anxiety  86.
• If diarrhoea, give loperamide 4mg initially, then 2mg • Advise to stop NSAIDS (e.g. ibuprofen/aspirin), quit smoking  141, limit alcohol, caffeine, • If patient has a life limiting illness,
after each loose stool if needed, up to 12mg/day. spicy food, fizzy drinks, late night meals. consider giving palliative care  170.
• If abdominal cramps are distressing, give hyoscine • If waist circumference > 80cm (woman) or 94cm (man), assess CVD risk  127. • Discuss/refer if:
butylbromide 10mg 6 hourly for up to 3 days if needed. • Give lansoprazole5 30mg daily for 14 days. - Nausea/vomiting persists > 2 weeks.
• Advise patient to drink lots of fluids, eat small frequent • Refer same week if any of: no better after 7 days treatment, symptoms return, painful/ - Uncertain of diagnosis.
meals as able and avoid fatty food. difficulty swallowing, persistent vomiting, blood in vomit or stool (occult blood positive),
• Advise patient to return if symptoms worsen, vomiting abdominal mass, weight loss, Hb < 12 (woman) or < 13 (man), new pain and > 50 years, or
> 3 days or not tolerating oral fluids. family history of stomach/oesophageal cancer.
1
Common allergens include medication, food or insect bite/sting within the past few hours. 2Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. 3Dilute 10mg morphine with 9mL of
sodium chloride 0.9%. 4One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer. 5If HIV positive on atazanavir/ritonavir, avoid lansoprazole, discuss/refer.
45
 DIARRHOEA
Give urgent attention to the patient with diarrhoea and any of:
• Thirst, dry mouth, poor skin turgor, sunken eyes, drowsiness/confusion, BP < 90/60, pulse ≥ 100, dehydration likely
• If patient has watery diarrhoea (with or without vomiting) and has been in cholera outbreak area in past 5 days, cholera likely 47.
Management:
• Give oral rehydration solution (ORS) and observe: encourage small frequent sips. Aim for at least 1-2L in first 2 hours. If patient vomits, wait 10 minutes and try again more slowly.
- If no better after 2 hours, give IV fluids as below and refer same day.
• If unable to drink or BP < 90/60, give sodium chloride 0.9% 1L IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. Refer same day.
• If patient has been in cholera outbreak area in past week, cholera likely. Give single dose ciprofloxacin 1g orally.

Approach to the patient with diarrhoea not needing urgent attention

• Confirm patient has diarrhoea: ≥ 3 loose stools/day.
• Ask about duration of diarrhoea:

Diarrhoea ≤ 2 weeks Diarrhoea > 2 weeks

Is there blood in the stool? • If blood/mucous in the stool, refer.

• Send stool for ova, cysts and parasites. Indicate on request form if patient has HIV.
No Yes • Test for HIV  110 and manage according to result:

Has patient been in cholera outbreak area in past 5 days? Dysentery likely HIV positive HIV negative or unknown
• Give
ciprofloxacin • Give routine HIV care  111. Treat for giardiasis: give
Yes No 500mg • LPVr can cause ongoing loose stools. metronidazole3 2g daily
12 hourly for for 3 days.
• Review symptoms and stool result in 1 week:
Cholera likely Gastroenteritis likely 3 days.
47. • Give loperamide 4mg initially, then 2mg after each loose • If no response
stool, up to 12mg/day. within 3 days, Isospora belli Cryptosporidium Review stool result:
• If vomiting, give metoclopramide 10mg 8 hourly as needed refer.
for up to 5 days. Give co-trimoxazole Stool negative Stool positive
• If abdominal cramps are distressing, give hyoscine 320/1600mg (4 tablets)
butylbromide 10mg 6 hourly for up to 3 days. 12 hourly for 10 days. Give loperamide 2mg as needed Treat according
• Advise antibiotics are not needed and to drink lots of fluids. up to 8mg/day. to result.
• If fever with cough/sore throat, consider COVID-19  40.
• Advise to return if: blood in stool, diarrhoea worsens or
persists > 2 weeks, or patient becomes confused. If diarrhoea persists despite treatment, refer for specialist review.

• Advise to increase fluid intake. Advise frequent handwashing, with soap and water, before preparing food/after going to toilet. Wash all surfaces/equipment used in food preparation.
Wash and peel all fruit and vegetables. Use only safe/disinfected water for preparing food/drinks/ice. Cook food thoroughly, avoid raw/uncooked food, especially meat and shellfish.
• If repeated episodes of diarrhoea and no access to clean water, refer to health promotion officer/social worker.
• If > 65 years, bed-bound or receiving palliative care, check for solid immobile bulk of stool in rectum. If present, impaction likely: gently remove stool using lubrication. If unsuccessful, refer.
• If patient has a life-limiting illness, also consider giving routine palliative care 170.
1
Rice water stool is cloudy watery diarrhoea with no blood/pus and no faecal odour (may have fishy odour). 2If > 2 hour delay between specimen collection and laboratory processing, discuss with laboratory. 3Advise no alcohol until 24 hours after last
dose of metronidazole.
46
 CHOLERA
• If patient has watery diarrhoea (with or without vomiting) and has been in cholera outbreak area in past 5 days, cholera likely.
• If possible, isolate patient. Health worker to wear gloves and apron while attending to patient. Disinfect surfaces contaminated with secretions with 70% alcohol or chlorine-based disinfectant.
• Check glucose: if glucose < 3 or > 11  17.
• Record each episode of diarrhoea and vomiting and use this to calculate ongoing losses1 when giving fluid replacement below. Decide on further management according to level of dehydration:

Any of: drowsy/decreased consciousness, confused, difficulty breathing, weak pulse?

Yes No
≥ 2 of: unable to drink (or drinking poorly), poor skin turgor, sunken eyes?

Yes No
≥ 2 of: restless, thirsty, dry mouth, pulse ≥ 100?

Yes: some dehydration likely No: dehydration unlikely

Give oral rehydration solution (ORS) 75mL/kg (or at least 2-4L) over 4 hours. Give ORS, at least 2L (as much as patient wants) over 4 hours.

Take specimen (see below) and reassess hourly. Either of:

• Signs of dehydration: unable to drink (or drinking poorly), poor skin turgor, sunken eyes, weak pulse (or pulse ≥ 100), not passing urine, unable to walk unaided
• Ongoing diarrhoea or vomiting?

Yes No: does patient have reliable transport to return if worse?

Manage as severe dehydration and refer urgently: No Yes

• Insert 2 large bore IV lines, if possible.
• Ideally give Ringer's lactate IV fluid as first choice of fluid replacement. If unavailable, give instead sodium chloride 0.9% IV: • Discuss/refer. • Discharge patient into
- Give Ringer's lactate 30mL/kg IV over first 30 minutes, then Ringer's lactate 70mL/kg over next 2.5 hours, while awaiting transfer. • Continue assessing reliable carer's care.
- Also calculate further IV fluids according to ongoing losses1 and increase rate of IV fluids to give new total volume of fluid over and managing for • Advise to return if worse,
the 2.5 hours. dehydration hourly (see unable to drink, bloody
- If transport delayed > 3 hours: continue 5mL/kg/hour IV, increasing rate as needed to keep up with ongoing losses1. above). diarrhoea, fever or becomes
- If unable to insert IV lines and unable to drink, insert nasogastric tube (NGT), if able, for giving fluid volumes above. Avoid NGT if • If some dehydration, drowsy.
vomiting. pregnant, ≥ 60 years • Advise to drink at least
• Reassess patient every 15-30 minutes: old or long-term health 250mL ORS2 after each stool.
- If no better or worse, discuss with referral centre. condition (e.g. HIV, • Advise frequent
- If awake, able to drink and pulse < 100, continue IV fluids, but also manage as some dehydration (see above). diabetes), give antibiotic: handwashing with soap
and water, before preparing
food/after going to toilet.
• Give single dose ciprofloxacin 1g orally, especially if pregnant, ≥ 60 years old or long-term health condition (e.g. HIV, diabetes). Use only safe/disinfected
• Send stool specimen or rectal swab for MCS and cholera. Ensure correct patient contact and address details appear on lab request form. water for preparing food/
- If laboratory processing delay > 2 hours: place specimen in Cary-Blair transport medium, if available. Place in fridge or cooler box with ice before transport. Avoid freezing. drinks/ice.
• Notify as suspected cholera.

1
Calculate ongoing losses: add 10mL/kg of IV fluid/ORS to fluids calculated above for every episode of diarrhoea or vomiting, e.g. if a patient weighing 50kg had 2 episodes of diarrhoea and 1 episode of vomiting during assessment period, add 1500mL
of IV/ORS fluid to IV/ORS fluid volumes above [(3 episodes of diarrhoea/vomiting) x (10mL x 50kg)]. 2If possible, give at least 4 sachets of ORS at discharge. Also advise on home ORS solution: add 8 teaspoons of sugar and half a teaspoon of salt to 1L of
boiled water. Advise to drink at least 250mL after each stool.
47
 CONSTIPATION
Give urgent attention to the patient with constipation and:
• No stools or flatus/wind in the past 24 hours with abdominal pain/distension
Refer same day.

Approach to the patient with constipation not needing urgent attention:

• Review diet, fluid intake and medication (amitriptyline, schizophrenia treatment, codeine and morphine can cause constipation: discuss with doctor). Ask about regular use of enemas or laxatives.
• Exclude pregnancy  157. If pregnant, advise that constipation is common during pregnancy and give advice as below.
• If weakness/tiredness, weight gain, low mood, dry skin or cold intolerance, check TSH. If abnormal, refer to doctor.
• If patient is bed-bound or has a life-limiting illness, also consider giving palliative care  170.
• If > 65 years, bed-bound or receiving palliative care, check for solid immobile bulk of stool in rectum. If present, impaction likely: gently remove stool using lubrication. If unsuccessful, refer.
• Advise a high fibre diet (vegetables, fruit, coarse mielie meal, bran and cooked dried prunes), adequate fluid intake and at least 30 minutes moderate exercise (e.g. brisk walking) most days of the week.
• If no better with diet and exercise, give sennosides A and B 13.5mg at night or lactulose 10-20 mL once or twice daily.
• If no response after 1 week of laxative use, or if recent change in bowel habits, weight loss, blood in stool or occult blood positive, or cause uncertain, refer.

ANAL SYMPTOMS
Give urgent attention to the patient with anal symptoms and any of:
• Extremely painful lump on anus • Unable to pass stool because of anal symptoms
Refer same day.

Approach to the patient with anal symptoms not needing urgent attention
• If patient has anal sex, ask about genital symptoms and treat partner  49. If painless bleeding, passing mucus or unable to pass stools despite feeling the need to (tenesmus), treat for sexually
transmitted proctitis: give single dose ceftriaxone 250mg IM1 and azithromycin 1g orally. If severe penicillin allergy2, omit ceftriaxone and increase azithromycin to 2g. If diarrhoea  46.
• Then examine anal area to look for cause:

Crack/s Lump/pile Ulcer/s or Red/raw skin Suspected worms

perianal wart/s
If constipated, also advise • Advise and treat as for constipation above, and • Advise good hygiene. • If tapeworm: give albendazole
and treat as above. advise to avoid straining. Treat as for • Look for contact cause. If diarrhoea  46. 400mg daily for 3 days. If other
• If pile cannot be reduced or is thrombosed, refer. genital ulcer • Wash with aqueous cream (UEA), avoid soap. worm or unsure: give single
49. • Apply zinc and castor oil ointment to raw dose mebendazole 500mg.
areas. If severe itching, also apply hydrocortisone • Educate on personal
Apply bismuth subgallate compound ointment 6-12 hourly or
1% cream twice a day for 5 days. hygiene and advise to avoid
lidocaine 2% cream before and after each bowel action.
undercooked meat.
• Treat household members at
If no better with treatment, refer. the same time.

1
Dissolve ceftriaxone 250mg in 0.9mL lidocaine 1% without epinephrine (adrenaline). 2History of anaphylaxis, urticaria or angioedema.
48
 GENITAL SYMPTOMS
Assess the patient with genital symptoms and his/her partner/s
Assess Note
Symptoms Ask about genital discharge, rash, itch, lumps, ulcers and lower abdominal pain and manage as below. If anal symptoms (painless bleeding, passing mucus or difficulty passing stool)  48.
Sexual health If risky sexual behaviour: new or multiple partner/s, uses condoms unreliably, has sex under influence of alcohol/drugs, give safe sex advice. Ask if patient has anal sex: if anal symptoms  48.
Abuse Ask about sexual assault. If yes  88.
Family planning Assess patient’s contraceptive needs  154 and discuss infertility. Exclude pregnancy  157.
Examination • Woman: examine abdomen for masses, look for discharge, ulcers, rash, lumps. Do pelvic examination to check for pain on moving cervix/pelvic masses and speculum examination for cervical abnormalities.
• Man: look for genital discharge, ulcers, rash, lumps, pubic lice or scrotal swelling, tenderness or masses.
HIV Test for HIV  110. If HIV positive, give routine care  111. If negative, consider need for PrEP  106.
Syphilis • Check syphilis serology if: sexually assaulted, secondary/tertiary syphilis1 suspected or atypical/fleshy/wet genital warts. If pregnant, test for syphilis at every visit  162. If syphilis positive  53.
• Repeat RPR at 6 months in all treated with doxycycline/amoxicillin/probenecid.
Cervical screen Do a cervical screen if needed  55. If abnormal vaginal discharge, delay routine cervical screen until treated  51. If discharge persists after treatment, do cervical screen. If cervix looks abnormal/
suspicious of cancer, refer same week.
 69
Advise the patient with genital symptoms and his/her partner/s
• Discuss safe sex. Provide male and female condoms, advise patient to stay with one partner at a time. Offer referral for medical male circumcision.
• If patient has a sexually transmitted infection (STI), educate about cause and increased risk of HIV transmission. Urge to adhere to treatment and abstain from sex for at least 1 week after treatment.
• Stress importance of partner treatment in cure of STI: give partner notification slip with the patient’s diagnosis code for each partner. Consider other notification methods like active tracing and treatment.

Treat the patient with genital symptoms

Discharge Scrotal pain/swelling Itch Ulcers/sores Lump/s Warts

Woman 51 Man 50 50 Discharge in woman 51 Glans penis 50 Pubic area 54 52 Groin 25 Skin 54

Treat the partner/s according to code given on notification slip

Notification code Treat the asymptomatic partner/s below. lf partner has other STI symptoms and signs, manage as per relevant STI algorithm found on pages listed above.
VDS or LAP Give partner single dose ceftriaxone 250mg IM3 and azithromycin 1g orally and metronidazole2 2g. If severe penicillin allergy4, omit ceftriaxone and increase azithromycin to 2g.
MUS or SSW Give partner single dose ceftriaxone 250mg IM3 and azithromycin 1g orally. If severe penicillin allergy4, omit ceftriaxone and increase azithromycin to 2g.
GUS (no discharge) Give partner doxycycline 100mg 12 hourly for 14 days. If partner pregnant, give instead single dose benzathine benzylpenicillin 2.4MU IM5.
GUS with VDS Give partner single dose ceftriaxone 250mg IM3 and azithromycin 1g orally and metronidazole2 2g. If severe penicillin allergy4, omit ceftriaxone and increase azithromycin to 2g.
GUS with MUS Give partner single dose ceftriaxone 250mg IM3 and azithromycin 1g orally. If severe penicillin allergy4, omit ceftriaxone and increase azithromycin to 2g.
RPR+ Test partner for syphilis: if positive  53. If negative, give partner doxycycline 100mg 12 hourly for 14 days. If partner pregnant, give instead single dose benzathine benzylpenicillin 2.4MU IM5.
Bubo Give partner single dose azithromycin 1g.
VDS: vaginal discharge syndrome LAP: lower abdominal pain MUS: male urethritis syndrome SSW: scrotal swelling GUS: genital ulcer syndrome RPR+: syphilis positive result BAL: balanitis
1
Secondary syphilis: 6-8 weeks after ulcer; generalised rash (includes palms/soles), flu-like symptoms, flat wart-like genital lesions, mouth ulcers, patchy hair loss. Tertiary syphilis: many years later; affects skin, bone, heart, nervous system. 2Advise no alcohol until
24 hours after last dose of metronidazole. 3Dissolve ceftriaxone 250mg in 0.9mL lidocaine 1% without epinephrine (adrenaline). 4History of anaphylaxis, urticaria or angioedema. 5Dissolve benzathine benzylpenicillin 2.4MU in 6mL lidocaine 1% without
epinephrine (adrenaline). If benzathine benzylpenicillin unavailable, give instead amoxicillin 1g 8 hourly and probenecid 250mg 8 hourly for 14 days. If severe penicillin allergy, discuss/refer.
49
 GENITAL SYMPTOMS IN A MAN
Give urgent attention to the man with genital symptoms and any of:
• Scrotal swelling/pain with any of: sudden severe pain, affected testicle higher/rotated, preceding trauma/strenous activity: torsion of testicle likely
• Foreskin retracted over glans and unable to be pulled back to normal position (reduced) with swollen and very painful glans: paraphimosis likely
• Prolonged erection > 4 hours: priapism likely
Management:
• If likely torsion of testicle or priaprism: refer urgently.
• If paraphimosis likely:
- If glans blue/black: refer urgently.
- If not, attempt manual reduction: wrap glans in gauze and apply increasing pressure for 10-15 minutes until foreskin can be replaced over glans. If unsuccessful, refer urgently.

Approach to the man with genital symptoms not needing urgent attention
• First assess and advise the man with genital symptoms  49.
• Check for urethral discharge: if no visible discharge, ask patient to milk the urethra. If no urethral discharge and urinary symptoms (burning/frequency/urgency) 59.

Urethral discharge Scrotal swelling or pain Painful, itchy or foul-smelling glans,

(with or without dysuria/burning urine) difficulty retracting foreskin

© University of Cape Town © University of Cape Town © University of Cape Town

Treat for male urethritis syndrome (MUS): Pain with/without swelling or discharge Painless If unable to retract foreskin, refer.
• Give single dose ceftriaxone 250mg IM1 and lump
• Give single dose azithromycin 1g. Treat for scrotal swelling (SSW): If able to, retract foreskin, wash with water, dry and examine:
• If severe penicillin allergy2, omit ceftriaxone • Give single dose ceftriaxone 250mg IM1 and Exclude • If ulcer  52.
and increase azithromycin to 2g. • Give azithromycin 1g now and another dose of Testicular • If glans inflamed, treat for balanitis/ balanoposthitis (BAL):
• If partner has vaginal discharge syndrome azithromycin 1g in 1 week. cancer - Advise to retract and wash daily with water, avoid soap. Dry fully.
(VDS), add single dose metronidazole3 2g. • If severe penicillin allergy2, omit ceftriaxone and increase - Give clotrimazole cream 12 hourly for 7 days.
• Give partner notification slip/s with code: MUS. azithromycin to 2g. - Check urine dipstick for glucose. If glucose present, check for
Refer.
• Give partner notification slip/s with code: SSW. diabetes  17.
Advise patient to return in 7 days if • For pain, give ibuprofen 400mg 8 hourly with food for - Offer referral for medical male circumcision.
symptoms persist: ceftriaxone treatment up to 5 days (avoid if peptic ulcer, asthma, hypertension, - Advise to return if no better in 7 days:
failure likely. Refer within 7 days. heart failure or kidney disease). • If poor adherence, repeat treatment.
• Review after 7 days or earlier if needed: if no better, refer. • If still no better, refer.

1
For ceftriaxone 250mg IM injection: dissolve 250mg in 0.9mL lidocaine 1% without epinephrine (adrenaline). 2History of anaphylaxis, urticaria or angioedema. 3Advise no alcohol until 24 hours after last dose of metronidazole.
50
 ABNORMAL VAGINAL DISCHARGE
Abnormal vaginal discharges are itchy or different in colour/smell. First assess and advise the patient with an abnormal vaginal discharge  49.

Approach to a woman with an abnormal vaginal discharge

Has patient been sexually active in the last 3 months?

Yes to either No to both

Ask about lower abdominal pain and do pelvic Is discharge itchy or curd-like or are vulva inflamed (red, swollen or painful)?
examination to check for pain on moving cervix:
No Yes
Is there lower abdominal pain or pain on moving cervix?
Treat for bacterial vaginosis: Vaginal
No Yes • Give single dose metronidazole3 2g. Advise to return if no better after 7 days. candidiasis
• If no better after 7 days, ask about lower abdominal pain, do pelvic examination to check for pain on likely
• Treat for cervicitis: moving cervix and speculum examination to look for red/swollen cervix or discharge from cervix: • Give single
- Give single dose dose
ceftriaxone1 Is there lower abdominal pain or pain on moving cervix? clotrimazole
250mg IM2 and vaginal
azithromycin pessary
Yes No 500mg
1g and
metronidazole3 2g. inserted
- Give partner Give urgent attention if any of: Is there red/swollen cervix or discharge at night or
notification slip/s • Recent delivery/TOP/miscarriage • Temperature ≥ 38°C • Abdominal mass from cervix? clotrimazole
with code: VDS. • Pregnant or missed/overdue period • Pulse > 100 • Peritonitis (guarding, vaginal
• If discharge itchy • Abnormal vaginal bleeding • BP < 90/60 rigidity, rebound) Yes No cream,
or curd-like or Manage and refer urgently: inserted with
vulva inflamed (red, • If BP < 90/60, give sodium chloride 0.9% 500mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. applicator,
Treat for Give 12 hourly for
swollen or painful), Stop if breathing worsens. cervicitis: metronidazole3
also treat for vaginal • Give ceftriaxone4 1g IV (avoid diluting with lidocaine 1%) and metronidazole3 400mg orally. 7 days.
• Give single dose 400mg • If skin of vulva
candidiasis (see ceftriaxone1 12 hourly for
adjacent). inflamed
250mg IM2 and 7 days. or itchy,
• Advise to return if no Approach to the patient not needing urgent attention
azithromycin also give
better after 7 days. 1g.
Pain on moving cervix No pain on moving cervix: check urine dipstick: clotrimazole
• Give partner topical
If no better after 7 days, notification cream, apply
give metronidazole3 Leucocytes and nitrites negative Leucocytes slip/s with code: 12 hourly for
400mg 12 hourly for or nitrites VDS. 7 days.
7 days. Treat for lower abdominal pain (LAP) syndrome: positive
• Give single dose ceftriaxone1 250mg IM2 and azithromycin 1g and metronidazole3 400mg
Advise to return 12 hourly for 7 days. For pain, give ibuprofen5 400mg 8 hourly with food for up to 5 days. 59.
if no better after • Give partner notification slip/s with code: LAP. Advise to return if no better after 7 days: refer.
7 days: refer. • Advise to return if no better within 3 days or urgently if worse: refer. Otherwise, review in 7 days.
1
If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), omit ceftriaxone and increase azithromycin dose to 2g. 2For ceftriaxone 250mg IM injection: dissolve 250mg in 0.9mL lidocaine 1% without epinephrine. 3Advise no alcohol until
24 hours after last dose of metronidazole. 4Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. 5Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease.
51
 GENITAL ULCER SYNDROME
First assess and advise the patient with genital ulcer/s  49. The patient may have a blister, sore or an ulcer.

First treat for herpes:

• Stress importance of condoms as herpes is a lifelong infection and transmission can occur even when no sores. HIV transmission risk increases when there are ulcers/sores.
• Advise to keep lesions clean and dry.
• If pain, give ibuprofen 400mg 8 hourly with food for up to 5 days (avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease).
• Give aciclovir 400mg 8 hourly for 7 days if any of:
- HIV positive or HIV unknown.
- Pregnant (if patient ≥ 28 weeks pregnant, consider risk of neonatal herpes, refer).
- Not sexually active in the last 3 months.
• If recurrent ulcers, refer for laboratory testing. If ≥ 4 episodes of laboratory-confirmed herpes simplex in 1 year, refer for ongoing suppressive therapy. © University of Cape Town

If patient sexually active in the past 3 months, also treat for genital ulcer syndrome (GUS) below:
Does patient have a vaginal/urethral discharge?

No Yes

Treat for GUS Treat for GUS with VDS/MUS

• Give single dose ceftriaxone 250mg IM2 and azithromycin 1g orally
and benzathine benzylpenicillin 2.4MU IM1.
Pregnant woman Man or non-pregnant woman
• If severe penicillin allergy3, omit ceftriaxone, increase azithromycin
Does patient have severe penicillin allergy3?
to 2g and give doxycycline 100mg 12 hourly for 14 days. If
• Give doxycycline 100mg pregnant/breastfeeding, refer instead.
Yes No 12 hourly for 14 days. • Advise to return in 6 months for RPR: if positive  53.
• Give single dose benzathine benzylpenicillin 2.4MU IM1. • Advise to return in 6 months • If patient or partner has vaginal discharge syndrome (VDS), also give
• If benzathine benzylpenicillin unavailable, give instead for RPR: if positive  53. single dose metronidazole4 2g orally. If patient has discharge that is
Refer for itchy or curd-like or vulva inflamed (red, swollen or painful), also give
amoxicillin 1g 8 hourly and probenecid 250mg 8 hourly for • Give partner notification
confirmation single dose clotrimazole vaginal pessary 500mg inserted at night.
14 days. Advise to return in 6 months for RPR: if positive  53. slip/s with code: GUS.
of diagnosis • Give partner notification slip/s with code: GUS + VDS/MUS.
• Give partner notification slip/s with code: GUS.
and possible
penicillin
desensitisation. Does patient also have enlarged, hot, tender lymph node/s in groin?

No Yes

Review in 7 days Also treat for bubo:

• If no better and patient already received • Give azithromycin 1g now and repeat azithromycin 1g weekly for another 2 weeks.
azithromycin, discuss/refer, otherwise give single • If fluctuant lymph node, aspirate pus through healthy skin in sterile
dose azithromycin 1g. manner every 3 days as needed. © University of Cape Town
• Advise to return if still no better after 7 days: refer. • Give partner notification slip/s with code: Bubo.
• Review in 14 days: if no better, refer.
1
For benzathine benzylpenicillin 2.4MU injection: dissolve benzathine benzylpenicillin 2.4MU in 6mL lidocaine 1% without epinephrine (adrenaline) and give half the volume into each buttock. 2For ceftriaxone 250mg IM injection: dissolve 250mg in
0.9mL lidocaine 1% without epinephrine (adrenaline). 3History of anaphylaxis, urticaria or angioedema. 4Advise no alcohol until 24 hours after last dose of metronidazole.
52
 POSITIVE SYPHILIS RESULT
Approach to the patient with a positive syphilis result
• If fingerprick syphilis test1 done and positive:
- If any of the following, start treatment same day with benzathine benzylpenicillin 2.4MU IM2: pregnant, partner treatment, genital ulcer present, signs of secondary syphilis3 present.
- Send blood for syphilis serology (RPR) to confirm result. On request form, write: “If RPR negative, do specific syphilis test on same specimen”. Review in 1 week.

Manage according to results:

Lab-based Lab-based specific syphilis test reactive Lab-based specific syphilis test not done (fingerprick syphilis test done)
specific
syphilis test RPR non-reactive RPR reactive
non-reactive Treat for syphilis: decide what treatment to give according to sex and pregnancy status:
No current active
No treatment syphilis infection. Man, or non-pregnant woman Pregnant woman
for syphilis • Reactive Is previous RPR result available? Treat according to symptoms:
needed. specific syphilis
• Continue test indicates a
routine No Yes If genital ulcer or signs If no symptoms (no
past infection. Does patient have a genital ulcer or New RPR titre is either: of secondary syphilis3, ulcer/s or signs of
screening • If pregnant,
for syphilis signs of secondary syphilis3? • ≤ 1:8 and unchanged or treat for early syphilis: secondary syphilis3), treat
continue • At least 4 times lower than before (e.g. was 1:32, now 1:8) • Give single dose for late syphilis:
using rapid routine
fingerprick No Yes benzathine • Give benzathine
screening for benzylpenicillin benzylpenicillin 2.4MU
tests. syphilis using No Yes
2.4MU IM2 . If IM2 weekly for 3 weeks.
RPR tests. Avoid Treat for late syphilis unavailable, give If unavailable, give
using rapid • Give benzathine Is there a negative RPR from the last • No further instead amoxicillin instead amoxicillin
tests. Make a benzylpenicillin 2 years? treatment 1g 8 hourly and 1g 8 hourly and
note of this 2.4MU IM2 weekly needed. probenecid 250mg probenecid 250mg
in her file and for 3 weeks. If Yes No • If partner/s 8 hourly for 14 days. 8 hourly for 28 days.
maternity care penicillin allergy4, not treated
record. or benzathine in the past,
• If sexual benzylpenicillin Treat for early syphilis Treat for late syphilis give partner • If severe penicillin allergy4, refer to hospital to
assault, repeat unavailable, give • Give single dose • Give benzathine notification confirm diagnosis and for possible penicillin
syphilis test at instead doxycycline5 benzathine benzylpenicillin slip/s with desensitisation.
4 months. 100mg 12 hourly for benzylpenicillin 2.4MU IM2 weekly for code: RPR+. • If weekly dose late by 2 weeks or more, restart
30 days and repeat 2.4MU IM2. If penicillin 3 weeks. If penicillin 3 injections.
RPR in 6 months. allergy4, or benzathine allergy4, or benzathine • Repeat RPR 3 months after completing to confirm
• Give partner benzylpenicillin benzylpenicillin treatment response. If new titre is ≤ 1:4 and
notification slip/s unavailable, give instead unavailable, give instead unchanged or at least 4 times lower than before
with code: RPR+. doxycycline5 100mg doxycycline5 100mg (e.g. was 1:32, now 1:8), no further treatment
12 hourly for 14 days and 12 hourly for 30 days and needed. If not, discuss/refer.
repeat RPR in 6 months. repeat RPR in 6 months. • Give partner notification slip/s with code: RPR+.
• Give partner notification • Give partner notification • Manage the baby born to mother with syphilis 167.
slip/s with code: RPR+. slip/s with code: RPR+. • If stillbirth, notify.
1
A rapid syphilis test remains positive for life, even if syphilis infection has been treated. If patient had previous positive rapid syphilis test result, avoid repeating rapid syphilis test. Send blood for syphilis serology (RPR) instead. 2For benzathine benzylpenicillin
2.4MU injection: dissolve benzathine benzylpenicillin 2.4 MU in 6mL lidocaine 1% without epinephrine (adrenaline). 3Secondary syphilis: 6-8 weeks after ulcer; generalised rash (includes palms/soles), flu-like symptoms, flat wart-like genital lesions, mouth
ulcers, patchy hair loss. 4History of anaphylaxis, urticaria or angioedema. 5If breastfeeding, avoid doxycycline and refer.
53
 OTHER GENITAL SYMPTOMS
• First assess and advise the patient  49.
• Then manage according to main symptom:

Lumps or warts Itchy rash in pubic area

Painless, raised skin coloured growths with round/ Papules with central dent Intensely itchy bites Itch worse at night, with red papules and nodules
cauliflower-like surface (skin around genitals, anus or cervix) May see lice or nits (size of a pinhead)
in pubic and peri-anal areas

Pubic lice (pediculosis) likely

• Apply benzyl benzoate
25% lotion to affected area
for 24 hours. Avoid mucous
membranes, face and eyes,
© University of Cape Town urethral opening and raw
areas. Repeat treatment after
Molluscum contagiosum 1 week.
likely • Advise to shave genital area.
• Reassure that most • Treat all sexual partners even
papules resolve if asymptomatic. © University of Cape Town
© University of Cape Town
spontaneously within • Before treatment, wash and
9-12 months. thoroughly dry clothing and
linen that may have been Genital scabies likely
Genital warts likely • Apply tincture of iodine • Apply benzyl benzoate 25% lotion from neck to
• If warts atypical/fleshy/wet, test for syphilis. If BP topically with an contaminated within past
2 days. soles of feet and rub in well:
positive  53. applicator to the core of - Leave on for 24 hours, then wash off with soap
• Arrange a cervical screen for patient/partner if the lesions. • For itch, give chlorphenamine
4mg 8 hourly as needed for and water.
needed  55. • If no response to - If severe, repeat once after 24 hours or within
• Offer to arrange medical male circumcision for treatment, refer. up to 10 days.
5 days.
patient/partner. • If no better, apply permethrin 5% lotion at
• Reassure that most warts resolve spontaneously If eyelashes/eyebrows involved, night from neck to soles of feet. Wash off after
within 2 years. pediculosis of eyelashes/ 8-12 hours. Repeat after 1 week if needed.
• Refer to gynaecology, urology or sexual health eyebrows likely. • For itch, give chlorphenamine 4mg 8 hourly for
services if: Apply yellow petroleum jelly up to 10 days. If mild itch, use only at night.
- Warts > 10mm to eyelid margins to (cover • Advise can return to work after first treatment.
- Numerous lesions eyelashes) and eyebrows daily • Treat all household contacts and sexual partners
- Warts inside vagina, involving cervix or urethra for 10 days to smother lice/nits. at the same time, even if asymptomatic.
- Pregnant with large warts Advise patient to avoid getting • Wash recently used linen and clothing in very hot
- Bleeding or infected warts petroleum in eye. water and dry well. Expose to direct sunlight.

If scratch marks infected (pus/red/swollen/crusts), also treat for likely impetigo  78.

1
Avoid in pregnancy and breastfeeding.
54
 CERVICAL SCREENING
A Pap smear (conventional cytology using glass slides/smear) is the common method of cervical screen. If available1, use instead liquid-based cytology (LBC) and human papillomavirus (HPV) DNA
testing. If cytology unavailable, use visual inspection with acetic acid (VIA).

Decide when the patient needs a cervical screen according to symptoms

Patient has no symptoms. Patient has symptoms.
• If HIV negative: do 3 screens in a lifetime, each 10 years apart from age 30. (Symptoms include: irregular or heavy vaginal bleeding, bleeding after sex or an abnormal vaginal discharge)
• If HIV positive: do cervical screen at HIV diagnosis (regardless of age), then 3-yearly. • Do cervical screen if symptoms are not responding to treatment, regardless of when routine screen was done.

Assess the patient needing a cervical screen

Assess Note
Symptoms • Manage symptoms as on symptom pages. If abnormal vaginal discharge  51; if abnormal vaginal bleeding  57. If routine cervical screen, delay until after treatment.
• If abnormal vaginal discharge/bleeding not responding to treatment, do cervical screen at same visit.
Family planning Assess patient’s contraceptive needs  154. If pregnant, do cervical screen safely up to 20 weeks gestation.
Examination • Do pelvic examination to check for pain on moving cervix and pelvic masses. If pain on moving cervix, treat for lower abdominal pain (LAP) syndrome  44. If mass, refer.
• Do speculum examination to look for abnormalities of cervix: if any lesion/mass/polyp/erosion/ulcer/sore, avoid cervical screening and instead refer same week for colposcopy/biopsy.
HIV Test for HIV  110. If HIV positive, give routine HIV care  111, and repeat cervical screening 3 yearly. If negative, consider need for PrEP  106.
Human papillomavirus (HPV) DNA test If liquid-based cytology (LBC) available1, also request HPV DNA test on same specimen.
 50
Advise the patient needing a cervical screen
• Educate that cervical cancer is a disease that affects the mouth of the womb. Certain types of HPV cause cervical cancer. HPV is transmitted sexually and can persist for years. Emphasise condoms.
• Cervical screening is able to prevent cervical cancer as it detects changes in the cervix years before cancer develops. Colposcopy is a closer examination of the cervix to confirm these abnormal changes.
• Advise that smoking increases the risk of cervical abnormalities. If patient smokes, encourage to stop  141.
• Advise patient to return if symptoms of cervical cancer (abnormal vaginal bleeding, vaginal discharge) occur.

Manage the patient according to results:

If specimen unsatisfactory or result not found, repeat cervical screen within 3 months.

Normal Abnormal
If available, check HPV DNA result:

HPV DNA negative or not done HPV DNA positive

Cervical screen negative Cervical screen positive

• Explain that patient has no abnormal changes of her cervix. • If abnormal Pap smear/LBC/VIA, explain that patient has changes on her cervix that need further examination to check for cancer.
• If HPV negative, explain that patient currently does not have the • If normal Pap smear/LBC/VIA but HPV DNA positive, explain patient does not have cancer but needs referral as HPV can cause cancer.
virus that can cause cancer changes. • If VIA is positive or HPV DNA positive for HPV types 16 and 18: refer for cryotherapy/LLETZ.
• If HIV negative: repeat after 10 years if < 3 previous routine screens. • If abnormal Pap smear/LBC, VIA suspicious for cancer or HPV DNA positive for other HPV types: refer for colposcopy.
• If HIV positive: repeat screen after 3 years. • Repeat screen in 1-3 years according to colposcopy findings/management needed.
1
These tests are only available in designated pilot facilities.
55
 MENSTRUAL SYMPTOMS
Approach to the patient with menstrual symptoms
Manage according to symptom: ask if abnormal periods, crampy pain during periods or bloating/headache/tender breasts/tired/moody around time of periods.

Abnormal periods Crampy lower abdominal or back pain Bloated/headache/tender breasts/

during periods. Headache, fatigue, nausea, tired/moody around time of periods
vomiting and diarrhoea may also occur.
Heavy/prolonged/ No bleeding
irregular bleeding Premenstrual syndrome (PMS) likely
Dysmenorrhoea likely • Educate that PMS can start 2 weeks
Amenorrhoea likely
• If abnormal vaginal discharge  49. before period and should get better
57. • If period never started before age 16 years, refer.
• Give ibuprofen 400mg 8 hourly as needed by end of period.
• If period has stopped:
with food for 3 days during periods. Avoid • If low mood, stress or anxiety  86.
- Exclude pregnancy  157.
if peptic ulcer, asthma, hypertension, heart • If symptoms severe, consider oral
- If > 40 years, ask about menopausal symptoms: hot flushes, night sweats, vaginal
failure or kidney disease. contraceptive ethinylestradiol/
dryness, mood changes, difficulty sleeping and sexual problems. If yes  169.
• Discuss contraception: if contraception levonorgestrel 30mcg/150mcg for
- Ask about contraception:
desired or if no better with ibuprofen, 6 months  154.
give oral contraceptive: ethinylestradiol/
Is patient using IUD, injectable contraceptive or subdermal implant? levonorgestrel 30mcg/150mcg for
6 months  154, then review. If
pregnancy desired, discuss/refer instead.
Yes No

If no response to treatment or symptoms interfere with daily activities,

Reassure little to • Reassure period should start again. discuss/refer for further assessment of possible underlying causes like fibroids.
no period can • Advise to return if no period for > 6 months.
be normal.
If no period > 6 months
• Look for and manage cause (like stress, excessive
exercise, sudden weight loss, underweight).
• If weakness/tiredness, weight gain, low mood,
dry skin, constipation or cold intolerance, check
TSH. If abnormal, refer to doctor.
• If still no period after cause treated/resolved or
unsure of cause, refer.

Advise the patient with menstrual symptoms

• Explain that menstruation (having a period) is normal and healthy, and educate what menstruation is: every month the uterus lining thickens to prepare for pregnancy. When pregnancy does not
happen, the thickened lining is released through the vagina, as bleeding for a few days.
• Reassure that dysmenorrhoea (abdominal/back pain with periods) is common. Encourage to continue with daily activities and exercise.
• If premenstrual syndrome: advise to do daily exercise and try relaxation techniques  86.

56
 ABNORMAL VAGINAL BLEEDING
Give urgent attention to the patient with vaginal bleeding and any of:
• Pregnant 159 • BP < 90/60 • Pallor with pulse ≥ 100, respiratory rate ≥ 30, dizziness/
• Recent delivery/miscarriage/termination of pregnancy 164 • Hb < 6 faintness or chest pain
Manage and refer urgently:
• If BP < 90/60, give sodium chloride 0.9% 500mL IV over 30 minutes, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens.

Approach to the patient with abnormal vaginal bleeding not needing urgent attention:
• Do a pelvic examination to check for pelvic masses, a speculum examination to visualise cervix and a cervical screen if needed  55. If abnormal, refer.
• If > 40 years, ask about menopausal symptoms: hot flushes, night sweats, vaginal dryness, mood changes, difficulty sleeping and sexual problems  169.
If new bleeding occurs > 1 year after final period, refer within 2 weeks.
• If patient is not menopausal, determine the type of bleeding problem:

Heavy or prolonged periods Irregular periods Spotting between periods Bleeding

(cycle < 21 days or after sex
• If bleeding from elsewhere like easy bruising/ > 35 days) • Assess for STI  49.
purple rash/bleeding gums, arrange FBC and • Check Hb: if Hb < 12, treat for likely anaemia  27. • Assess
refer to doctor next day. • If weight change, • If on hormonal contraceptive, manage according to method: for STI
• If Hb < 12, treat for likely anaemia  27. pulse ≥ 100, tremor,  49.
• Give COC1: ethinylestradiol/levonorgestrel weakness/tiredness, Oral contraceptive: Injectable contraceptive or IUD: • If assault
30mcg/150mcg for 3 months  154. If dry skin, constipation • Ensure correct use and reassure that spotting is subdermal implant: • Reassure that or abuse
pregnancy desired or COC contraindicated2, or intolerance to cold common in first 3 months. • Reassure that spotting is spotting is  88.
discuss/refer. or heat, check TSH. • If > 24 hours diarrhoea/vomiting, advise to use common in first 3 months. common in
• Give ibuprofen3 400mg 8 hourly with food for If abnormal, refer to condoms (continue for 7 days once diarrhoea/ • If bleeding troublesome, give first 3 months,
3 days. doctor. vomiting resolved). combined oral contraceptive is not harmful
• If on injectable contraceptive or subdermal • Give COC1: • If on ART, rifampicin, phenytoin or carbamazepine, (COC) ethinylestradiol/ and usually
implant: reassure that abnormal bleeding is ethinylestradiol/ change to copper IUD or injectable  154. levonorgestrel 30mcg/150mcg. resolves.
common in first 3 months. levonorgestrel • If bleeding persists > 3 months: Duration depends on • Give
• If bleeding persists > 3 months, give COC1 or 30mcg/150mcg for - If on progesterone-only pill and bleeding contraceptive method: ibuprofen3
ibuprofen as above. 6 months  154. If troublesome, change method  154. - If subdermal implant, give for 400mg
• Refer the patient: pregnancy desired or - Switch to COC1 containing lowest dose of 20 days. 8 hourly
- Same week if mass in abdomen COC contraindicated2, ethinylestradiol (i.e. 30mcg). If bleeding persists, - If on injectable, give for 14 days. with food for
- If no better after 3 months on treatment discuss/refer. switch to cyproterone/ethinylestradiol • If COC contraindicated2, give 3 days.
- If excessive bleeding after IUD insertion 2mg/0.035mg daily or advise alternative instead ibuprofen3 400mg
- If sexual abuse suspected method. If no better after 3 cycles, discuss. 8 hourly for 3 days.
- If history of foreign body inserted into vagina
Refer the patient within 2 weeks if:
If pain during periods  56. • Unsure of diagnosis.
• Patient complains of pelvic pain.
• Bleeding persists > 1 week after STI treatment or after diarrhoea/vomiting stop.
• Bleeding persists despite treatment.

1
Combined oral contraceptive. 2Avoid COC if smoker ≥ 35 years, migraines and ≥ 35 years old or visual disturbances, up to 6 weeks postpartum, BP ≥ 140/90, hypertension, CVD risk > 10%, blood clots, previous stroke, ischaemic heart disease or diabetes
complications (eye, nerve, kidney damage). 3Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease.
57
 SEXUAL PROBLEMS
Ask about problems getting or maintaining an erection, pain with sex, painful ejaculation or loss of libido:

Problems getting or maintaining an erection Painful ejaculation Pain with sex (vaginal or anal). Loss of libido
If painful ejaculation, manage in adjacent column.
Does patient often wake with an erection in morning? • If genital Ask if pain with sex or if problem
symptoms  49. Is the pain superficial or deep? with erections, and manage in
• If urinary adjacent columns.
Yes No
symptoms  59.
Superficial pain Deep pain
• Review
medication: • If stress or anxiety  86.
• If stress or anxiety  86. • Assess CVD risk  127.
antidepressants • Review medication: phenytoin,
• Ask about relationship • Review medication: • If genital symptoms  49. • If genital
and schizophrenia hydrochlorothiazide, spironolactone,
problems, anxiety/fear hydrochlorothiazide, • If anal symptoms  48. symptoms  49.
treatment can chlorpromazine, risperidone,
about sex, unwanted spironolactone, risperidone, • If urinary symptoms  59. • If recurrent
cause painful fluoxetine, amitriptyline and
pregnancy, infertility fluoxetine and amitriptyline can • Ask about vaginal dryness: abdominal pain
ejaculation. Discuss lopinavir/ritonavir can cause loss of
and performance cause sexual problems. Discuss - If woman > 40 years, ask about relieved by
with doctor. libido. Discuss with doctor.
anxiety. with doctor. menopausal symptoms: passing stool,
• If no cause found, • In the past month, has patient:
• If sexual assault or • In the past year, has patient: hot flushes, night sweats, with bloating,
refer. 1) felt down, depressed, hopeless
abuse  88. 1) drunk ≥ 4 drinks1/session, mood changes and difficulty constipation and/
or 2) felt little interest or pleasure in
• In the past month, has 2) used illegal drugs or 3) misused sleeping. If yes  169. or diarrhoea,
doing things? If yes to either  143.
patient: 1) felt down, prescription or over-the-counter - Review medication: irritable bowel
• In the past year, has patient: 1) drunk
depressed, hopeless medications? If yes to any  142. oral contraceptive, syndrome likely.
≥ 4 drinks1/session, 2) used illegal
or 2) felt little interest • If patient smokes, encourage to antidepressants and Refer to doctor.
drugs or 3) misused prescription or
or pleasure in doing stop  141. hypertension treatment • Refer if:
over-the-counter medications? If yes
things? If yes to either • If low mood, stress or anxiety can cause vaginal dryness. - Heavy, painful
to any  142.
 143.  86. Discuss with doctor. or prolonged
• Ask about relationship problems,
• Discuss condom use. • If no better once chronic • Advise patient to use lubricant periods
anxiety/fear about sex, unwanted
Ensure patient knows condition/s stable and treatment during sex. Ensure it is - Infertility
pregnancy, infertility and
how to use condoms optimised, refer. condom-compatible, avoid - Abdominal/pelvic
performance anxiety.
correctly. using petroleum jelly with mass
• If woman > 40 years, ask about
condoms. - Anal/rectal mass
menopausal symptoms: hot flushes,
night sweats, mood changes and
• If low mood, stress or anxiety  86. difficulty sleeping. If yes  169.
• If sexual assault or abuse  88. • If sexual assault or abuse  88.
• Assess the patient’s contraceptive
needs  154.
• Offer referral to counsellor.

If sexual problems do not improve, refer to specialist.

1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer.
58
 URINARY SYMPTOMS
Give urgent attention to the patient with urinary symptoms and any of:
• Unable to pass urine with lower abdominal discomfort/distention • Flank pain with leucocytes/nitrites on urine dipstick, and any of: vomiting,
• Blood/protein in urine and new swelling of face/feet, BP ≥ 140/90 or passing little urine: kidney disease likely BP < 90/60, pulse ≥ 100, diabetes, male, pregnant or post menopause:
• Blood in urine and sudden, severe, one-sided pain in flank or groin: kidney stone likely complicated pyelonephritis likely
Manage and refer urgently:
• If unable to pass urine, insert urinary catheter.
• If kidney disease likely: if pulse > 100 or respiratory rate ≥ 30, give face mask oxygen and furosemide 80mg slow IV, avoid IV fluids. If BP > 150/100, give amlodipine 5mg and furosemide 40mg orally.
• If kidney stone likely: give sodium chloride 0.9% 1L IV 6 hourly. If pain severe, give morphine 10mg IM or 3-10mg slow IV . For IV: dilute 10mg morphine with 9mL of sodium chloride 0.9%.
• If complicated pyelonephritis likely: first collect urine for MCS and then give ceftriaxone 1g IV1/IM. If BP < 90/60, give sodium chloride 0.9% 500mL IV over 30 minutes, repeat until systolic BP > 90.
Continue 1L 6 hourly. Stop if breathing worsens.

Approach to the patient with urinary symptoms not needing urgent attention
If flank pain with leucocytes/nitrites, uncomplicated pyelonephritis likely: send urine MCS. Give ciprofloxacin 500mg 12 hourly for 7 days and paracetamol 1g 4-6 hourly. Advise to return if worse: refer.

Burning/frequency/urgency or leucocytes/nitrites on dipstick No burning/frequency/urgency and no leucocytes/nitrites on dipstick

Woman Man Blood on dipstick5 Flow problem

• If no leucocytes or nitrites: • Check for urethral discharge. If present, MUS likely 50.
- If glucose, exclude diabetes  17. • Any of: fever, perineal/body pain or prostate tender on rectal exam? Send urine for microscopy. If at risk of Leakage of urine Poor stream
- If frequency, exclude pregnancy  157. bilharzia6,7, also request for Schistosoma ova: or difficulty
- If none of above, discuss/refer. No Yes passing
• If leucocytes or nitrites: is there a catheter, • If on
Are there leucocytes/nitrites on dipstick? Schistosoma Schistosoma positive furosemide, urine
diabetes or urinary tract problem?
Acute prostatitis likely negative or doctor to
Yes No • If ≤ 35 years, give not at risk of Schistosomiasis likely review. If on
No Yes ceftriaxone2 250mg bilharzia • If vaginal amitriptyline,
• If fever, cough,
If no frequency/urgency, • If IM3 and azithromycin headache or urticaria, atrophy doctor to
Simple UTI likely MUS likely 50. glucose 1g. If blood on refer same day.  169, if review,
Give single dose Otherwise treat for: on • If > 35 years, give microscopy, • Give single dose constipation otherwise
gentamicin 160mg dipstick, ciprofloxacin 500mg refer same praziquantel 40mg/kg.  48. refer.
IM. If kidney disease or exclude 12 hourly for 14 days. week. • Advise when in • Advise to
pregnant (or gentamicin Complicated UTI likely • Give ibuprofen4 reduce
• Give ciprofloxacin 500mg 12 hourly for 7 diabetes bilharzia area to boil
unavailable), give  17. 400mg 8 hourly with water before use and alcohol and
instead single dose days. If pregnant, give instead nitrofurantoin food for up to 5 days. caffeine, and
100mg 6 hourly for 5 days or if unavailable, • If no avoid swimming in
fosfomycin 3g or glucose, • Refer if temperature contaminated water. do pelvic
nitrofurantoin 100mg single dose fosfomycin 3g. ≥ 38°C, difficulty muscle
• If catheterised, change catheter. discuss/ • Refer if swelling of
6 hourly for 5 days. refer. passing urine, face/feet develop or exercises8.
recurrent episodes, no blood in urine persists • If vaginal
• If complicated/recurrent UTI or no better, send urine MCS. Review after better after 2 days or ≥ 2 months after prolapse or
2 days: if resistant/no better, discuss/refer. blood in urine persists. treatment. no response,
• If blood in urine, treat. Then send urine MCS: if blood persists, refer. refer.
1
Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. 2If severe penicillin allergy (history of anaphylaxis, urticaria or angioedema), omit ceftriaxone and increase azithromycin to 2g.
3
For ceftriaxone 250mg IM injection: dissolve 250mg in 0.9mL lidocaine 1% without epinephrine (adrenaline). 4Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. 5If menstruating, repeat dipstick after period has finished.
6
Patient at risk of bilharzia if s/he has washed/swam in dams, streams or lakes in an endemic area (Limpopo, North West, Mpumalanga, KwaZulu-Natal and parts of Eastern Cape). 7If microscopy not available and patient lives in endemic area, treat as
schistosomiasis. 8Repeated contraction and relaxation of pelvic floor muscles.
59
 BODY/GENERAL PAIN
• A patient has body/general pain if his/her body aches all over or most of body is painful.
• If pain localised to one area: if in back 63, arm/hand 64, leg 65, foot 66, neck 64.

Approach to the patient with body/general pain

• If on abacavir or zidovudine, check for urgent side effects  116.
• If unintentional weight loss of ≥ 5% of body weight in past 4 weeks  23.
• Are there any of: temperature ≥ 38°C, cough, blocked/runny nose, sore throat?

No Yes

Screen for joint problem: • If temperature ≥ 38°C 24. • If abdominal pain  44.
• Ask patient to place hands behind head, then behind back. Bury nails in palm and open hand. Press • If cough 38. • If nausea or vomiting  45.
palms together with elbows lifted. Walk. Sit and stand up with arms folded. • If blocked/runny nose 34. • If diarrhoea  46.
• Is patient able to do all actions comfortably? • If sore throat 35. • If burning urine  59.
• If none of these:
No Yes
Is there recent onset body pain, headache,
Check joints: are joint/s warm, tender, swollen or have limited movement? fever, or nausea/vomiting?

Yes No Yes No

62 • Test for HIV  110. If neck stiffness, drowsy/confused or Discuss with
• If low mood, stress or anxiety  86. purple/red rash, meningitis likely 30. doctor.
• Review patient's medication. If on simvastatin and muscle pain/cramps and weakness, reduce simvastatin
dose to 20mg at night. If no better, reduce dose further to 10mg or discuss with doctor/specialist. Acute viral infection likely
• If patient has a life-limiting illness, also consider giving palliative care  170. • If fever, chills or body pain, influenza or
• Ask about duration of pain: COVID-19 more likely. Consider COVID-19
 40.
< 4 weeks ≥ 4 weeks • Advise on cough/sneeze hygiene and to
wash hands regularly.
• For pain or fever, give paracetamol 1g
• Give paracetamol • Give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) as needed for up to 5 days. 4-6 hourly (up to 4g in 24 hours) as needed
1g 4-6 hourly (up Advise to only use analgesia when necessary and avoid long term regular use. for up to 5 days.
to 4g in 24 hours) • Assess and advise on chronic pain  61. • Advise antibiotics are not needed.
as needed for up • Check glucose  17. • Advise to return if symptoms persist > 7 days,
to 5 days. • Check Hb: if < 12 (woman) or < 13 (man)  27. or if fever returns and any of:
• Advise to return • Check CRP, creatinine (eGFR). If weakness/tiredness, weight gain, low mood, dry - Cough  38.
if no better after skin, constipation or cold intolerance, also check TSH. Review in 2 weeks: - Ear pain  33.
2 weeks. - If blood results normal, consider fibromyalgia 153. - Pain over cheeks, sinusitis likely  30.
- If blood results abnormal, refer to doctor. - Advise yearly influenza vaccine if HIV, heart
or lung disease.

1
Test for malaria with rapid diagnostic test if available, and parasite slide microscopy.
60
 CHRONIC PAIN
Chronic pain is pain that lasts longer than 4 weeks. A doctor should confirm the underlying cause of the pain.

Assess the patient with chronic pain at every visit

Assess Note
Site and duration of pain Ask where the pain is and when the pain started. Does pain radiate anywhere?
Type of pain • Does patient have cancer pain or non-cancer pain?
• If non-cancer pain, decide if patient has tissue pain, nerve pain or central pain:
- If arthritis, joint pain, lower back/neck pain or chronic lung problem, tissue pain likely.
- If previous shingles, trigeminal neuralgia, peripheral neuropathy or diabetic neuropathy, nerve pain likely
- If fibromyalgia or irritable bowel syndrome, central pain likely.
Severity of pain • Does pain limit activity or affect sleep, activities of daily living, mood or social/work functioning?
• Ask patient to grade pain on a scale from 0 - 10, with 0 being no pain and 10 being the worst pain: classify pain as mild (1-3), moderate (4-7) or severe (8-10).
Relieving and aggravating factors What makes the pain better or worse? What has patient been using to help pain? Does pain medication help? Use this to help patient decide which pain strategies will help the most.
Mental health Ask how patient is coping and what support and/or spiritual care is needed. If low mood, stress or anxiety  86.
Alcohol/drug use In the past year, has patient: 1) drunk ≥ 4 drinks1/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.
Chronic conditions Ensure patient is receiving appropriate care for all his/her other chronic conditions. Manage as on routine care page/s.
Palliative care If patient has a life-limiting illness, also consider giving palliative care  170.
Examine area of pain If skin problem 67. If joint problem  62. If back, neck, leg, foot, arm or hand problem, manage as on symptom page.

Advise the patient with chronic pain

• Ask what patient thinks is causing pain and what impact it is having on his/her life and family. Address patient’s and family's concerns about pain. For tips on communicating effectively  176.
• Educate that non-cancer chronic pain can be because pain signals in the brain stop working normally and get stuck in the ‘on’ position, even when the cause has resolved. It does not always mean a
disease or cancer. Tests cannot always show the reason for the pain and often are not needed.
• Help the patient, along with his/her family, to choose strategies to get help and cope with chronic pain:
Get enough sleep Encourage patient to take time to relax: Get active Access support
If patient has difficulty Find a Aim for at least 30 minutes Link patient with helpline or
Do relaxing breathing
sleeping, give advice creative or of moderate exercise support group  178.
and stretching exercises
 87. fun activity most days. Start with
each day.
to do. 10 minutes/day and
increase steadily. Limit alcohol and avoid drugs
Manage activities • Limit alcohol to ≤ 2 drinks/day and
Advise to stagger tasks and to avoid trying avoid alcohol on at least 2 days/week.
to fit too many activities into one day. • Avoid drugs and unnecessary pain
Spend time with supportive friends or family. medication.

Treat the patient with chronic pain

• Manage pain together with patient and interdisciplinary team: refer if needed to physiotherapist, occupational therapist, spiritual counsellor/psychologist, social worker and community health worker.
• Together with the patient, set realistic pain management goals: to be as pain-free as possible (this might not be completely pain-free) so that s/he can do the things s/he wants and enjoys doing.
• Treat the patient’s chronic pain on relevant symptom or routine care page. If appropriate, suggest patient tries movement exercise and heat/cold packs as these may help ease the pain.
1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer.
61
 JOINT SYMPTOMS
Give urgent attention to the patient with a joint symptom/s and:
• Short history of single warm, swollen, extremely painful joint with limited range of movement, septic arthritis likely • Temperature ≥ 38°C
• Injury in past 48 hours and severe pain/swelling or deformity, fracture likely 18. • Unable to weight-bear
Management:
• If known gout and affected joint involves big toe, midfoot or ankle and no fever, wound, surgery or injection into joint, discuss with specialist if referral needed:
if not, acute gout likely 152.
• Refer urgently.

Approach to the patient with joint symptoms not needing urgent attention
• Check joints and ask patient to place hands behind head, then behind back. Bury nails in palm and open hand. Press palms together with elbows lifted. Walk. Sit and stand up with arms folded.
• Is there any of: joint warm/tender/swollen or unable to do all actions comfortably?

No Yes
Joint problem unlikely Has there been recent injury?

• If body/general pain No Yes

60.
• If back pain 63. Ask about duration of joint pain. Has joint pain lasted ≥ 6 weeks? Sprain/strain likely
• If neck pain 64. • Rest and elevate joint.
• If arm symptoms 64. • Apply ice and a pressure
• If leg symptoms 65. No Yes
Has patient had recent genital discharge or painless non-itchy skin rash? Chronic bandage.
• If foot symptoms 66. • Give paracetamol
arthritis
likely 1g 4-6 hourly (up to
Yes No 4g in 24 hours) as
Gonococcal Any sudden onset of 1-3 warm, extremely painful, red, 151.
needed for up to 5
arthritis likely swollen joints (often big toe or knee)? days. If no response,
• Usually involves give ibuprofen 400mg
wrists, ankles, No Yes 8 hourly with food as
hands and feet. needed for up to 7 days
• Refer/discuss (avoid if peptic ulcer,
same day. • Give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) as needed for Acute asthma, hypertension,
• Treat patient's up to 5 days and methyl salicylate ointment to rub on affected joint. gout likely heart failure, kidney
partner/s as for If no response, give ibuprofen 400mg 8 hourly with food as needed for 152. disease).
cervicitis/male up to 5 days (avoid if peptic ulcer, asthma, hypertension, heart failure, • If available, arrange
urethritis 49. kidney disease). physiotherapy.
• Test for HIV  110. • Advise to mobilise joint
• Review after 1 month or sooner if joint pain worsens. If worsens, refer. after 2-3 days, if not too
• While waiting for appointment: painful.
- If pain in hands or feet, refer to occupational therapist, if available, • Review after 1 week: if
and if pain in other joints, refer to physiotherapist, if available. no better, arrange x-ray
- Assess and advise on chronic pain  61. and doctor review.

62
 BACK PAIN
Give urgent attention to the patient with back pain and any of:
• Bladder or bowel disturbance- retention or incontinence • Pulsatile abdominal mass: abdominal aortic aneurysm likely
• Numbness of buttocks, perineum or legs • If flank, check urine dipstick:
• Leg weakness or difficulty walking - If leucocytes/nitrites with fever with, and any of: vomiting, BP < 90/60, pulse ≥ 100, diabetes, male,
• Recent injury and x-ray unavailable or abnormal pregnant or post menopause: complicated pyelonephritis likely
• Sudden onset severe upper abdominal pain with nausea/vomiting: - If blood with sudden, severe, one-sided pain radiating to groin: kidney stone likely
pancreatitis likely • Known cancer patient
Manage and refer urgently:
• If abdominal aortic aneurysm likely: avoid giving IV fluids even if BP < 90/60 (raising blood pressure may worsen rupture).
• If BP < 90/60 or pancreatitis likely, give sodium chloride 0.9% 500mL IV over 30 minutes, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens.
• If complicated pyelonephritis likely: first collect urine for MCS and then give ceftriaxone 1g IV1/IM.
• If kidney stone likely: give sodium chloride 0.9% 1L IV 6 hourly. If pain severe, give morphine 10mg IM or 3-10mg slow IV2.
• If patient known to have cancer, refer same day.

Approach to patient with back pain not needing urgent attention

• If flank pain with leucocytes/nitrites on urine dipstick, uncomplicated pyelonephritis likely: send urine for microspcopy, culture, sensitivity. Give ciprofloxacin 500mg
12 hourly for 7 days and paracetamol 1g 4-6 hourly (up to 4g in 24 hours) as needed for up to 5 days. If no better after 2 days, refer same day.
• Does patient have any of: cough, weight loss, night sweats or fever?

Yes No
Any of: > 50 years, pain progressive or for > 6 weeks, previous cancer or back surgery, osteoporosis, oral steroid use, HIV, IV drug use or deformity?
Exclude TB
 92 and Yes No
Any of: < 40 years, sleep disturbed by pain, pain better with exercise, does not get better with rest?
• Doctor to do back x-ray and CRP.
• Discuss results with specialist/refer. No Yes Unsure
Mechanical back pain likely Inflammatory back
• Measure waist circumference: if > 80cm (woman) or 94cm (man), assess CVD risk  127. pain likely
• If low mood, stress or anxiety  86.
• Reassure patient that back pain is very common, and usually gets better on its own. Explain that pain does not
Doctor to:
always mean a disease or cancer, and tests cannot always show the reason for the pain and often are not needed.
• Check CRP and test for HIV  110.
• Advise patient to be as active as possible, continue to normal activity and avoid resting in bed.
• Give ibuprofen3 400mg 8 hourly
• Advise patient that regular exercise may prevent recurrence of back pain.
with food for up to 5 days.
• Give pain relief:
• Do back x-ray.
- Give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) as needed for up to 5 days.
• Discuss results with specialist/refer.
- If poor response after 1 week, add ibuprofen3 400mg 8 hourly with food for up to 5 days.
- If still a poor response add tramadol 50mg 6 hourly for up to 5 days.
• If pain persists > 2 weeks, or unable to cope with daily activities/work, refer for physiotherapy.
• If pain persists ≥ 4 weeks, assess and advise  61, and refer to doctor. If bladder/bowel disturbance, numbness or
weakness develops, refer urgently.
1
Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. 2Dilute 10mg morphine with 9mL of sodium chloride 0.9%. Give diluted morphine 3mL IV over 3 minutes (1mL/minute). If needed, give
another 1mL/min until pain improved, up to 10mL. Stop if BP drops < 90/60. 3Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. If patient also taking aspirin, advise to wait at least 30 minutes after taking aspirin before taking ibuprofen.
63
 NECK PAIN
Give urgent attention to the patient with neck pain and any of:
• Neck stiffness and any of: temperature ≥ 38°C, headache, drowsy/confused or purple/red rash: meningitis likely. Give ceftriaxone 2g IV1/IM. Avoid injecting > 1g IM at one injection site.
• Neurological symptoms in arms/legs: weakness, numbness, clumsiness, stiffness, change in gait or difficulty with co-ordination
• Recent injury and x-ray unavailable/abnormal or neurological symptoms: apply rigid neck collar and immobilise head with tape and sandbags/IV fluid bags on either side of head.
Refer urgently.

Approach to the patient with neck pain not needing urgent attention
Any of: >50 years, pain progressive or lasting > 6 weeks, oral steroid use, HIV, diabetes, IV drug use, unexplained weight loss/fever or TB/neck surgery/previous cancer?

Yes No

• Do cervical spine x-ray. • Give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) for up to 5 days. If no response, give ibuprofen2 400mg 8 hourly with food for up to 5 days.
• Check CRP. • If no better after 5 days and no arm pain, refer for physiotherapy. If pain ≥ 4 weeks, assess and advise  61.
• Discuss with specialist. • If no response after 6 weeks, arm pain, weakness/numbness develops or pain worsens, do cervical spine x-rays and refer.

ARM OR HAND SYMPTOMS

• Check joints and ask patient to place hands behind head, then behind back. Bury nails in palm and open hand. Press palms together with elbows lifted. Walk. Sit and stand up with arms folded.
• If joint warm/tender/swollen or unable to do all actions comfortably, joint problem likely 62.

Give urgent attention to the patient with arm or hand symptoms and any of:
• Arm pain with chest pain 37.
• If recent injury and severe pain/swelling or deformity, fracture likely 18.
• New sudden onset of weakness of arm with/without difficulty speaking or visual disturbance: consider stroke or TIA 136.

Approach to the patient with arm or hand symptoms not needing urgent attention

Painful shoulder Wrist/hand pain: intermittent, worse Elbow pain with or after elbow flexion/extension. Pain at base of thumb worsened by thumb or
at night, relieved by shaking. May be May have decreased grip strength. wrist movement or catching/locking of finger
Referred pain likely numbness/tingling in 1st, 2nd and 3rd
Ask about neck pain (see above), cough/ fingers or weakness of hand. Tennis or golfer’s elbow likely Tenosynovitis of hand/wrist likely
difficulty breathing 38, chest pain • Advise patient to apply ice to elbow and rest arm. • Rest and splint joint.
37, abdominal pain 44, pregnancy Carpal tunnel syndrome likely • Give ibuprofen2 400mg 8 hourly with food for 10 days. • Give ibuprofen2 400mg 8 hourly with food
157. Splint wrist in neutral position at night. • Refer for physiotherapy. for up to 5 days.

If no better after 6 weeks or worsens, refer to doctor.

Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. 2Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. If patient also taking aspirin, advise to wait at least 30
1

minutes after taking aspirin before taking ibuprofen.

64
 LEG SYMPTOMS
• Screen for joint problem:
- Check joints and ask patient to place hands behind head, then behind back. Bury nails in palm and open hand. Press palms together with elbows lifted. Walk. Sit and stand up with arms folded.
- If joint warm/tender/swollen or unable to do all actions comfortably, joint problem likely 62.
• If the problem is only in the foot 66.

Give urgent attention to the patient with leg symptoms and any of
• Unable to bear weight following injury, fracture likely  18.
• Swelling and pain in one calf: deep venous thrombosis likely, especially if BMI1 > 30, smoker, immobile, pregnant, on oestrogen, leg trauma, recent hospitalisation, TB or cancer
• Sudden severe leg pain at rest with any of the following in the leg: numbness, weakness, pallor, no pulse: acute limb ischaemia likely
• Muscle pain in legs or buttocks on exercise associated with pain at rest, gangrene or ulceration: critical limb ischaemia likely
Refer urgently.

Approach to the patient with leg symptoms not needing urgent attention:
• Review patient’s medication. If on simvastatin and muscle pain/cramps and weakness, reduce simvastatin
dose to 20mg at night. If no better, reduce dose further to 10mg or discuss with doctor/specialist.
• Is there leg swelling?

No Yes

Pain in buttock radiating down back of lower leg Muscle Both legs swollen One leg swollen
pain in
Irritation of sciatic nerve likely legs or Is there difficulty breathing Has there been a recent injury?
• Give paracetamol 1g 4-6 hourly (up to 4g in 24 buttocks worse on lying flat?
hours) as needed for up to 5 days. on exercise
that is Yes No
• If no better, add ibuprofen2 400mg 8 hourly Yes No
with food for up to 5 days. relieved
• Advise to be as active as possible, continue by rest Sprain/strain likely Check skin: are there painful areas, ulcer/s,
normal activity and avoid resting in bed. Heart • Exclude • If unable to weight-bear, refer same day. lump/s or changes in skin colour?
• If available, refer for physiotherapy. Peripheral failure pregnancy • Rest and elevate leg.
• Explain that pain does not always mean a vascular likely  157. • Apply ice and a pressure bandage. Yes No
disease or cancer, and tests cannot always disease 135 • Check for kidney • Give ibuprofen 400mg 8 hourly with
show the reason for the pain and often are not likely disease on urine food and paracetamol 1g 4-6 hourly
dipstick: if blood (up to 4g in 24 hours) as needed for 67 Is there a groin lump/s?
needed. 139.
• Advise patient to return and refer same day if: or protein, check up to 5 days. Avoid ibuprofen if peptic
- Retention or incontinence of urine or stool BP  132 and ulcer, asthma, hypertension, heart Yes No
- Numbness of buttocks, perineum or legs refer to doctor. failure or kidney disease.
- Leg weakness • If none of the • Advise to mobilise leg after 2-3 days, 25 Refer
- Difficulty walking above or unsure even if mild to moderate pain. same
• If pain ≥ 4 weeks, assess and advise  61 and of diagnosis, refer • Refer for physiotherapy. week.
refer to confirm diagnosis. same week. • Review after 1 week: if no better,
arrange x-ray and doctor review.

1
BMI = weight (kg) ÷ height (m) ÷ height (m). 2Avoid if peptic ulcer, asthma, hypertension, heart failure, kidney disease.
65
 FOOT SYMPTOMS
Check if problem is in the joint: ask patient to walk. Sit and stand up with arms folded. If unable to do all actions comfortably and problem seems to be specifically in the joint  62.

Give urgent attention to the patient with foot symptoms and any of:
• Unable to bear weight following injury  18.
• Sudden severe foot pain at rest with any of the following in the leg: numbness, weakness, pallor, no pulse: acute limb ischaemia likely
• Muscle pain in legs or buttocks on exercise associated with foot pain at rest, ulcer or gangrene on foot: critical limb ischaemia likely.
Refer urgently.

Approach to the patient with foot symptoms not needing urgent attention
If cracks/peeling/scaly lesions between toes or thickened scaly skin on soles/heels/sides of feet, tinea pedis (athlete's foot) likely 70.

Generalised foot pain Localised pain

Ensure that shoes fit properly.
Constant burning pain, pins/needles or numbness of feet worse at night Foot
pain with Heel pain, worse on starting walking Foot deformity
Peripheral neuropathy likely muscle Bony lump at base of
pain in legs Plantar fasciitis likely big toe; may have callus,
• Test for HIV  110 and syphilis. If HIV positive, give routine care  111. If syphilis positive  53.
or buttocks • Advise to: decrease aggravating physical activity redness or ulcer
• Exclude diabetes  17.
• In the past year, has patient: 1) drunk ≥ 4 drinks1/session, 2) used illegal drugs or 3) misused (like running). Apply ice. Avoid bare feet - wear
prescription or over-the-counter medications? If yes to any  142. If harmful alcohol use, Peripheral shoes with good support or use shoe inserts. Stretch Bunion likely
give thiamine 100mg daily. vascular and exercise feet regularly: stretch calf muscle/s • Give paracetamol 1g
• Give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) when needed and amitriptyline2 disease on waking and before sleep, roll foot/feet over 4-6 hourly (up to 4g
25mg (or 10mg if ≥ 65 years) at night. If needed, increase by 25mg (or 10mg if ≥ 65 years) likely colddrink bottle. in 24 hours) for up to
every 2 weeks, up to 75mg at night. 139. • If BMI3 > 25, assess CVD risk  127. 5 days.
• If on isoniazid, increase pyridoxine to 25mg 8 hourly for 3 weeks, followed by 50mg daily. If • Give as needed: paracetamol 1g 4-6 hourly (up to • If severe pain or
pregnant, discuss/refer. 4g in 24 hours) or ibuprofen 400mg 8 hourly with ulcer, refer.
• If one-sided, weakness or severe numbness, refer same week. food for up to 5 days (avoid ibuprofen if peptic ulcer,
• If patient known to have cancer, refer same day. asthma, hypertension, heart failure or kidney disease).
• If no better with treatment, discuss/refer. • Refer for physiotherapy, if available.

In the patient with diabetes or PVD identify the foot at risk. Review more frequently the patient with diabetes or PVD and any of:
• Skin: callus, corns, cracks, wet soft skin between toes  70, ulcers  75. • Sensation: light prick sensation abnormal after 2 attempts.
• Foot deformity: most commonly bunions (see above). If foot deformity, refer for specialist care. • Circulation: absent or reduced foot pulses.
 59
Advise patient with diabetes or PVD to care for feet daily to prevent ulcers and amputation
• Inspect and wash feet daily and carefully dry between the toes. Avoid soaking your feet. • Avoid walking barefoot or wearing shoes without socks. Change socks/stockings daily. Inspect inside shoes daily.
• Moisten dry cracked feet daily with emulsifying ointment (UE). Avoid moisturising • Clip nails straight, file sharp edges. Avoid cutting corns or calluses yourself and chemicals/plasters to remove them.
between toes. • Avoid testing water temperature with feet or using hot water bottles or heaters near feet.
• Tell your health worker at once if you have any cuts, blisters or sores on the feet.
1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer. 2Avoid if on bedaquiline. 3BMI = weight (kg) ÷ height (m) ÷ height (m).
66
 SKIN SYMPTOMS
Give urgent attention to the patient with skin symptoms and any of:
• If sudden generalised itch/rash or face/tongue swelling and any of: wheeze, difficulty breathing, BP < 90/60, dizziness/collapse, abdominal pain, vomiting or exposure to possible
allergen1, check for anaphylaxis  20.
• Purple/red rash with any of: neck stiffness, drowsy/confused, temperature ≥ 38°C, headache: meningococcal disease likely
• Diffuse rash appearing within 3 months of starting a new medication and any of the following, serious drug reaction likely:
- BP < 90/60 - Involves mouth, eyes or genitals
- Temperature ≥ 38°C - Blisters, peeling or raw areas
- Abdominal pain - Jaundice
- Vomiting or diarrhoea
Management:
• If meningococcal disease likely: give ceftriaxone 2g IV2/IM. Avoid injecting > 1g IM at one injection site.
- Prevent disease in close household contacts:
• If pregnant or child contact < 6 years old, give ceftriaxone 250mg IM.
• If child 6-12 years old, give ciprofloxacin 250mg as a single dose.
© University of Cape Town
• If ≥12 years, give ciprofloxacin 500mg as a single dose.
• If serious drug reaction likely: stop all medication. If peeling or raw skin, also manage as for burns before referral  21.
• If BP < 90/60, give sodium chloride 0.9% 500mL IV over 30 minutes, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens.
• Refer urgently.

Approach to the patient with skin symptoms not needing urgent attention
Manage according to skin symptom/s:

Pain Itch Generalised, Lump/s Pimples/ Ulcer/s or Crusts Flaky skin Changes in Scalp
non-itchy rash blackheads non-healing skin colour symptoms
wound
68 Rash No rash 78
72 74 79 80
Generalised 75
Localised 71

69 70

If rash is extensive, recurrent or difficult to treat, test for HIV  110.

1
Common allergens include medication, food or insect bite/sting within the past few hours. 2Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone.
67
 PAINFUL SKIN
Check if the patient needs urgent attention  67.

Red, warm, painful lump which may be Red, warm, swollen skin Painful blisters in a band along one side
fluctuant in the centre. May discharge pus. Are borders poorly or clearly defined?

Poorly-defined borders Clearly-defined raised borders

© University of Cape Town

© University of Cape Town

Boil/abscess likely
• If fluctuant, arrange incision and drainage.
• Give paracetamol 1g 4-6 hourly (up to 4g in Herpes zoster (shingles) likely
24 hours) as needed for up to 5 days. • Test for HIV  110.
• If multiple lesions, lesion on face, extensive • Advise to keep lesions clean and dry, and to avoid skin contact
surrounding infection, temperature ≥ 38°C, with others until crusts have formed.
HIV or diabetes, give antibiotic: © University of Cape Town © University of Cape Town • Give aciclovir 800mg 5 times a day (4 hourly missing the middle
- Give flucloxacillin 500mg 6 hourly or of the night dose) for days if:
cefalexin 500mg 6 hourly for 5 days. - ≤ 3 days since onset of rash or
- If severe penicillin allergy1, give instead Cellulitis likely Erysipelas likely - At risk of severe infection (> 65 years, HIV, diabetes, severe heart/
azithromycin 500mg daily for 3 days. liver disease or alcohol abuse) and lesions not yet crusted.
• Advise to wash with soap and water, keep • Give flucloxacillin 500mg 6 hourly or cefalexin 500mg 6 hourly for 5 days. If • For pain:
nails short and avoid sharing clothing or severe penicillin allergy1, give instead azithromycin 500mg daily for 3 days. - Give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) as needed.
towels. • Give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) as needed for up - If needed, add tramadol 50mg 6 hourly. If poor response, doctor
• If recurrent boils or abscesses: to 5 days. to increase dose to tramadol 100mg 6 hourly.
- Test for HIV  110 and diabetes  17. • If limb affected, advise to keep elevated. - If pain persists after rash has healed, give amitriptyline2 25mg
- Wash once with chlorhexidine 0.05% • Refer same day if: at night. If no response, increase by 25mg every 2 weeks, up to
solution from neck down. - BP < 90/60 75mg if needed.
• Refer same day if: - Pulse > 100 - If still poor response, refer.
- BP < 90/60 - Confused • If infected (skin red, warm, swollen):
- Pulse > 100 - Hand, face or scalp involvement - Give flucloxacillin 500mg 6 hourly or cefalexin 500mg 6 hourly
- Deep abscess difficult area to drain (hands, - Extensive infection for 5 days.
breast, perineum) - Blisters or grey/black skin - If severe penicillin allergy1, give instead azithromycin 500mg
- No response to treatment within 2 days - Poorly controlled diabetes daily for 3 days.
- Recurrent infections with underlying problem (like lympoedema) • Refer same day if:
- No response to treatment within 2 days - Eye, ear or nose involvement
- Suspected meningitis (headache, temperature ≥ 38°C,
neck stiffness)
- Rash involves more than one region
1
History of angioedema, anaphylaxis or urticaria. 2Avoid if on bedaquiline.
68
 GENERALISED ITCHY RASH
Check if the patient needs urgent attention  67.

If red itchy crops of bumps that may have blistered or healed with darkening of skin, may have scratch marks, insects bites likely 70.

Small red bumps and burrows in webspaces Hyperpigmented, itchy Patches of dry, scaly, itchy skin on wrists, Very itchy, red, raised Diffuse red rash
of fingers, axillae, waist and genitals. Very itchy, bumps on limbs, trunk or face ankles, inside elbows or behind knees. wheals that appear mainly on trunk,
especially at night. suddenly and usually arms and legs,
disappear within 24 hours which appeared
within 3 months
of starting a new
medication.

© University of Cape Town

© University of Cape Town
© University of Cape Town
© University of Cape Town Eczema likely
• Advise that eczema is a chronic condition with Urticaria likely
Papular pruritic eruption
Scabies likely episodes of acute exacerbations. • Help to identify and © BMJ Best Practice
(PPE) likely
• Apply benzyl benzoate 25% lotion from neck to • Advise to avoid triggers such as soap, detergents, heat, advise to avoid triggers2.
• Test for HIV  110.
soles of feet and rub in well: fabrics that cause itch, overheating at night. • Apply calamine lotion
• If lesions in webspaces,
as needed. Drug reaction likely
- Leave on for 24 hours, then wash off with soap axillae or genitals, also • If low mood, stress or anxiety  86. 73.
and water. • If severe, start at Step 3. • If recurrent eye problem,
treat for scabies in adjacent
- If severe, repeat once after 24 hours or within • Step 1. Wash with aqueous cream (UEA) instead of exclude allergic
column.
5 days. soap. Moisturise skin with emulsifying ointment (UE) conjunctivitis  31.
• Apply hydrocortisone 1%
• Only if no better, apply permethrin 5% lotion twice a day and immediately after bathing. • If recurrent nose
cream twice a day for 7 days
at night from neck to soles of feet. Wash off after • Step 2. If no better after 7 days or more severe problem, exclude
(apply sparingly to face,
8-12 hours. Repeat after 1 week if needed. Avoid eczema: apply hydrocortisone 1% cream twice a day allergic rhinitis  34.
avoid eyes)
using permethrin and benzyl benzoate together for 7 days (apply sparingly to face, avoid eyes). If good • If recurrent cough or
• For itch, give certirizine
as may be toxic. response, reduce to once a day for 3 days, then stop. wheeze, exclude asthma
10mg daily.
• For itch, give chlorphenamine 4mg 8 hourly for up • Step 3. If poor response to hydrocortisone or severe  123.
• Advise patient:
to 10 days. If mild itch, use only at night. eczema, apply instead betamethasone 0.1% ointment • For itch, give
- Reduce exposure to insect
• Advise can return to work after first treatment. once a day for 7 days (avoid face and neck). If good chlorphenamine 4mg
bites.
• Treat all household contacts and sexual partners response, reduce to once a day for 3 days, then stop. 6-8 hourly.
- May be long-standing
at the same time, even if asymptomatic. • For itch, give certirizine 10mg daily. • Advise to return
and skin often remains
• Wash recently used linen and clothing in very hot • If oozing, pus or yellow crusts, treat for infection: give immediately if
hyperpigmented.
water and dry well. Expose to direct sunlight. flucloxacillin 500mg 6 hourly or cefalexin 500mg any symptoms of
- May temporarily worsen
• If yellow crusts, also treat for likely impetigo  78. 6 hourly for 5 days. If severe penicillin allergy1, give anaphylaxis3 occur.
after starting ART.
instead azithromycin 500mg daily for 3 days. • If no better after 24
• Refer if: no better after 2 weeks, extensive hours, refer.
If no response to treatment, discuss/refer. involvement or painful pustules.

1
History of anaphylaxis, urticaria or angioedema. 2Common triggers include foods (milk, eggs, nuts, wheat, seafood), medications, insect bites/stings and latex. 3Symptoms of anaphylaxis include wheeze, difficulty breathing, dizziness/collapse, abdominal
pain, vomiting.
69
 LOCALISED ITCHY RASH
Check if the patient needs urgent attention  67.

• If rash on scalp  80.

• If very itchy, small red bumps and burrows in webspaces of fingers, axillae, waist or genitals, scabies likely 69.
• If patches of dry, scaly, itchy skin on wrists, ankles, inside elbows or behind knees, eczema likely 69.

Are there red itchy bumps that may have blistered or healed with darkening of skin?

Yes No: check site of rash.

Usually occurs in crops. Head/face, trunk or limbs Feet

Ask where rash started and how it has progressed. Look at distribution of rash, check for raised edges and check nails. Cracks, peeling or scaly
lesions between toes, or
Well-defined, raised plaques covered Started as one large Slow-growing lesion/s with raised thickened scaly skin on
with silvery scale. Often on knees, elbows, ring on chest or back edges/ring of scale, clear in centre soles, heels and
lower back, scalp. May have pitted nails. (herald patch) with fine sides of feet.
scale in centre. Typically
followed within 2 weeks
by smaller, oval, scaly
© University of Cape Town patches. May be in
pattern of christmas tree
Insect bites likely © University of Cape Town on the back.
• Advise to reduce exposure to © University of Cape Town
insects: Psoriasis likely
© CDC Public Health Image Library
- Treat pets, use bed nets, wash • Refer to specialist to confirm diagnosis. Tinea corporis (ringworm) likely
bedding, use insect repellents. • While waiting for appointment: Tinea pedis
- Clear away puddles of water - Moisturise skin with emulsifying (athlete's foot) likely
around house. ointment (UE) twice a day.
• Advise to avoid scratching. - Apply betamethasone 0.1% ointment • Advise to keep skin clean, to dry well and avoid sharing towels,
• Apply calamine lotion as needed. twice a day. Once improving, apply © University of Cape Town
clothes, combs and hair brushes.
• If severe itch, give instead hydrocortisone 1% twice a day, • If on feet, encourage open shoes and avoid socks of
chlorphenamine 4mg at night, or then reduce to once a day. Stop as soon Pityriasis rosea likely synthetic material.
up to 6-8 hourly for up to 5 days. as better or • Reassure that rash will resolve within 2 months. • Apply clotrimazole 1% cream 3 times a day or, if on feet, twice
• If blisters/heals with darkened - Apply liquor picis carbonis (LPC) BP 5% • Apply aqueous cream (UEA) 3 times a day. a day. Continue for 2 weeks after rash has cleared (at least
skin, manage as likely papular ointment once a day. • For itch: 4 weeks for tinea pedis).
urticaria  22. • Encourage to expose skin to sunlight - Give chlorphenamine 4mg at night. • If extensive or recurrent, test for HIV  110 and diabetes  17.
• If yellow crusts, impetigo likely before 10am or after 3pm for up to - If itch no better or severe daytime itch, give • If involves nails  82.
 78. 30 minutes per day. instead certirizine 10mg daily. • If extensive or no better after 1 month, refer.

If diagnosis uncertain, discuss/refer.

70
 ITCH WITH NO RASH
Check if the patient needs urgent attention  67.

• Confirm there is no rash, especially scabies, lice or insect bites.

- If generalised itchy rash 69.
- If localised itchy rash 70.
• If itch around anus only 48.

Is the skin very dry?

Yes No

Dry skin (xeroderma /ichthyosis) likely Did the patient start any new medications in the weeks before the itch started?

Yes No

Medication side-effect likely • If yellow skin/eyes, jaundice likely 79.

• Continue the medication only if still necessary. • If itch persists > 2 weeks:
• Advise to return if rash develops or itch persists. - Test for anaemia  27, HIV  110 and diabetes  17.
- Check CRP, creatinine (eGFR), ALT and TSH.
- Refer to doctor.

• Advise to:
- Avoid hot baths, wool/itchy fabrics and scratching as these may worsen itch.
- Wash with aqueous cream (UEA) instead of soap. Avoid using aqueous cream as moisturiser (emollient).
- Moisturise skin with emulsifying ointment (UE) twice a day.
- Avoid scrubbing the skin and washing more than once a day. Gently pat skin dry.
- Keep nails short.
• If severe itch, give chlorphenamine 4mg at night, or up to 6-8 hourly for up to 5 days.
• If known with a life-limiting illness, consider giving palliative care  170.
• If no better, discuss/refer.

If diagnosis uncertain, discuss/refer.

71
 GENERALISED NON-ITCHY RASH
Check if the patient needs urgent attention  67.

• Check for tick bite (small dark brown/black scab). If tick bite or tick present and headache, fever or body pain, tick bite fever likely 24.
• Test for syphilis and HIV  110.

Syphilis positive HIV positive Syphilis and HIV negative

Secondary syphilis likely Give routine HIV care Was patient at risk1 of HIV in the past 6 weeks?
Rash often on palms and soles. May have wart-like lesions on  111.
genitals and patchy hair loss.
Yes No

• Rash may be part of HIV seroconversion illness.

Repeat HIV test after 6 weeks.
• Encourage safe sex practices.

© CDC Public Health Image Library © University of Cape Town

Treat for early syphilis  53.

Has patient started anticonvulsant, ART, TB medication, co-trimoxazole or TB preventive treatment (TPT) in the past 3 months?

Yes No

Consider drug rash 73. Non-specific viral rash likely

• Patient may have fever, headache, lymphadenopathy, muscle pain/body aches.
• Reassure rash will resolve on its own.
• If fever or pain, give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) as needed for up to 5 days.

If rash persists ≥ 2 weeks or diagnosis uncertain, discuss/refer.

1
HIV can be transmitted though sexual contact (assault or consensual, burst condom), occupational exposure (sharps injury, splash to eye, mouth, nose or broken skin), human bite, sharing needles, contact with used condom and exposure to blood in
sport or at accident scene.
72
 DRUG RASH
• A drug rash can be caused by any medication, commonly antibiotics, anticonvulsants especially lamotrigine, ART, TB medication, co-trimoxazole, TB preventive treatment (TPT) and NSAIDs (like ibuprofen).
• Suspect a drug rash in a patient with a generalised rash which appeared within 3 months of starting a new medication.

Give urgent attention to the patient with a drug rash and any markers of severity:
• Face or tongue swelling • BP < 90/60 • Abdominal pain • Involves mouth, eyes or genitals • Jaundice
• Difficulty breathing • Temperature ≥ 38°C • Vomiting or diarrhoea • Blisters, peeling or raw areas
Manage and refer urgently:
Serious drug reaction likely:
• Stop all medication. If peeling or raw skin, also manage as for burns before referral  21.
• If BP < 90/60, give sodium chloride 0.9% 500mL IV over 30 minutes, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens.

Approach to the patient with a drug rash not needing urgent attention
Is patient on ART, first-line TB medication1, co-trimoxazole (CPT) or TPT?

Yes No

• Refer to doctor if available. • Discuss with doctor

• If on ART: whether to stop or
- If on abacavir, check for abacavir hypersensitivity reaction (AHR)  116. change medication.
- If on nevirapine, doctor to switch ART  117. • If itchy, give
• If on first-line TB medication1 or TPT, continue. chlorphenamine 4mg
• If on co-trimoxazole prophylaxis2, stop it until rash resolved. If rash resolves, discuss with at night, or up to 8
doctor about re-starting co-trimoxazole. hourly for up to 5 days.
• If on any other medications, discuss with doctor whether to stop or change them. • If dark coloured
© University of Cape Town • If itch, give chlorphenamine 4mg at night, or up to 8 hourly for up to 5 days. round macules (flat
spots) that occur
anywhere on body
Check ALT. Review patient and result within 24 hours: following ingestion of
a medication and often
start as itchy patches
Patient unwell or ALT ≥ 120 Patient well and ALT < 120
with red edges, fixed
drug eruption likely:
• Continue medications and review daily until improving. apply hydrocortisone
• Advise to return urgently if rash worsens or markers of severity occur. 1% to affected areas
• Repeat ALT in 1 week. Review patient and result within 24 hours: daily for 5 days.
• Advise to return
urgently if markers of
Patient unwell or ALT ≥ 120 Patient well and ALT < 120 severity occur.
Continue medications at same dose.

Give urgent attention 67.

Advise to return if rash persists ≥ 2 weeks: discuss/refer.

First-line TB medications include isoniazid (INH), rifampicin (RIF) and pyrazinamide (PZA) and ethambutol (ETH). 2If on co-trimoxazole treatment for pneumocystis pneumonia (PJP), toxoplasmosis or Isospora belli diarrhoea, discuss with specialist.
1

73
 SKIN LUMP/S
Refer same week the patient with a mole that:
• Is irregular in shape or colour • Differs from surrounding moles • Bleeds easily
• Changed in size, shape or colour • Is > 6mm wide • Itches

If painful, firm, red, warm lump which softens in the centre to discharge pus, boil/abscess likely 68.

Round, raised papules with Small, skin-coloured Painless, Smooth, well defined lump beneath skin Red papules, pustules, nodules and
rough surfaces pearly bumps with purple/brown blackheads, usually on face.
central dimples lumps on skin Round, firm lump. May have Soft, doughy lump May involve chest, back and upper arms
central hole and discharge which is painless
white substance. and moves easily.

© University of Cape Town

© University of Cape Town

Warts likely © University of Cape Town

• Usually on hands, knees or © University of Cape Town Acne likely
elbows but can occur anywhere. © University of Cape Town • Advise to wash skin with mild soap twice
• Plantar warts on the soles of Molluscum Epidermoid cyst likely a day and to avoid picking, squeezing and
the feet are thick and hard with contagiosum likely © BMJ Best Practice Usually found on face and trunk, scratching.
• Test for HIV  110. Lipoma likely • Advise to avoid oily cosmetics and hair products.
black dot/s. uncommon on limbs. Usually found on trunk
• Reassure that • If blackheads only:
Kaposi’s sarcoma or upper limb.
lesions often resolve - Apply tretinoin 0.05% cream sparingly
• Reassure that warts often resolve likely • If not infected, reassure there is
spontaneously after at night until better, for at least 6 weeks.
spontaneously. • Lesions vary from no need to treat.
several years or with • Reassure lump will Avoid if pregnant or breastfeeding and
• If treatment desired: isolated lumps to • If infected (skin red, warm,
ART. not become cancer limit sun exposure. Acne may worsen
- Soften wart/s by soaking in warm large ulcerating painful):
• If treatment desired: and usually does not before improving. Review after 6 weeks.
water for 5 minutes at night and tumours. - If fluctuant, arrange incision
open molluscum need removal. • If red and swollen areas:
scrub gently with clean nail file. • May also appear and drainage. If on face, refer
with sterile needle • Refer if: - Apply instead benzoyl peroxide 5% gel
- After drying well, apply in mouth and on instead.
and apply tincture of - > 3cm to affected areas in morning. Wash off in
petroleum jelly to surrounding genitals. - Give flucloxacillin 500mg
iodine BP to center - Causing pain or evening. If no better and tolerating gel,
skin to protect it, then apply of each lesion. 6 hourly or cefalexin 500mg 6 discomfort apply twice daily and give doxycycline2
salicylic acid 15-30% to wart, • Refer if: • Test for HIV  110. hourly for 5 days. - Getting bigger 100mg daily with meals, for 3 months.
and cover with plaster. - Extensive • Refer for biopsy to - If severe penicillin allergy1, give - Firm or deep • If woman needing contraception, advise
- Repeat every night and continue - Lesions on eyelid confirm diagnosis instead azithromycin 500mg beneath skin combined oral contraceptive  154.
for a week after wart has - Intolerable and and for further daily for 3 days. - New lump that • Advise that response may take several
come off. not responding to management. • If intolerable or recurrent persists > 1 month weeks to months.
• If extensive warts or plantar wart treatment infections, arrange for excision - Intolerable • If severe or no response after 6 months of
in diabetic, refer. once infection resolved. treatment, refer.

If diagnosis uncertain, refer.

1
History of angioedema, anaphylaxis or urticaria. 2Doxycycline may interfere with oral contraceptive, advise patient to use condoms as well. Avoid if pregnant or breastfeeding. Avoid giving together with iron or antacids.
74
 SKIN ULCER OR NON-HEALING WOUND: DIAGNOSIS
Give urgent attention to the patient with a skin ulcer or non-healing wound and any of:
• Infection (surrounding skin red/warm/swollen) with any of: BP < 90/60, pulse > 100, temperature ≥ 38°C, confused, blisters, crepitus1 or severe pain
• Sudden severe leg pain at rest with any of the following in the leg: numbness, weakness, pallor, no pulse: acute limb ischaemia likely
Refer urgently.

Identify cause of skin ulcer or non-healing wound

• If genital ulcer 49.
• Is patient bedridden/in wheelchair and is ulcer in common pressure ulcer site (see below)?

Yes No

Is ulcer on the lower leg or foot?

Yes No

Does patient have muscle pain in legs/buttocks on exercise or reduced/absent foot pulses?

Yes No

Is there darkening of skin around ulcer, varicose veins or chronic swelling of the leg?

Yes No

Is patient known with diabetes?

Yes No

• Ask about previous trauma, surgery, skin rash, burn,

cancer or radiation therapy.
• Exclude diabetes: check glucose  17.
• Test for HIV  110.
Pressure ulcer likely Source: Francois Coetzee • If cough ≥ 2 weeks, weight loss, night sweats or
Source: University of Cape Town Source: BMJ Best Practice fever ≥ 2 weeks, exclude TB  92.
Arterial (ischaemic)
ulcer likely Venous ulcer likely Diabetic ulcer likely

• Give routine care for ulcer/wound 76.

• If pressure ulcer, also arrange for doctor review.
• If arterial, venous or diabetic ulcer, or cause uncertain, also refer patient to district hospital for further assessment.
1
Crepitus is a crackling, popping or grating sound or feeling under the skin.
75
 SKIN ULCER OR NON-HEALING WOUND: ROUTINE CARE
If arterial, venous or diabetic ulcer, or cause uncertain, ensure patient has been referred to district hospital for further assessment.

Assess the patient with a skin ulcer or non-healing wound

Assess When to assess Note
Pain Every visit • If pain ≥ 4 weeks, assess and advise  61.
• If new or worsening wound pain, also check for wound infection as below.
• If muscle pain in legs/buttocks on exercise that is relieved by rest, or reduced/absent foot pulses, peripheral vascular disease (PVD) likely: give routine care  139. If
newly diagnosed with PVD, also refer same week.
Chronic conditions As needed Ensure patient is receiving routine care for all his/her chronic conditions. If diabetes  130, hypertension  133, peripheral vascular disease (PVD)  139, HIV  111.
Medications Every visit Review medication: NSAIDs (e.g. ibuprofen), prednisone and chemotherapy can cause delayed healing. Discuss with doctor.
Depression Monthly In the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either  143.
Alcohol/drug use First visit In the past year, has patient: 1) drunk ≥ 4 drinks1/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.
Palliative care First visit If patient has a life-limiting illness, also consider giving palliative care  170.
BMI and nutrition
2
Monthly • If BMI < 19.5: arrange nutritional support. If BMI < 18.5 or signs of nutritional deficiency3, also refer to dietitian.
• If BMI > 25: advise healthy diet and regular physical activity  11. If no improvement or if BMI > 30, also refer to dietitian.
CVD risk First visit If any CVD risk factors4, assess CVD risk  127.
Wound and Every visit • Measure size and depth of wound and record in notes.
surrounding skin - If > 10cm, circumferential (whole way round limb), visible fat/muscle/tendon/bone or increasing in size or depth, refer.
• Assess colour of wound bed: is it pink (epithelialising), red (granulating), yellow (sloughy) or black (necrotic)?
• Assess wound discharge: check colour, consistency, amount and smell.
• If surrounding skin red/warm/swollen, or if diabetic ulcer and increasing discharge, pus or offensive smell, infection likely:
- If BP < 90/60, pulse > 100, temperature ≥ 38°C, confused, blisters, crepitus5 or severe pain, refer urgently.
- If infection extensive or getting worse despite antibiotics, undermined wound edge, ulcer/wound extends to bone, poorly controlled diabetes or previous surgery with
artificial implant (like pin, plate or joint replacement), refer same day.
Blood supply to leg If ulcer/wound on leg: • If reduced or absent foot pulses, capillary refill time > 5 seconds, difference in temperature between feet, change in skin colour, loss of hair, shiny skin, numbness or
every visit weakness, reduced blood supply likely:
- If new changes, discuss urgency of referral with specialist or referral hospital.
- If known with reduced blood supply and already assessed at referral hospital, continue management plan given.
Mobility Every visit If problem with mobility, refer to physiotherapist or occupational therapist for rehabilitation support.
Glucose First visit If not known with diabetes, check glucose  17. If known diabetes, give routine care  130.
Hb First visit If Hb < 12 (woman) or < 13 (man), anaemia likely  27.
HIV First visit Test for HIV  110. If HIV positive, give routine care and ensure patient is on ART  111.
Wound swab If infected and no better • Clean wound with sodium chloride 0.9% and leave for 5 minutes. Then, avoiding wound edges, move swab across wound bed in a zig-zag motion, while rotating swab
after 2-3 days of antibiotic between the fingers. If wound dry, moisten swab tip with sodium chloride 0.9% solution before taking swab.
• Follow-up results to check infection has been treated appropriately.
1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer. 2BMI = weight (kg) ÷ height (m) ÷ height (m). 3Signs of nutritional deficiency include red/cracked corners of mouth, brittle/ridged nails, dry hair that falls out
easily, very dry skin, muscle wasting. 4CVD risk factors include smoking, BMI > 25, waist circumference > 80cm (woman) or 94cm (man), hypertension, diabetes, cholesterol > 5.2, parent/sibling with early onset CVD (man < 55 years or woman < 65 years).
5
Crepitus is a crackling, popping or grating sound or feeling under the skin.
76
 Advise the patient with a skin ulcer or non-healing wound
• Advise a healthy diet  11 and to be as active as possible. If patient smokes, advise that smoking delays healing and encourage to stop  141. Support patient to change  177.
• If pressure ulcer, advise to move (lift, avoid dragging) patient every 1-2 hours if unable to shift own weight.
• If venous or diabetic ulcer, advise to avoid prolonged standing and to elevate limb whenever possible.
• If diabetes or PVD, give foot care education  66.
• Encourage patient to adhere to chronic treatment and to aim towards achieving control of chronic conditions. If difficulty with adherence  173.
• Advise patient to keep dressing in place and not to tamper with wound/dressing. If patient instructed to change dressing, advise to wash hands with soap and water before doing so.
• Refer patient to community health worker. Also consider referral to social worker if available.

Treat the patient with a skin ulcer or non-healing wound

• If pain worse with dressing changes, give dose of patient’s regular pain medication one hour before removing dressing.
• Gently remove dressing to avoid damaging healing tissue. If dressing sticks, wet with sodium chloride 0.9% solution and wait 5-10 minutes before gently re-attempting.
• Remove dead tissue from wound. If large areas of dead tissue or undermined wound edges, arrange for debridement. Avoid debridement if reduced blood supply or cancer wound.
• Gently clean/irrigate wound, remove any plaster debris and apply appropriate dressing, if available, according to type of wound bed:
Epithelialising wound (pink) Granulating wound (red) Sloughy wound (yellow) Necrotic wound (black, dry) Infected wound
Normal edge Undermined edge

Source: Francois Coetzee Source: Anne Berzen

Source: Anne Berzen Source: Vanessa Lomas Source: Vanessa Lomas • Irrigate wound and clean surrounding skin
• Avoid cleaning wound bed: • Irrigate wound and • Irrigate wound and clean with sodium chloride 0.9% solution or
clean surrounding skin only with clean surrounding skin surrounding skin with sodium Source: Anne Berzen povidone iodine 10% solution (up to 2 weeks
sodium chloride 0.9% solution with sodium chloride chloride 0.9% solution or clean • Apply hydrogel to wound, only). If slough remains, gently remove with
or clean tap water. 0.9% solution or clean tap water. If slough remains, gently then apply paraffin or moistened gauze.
• Apply paraffin or petroleum tap water. remove with moistened gauze. petroleum gauze, or other • Apply thin layer of silver sulfadiazine or
gauze, or other non-adherent • Apply paraffin or • If excessive discharge, apply barrier non-adherent dressing. Cover medicinal honey to wound, then apply
dressing. petroleum gauze, or film/paste to surrounding skin. with film dressing if available. absorbant dressing.
• If wound dry, apply hydrogel to other non-adherent • Apply hydrocolloid, hydrofibre or • Doctor to assess need for • If excessive discharge, apply instead silver
wound before dressing. dressing. foam dressing. debridement. hydrofibre or alginate dressing.
• If non-adherent dressing used, cover with cling bandage. Avoid compression if reduced blood supply to limb.
• If venous ulcer, apply compression bandage over dressing, starting at toes (not higher on foot) and ending below knee.
- Avoid compression bandage if reduced blood supply to limb.
- If numbness, pins and needles, or severe pain develop, advise patient to remove compression bandage and return immediately.
• If pain, give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) as needed. If no response, give ibuprofen1 400mg 8 hourly with food as needed.
• If infection likely, give amoxicillin/clavulanic acid2 875/125mg 12 hourly for 7 days, or 10 days if diabetic ulcer. If no better after 2-3 days, take wound swab  76. If worsens despite antibiotic, refer
same day.

Review the patient with a skin ulcer or non-healing wound

• If wound infected: change dressing daily. If silver hydrofibre dressing used, change dressing every 2-3 days instead.
• If wound sloughy or necrotic: change dressing around every 2 days, depending on amount of discharge.
• If wound epithelializing or granulating: change dressing weekly.

If cause uncertain, recurrent ulcers or no better after 1 month, refer.

1
Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. 2If penicillin allergy, discuss/refer.
77
 CRUSTS OR FLAKY SKIN
Check if the patient needs urgent attention  67.

Are there crusts or flaky skin?

Crusts Flaky skin

Blisters which dry to form yellow crusts often Red/pink scaly patches with fine, greasy scales. Well-defined, raised plaques Patches of dry, scaly, itchy skin on
around mouth or nose. May complicate insect Usually on scalp, between eyebrows, in nose folds, covered with silvery scale. wrists, ankles, inside elbows or
bites, scabies or skin trauma. behind ears, in axillae, groin, under breasts. Often on knees, elbows, lower behind knees.
back, scalp. May have pitted nails.

© University of Cape Town © University of Cape Town

Impetigo likely Eczema likely

• Impetigo is contagious: Manage  69.
- Advise to avoid close contact with others and
sharing of towels, and to keep nails short. © University of Cape Town
- Advise patient and household contacts to wash
with soap and water twice a day. Psoriasis likely
• Apply povidone iodine 5% cream or povidone • Refer to specialist to confirm diagnosis.
iodine 10% ointment to lesions 8 hourly. • While waiting for appointment:
• Give flucloxacillin 500mg 6 hourly or cefalexin © University of Cape Town - Moisturise skin with emulsifying
500mg 6 hourly for 5 days. If severe penicillin ointment (UE) twice a day.
allergy1, give instead azithromycin 500mg daily - Apply betamethasone 0.1% ointment
for 3 days. Seborrhoeic dermatitis likely
• If extensive, test for HIV  110. twice a day. Once improving, apply
• If not completely resolved, repeat antibiotic instead hydrocortisone 1% cream
course. • If on scalp  80.
• Advise patient to avoid scratching, keep nails short twice a day, then reduce to once a day.
• If sores have been present for > 1 week, check Stop as soon as better or apply liquor
urine dipstick. and to avoid scented soap.
• Apply hydrocortisone 1% cream twice a day. Once picis carbonis (LPC) BP 5% ointment
• Refer if: once a day.
- No better after 2nd course of antibiotics improved, reduce to once or twice a week as needed.
• If poor response or severe, apply instead • Encourage to expose skin to sunlight
- If ≥ 1+ blood on urine dipstick or little/no urine. before 10am or after 3pm for up to 30
- Swelling of face or limbs. betamethasone 0.1% ointment once a day for
7 days (avoid face, neck and creases). minutes per day.
• If no response within 3 months, refer.

1
History of angioedema, anaphylaxis or urticaria.
78
 CHANGES IN SKIN COLOUR
Is the skin yellow, too dark, too light or absent of colour?

Yellow skin Dark patches Light Absence of colour

patches
Jaundice likely Where are patches on body? Is absence of colour patchy or generalised?

Refer urgently the patient with jaundice and any of: Lower legs Face Trunk Patchy Generalised
• Temperature ≥ 38°C
• Hb < 12 (woman) or < 13 (man) Red-brown discolouration. Flat, brown patches on Light or dark patches with Present from birth.
• BP < 90/60 May have breaks in skin or cheeks, forehead and fine scale. Usually on trunk, Involves skin, hair
• Severe abdominal pain ulcers, spidery veins. upper lip neck and upper arms. and eyes.
• Drowsy or confused
• Easy bruising or bleeding Albinism likely
• Pregnant • Advise to avoid
• Alcohol dependent  142 or recent alcohol binge sunburn:
(≥ 4 drinks1/session) © University of Cape Town
- Avoid sun exposure,
• Using any medication2 or illegal drugs especially between
Vitiligo likely 10am and 3pm.
© University of Cape Town • Refer to - Apply zinc oxide
• Send blood for ALT, ALP, total bilirubin, full blood © University of Cape Town dermatologist. ointment or
count, INR, hepatitis A IgM, HBsAg.
Melasma likely • Advise to avoid titanium dioxide
• Advise to return if worsens.
• Hormones and sunlight Tinea versicolor likely excessive sun- ointment/cream
• Review with results within 2 days:
© BMJ Best Practice will worsen melasma: • Advise to wear cool exposure and (UV block) daily at
- Advise to apply clothing in hot weather to apply titanium least 15 minutes
Refer if ALT ≥ 200, INR ≥ 1.5, ALP raised out of proportion reduce perspiration. dioxide before going into
Venous stasis likely sunscreen daily and
to ALT, Hb < 12 (woman), Hb < 13 (man) or plts < 150. avoid sun exposure to • Apply selenium sulphide ointment/cream sun. Reapply 2
• Encourage exercise.
• Advise elevating leg face. 2.5% suspension. Lather on (UV block) at least hourly if in the sun.
Hepatitis A IgM positive Hepatitis when possible and - Avoid oral contraceptive, affected areas: 15 minutes before - Use sun hat and
A IgM to avoid prolonged rather use a different - Apply daily for 3 days: going into sun sunglasses and
negative standing. method  154. leave on for 30 minutes between 10am wear long-sleeves.
Patient has acute hepatitis A infection
• Apply compression • Advise patient: then wash off or and 3pm. Some • Refer to
• Notify.
bandage from foot to - If pregnant, may take up - Apply weekly for 3 weeks: sun-exposure is dermatologist and
• Educate that infection will resolve by Check
knee. to 1 year after pregnancy leave on overnight then beneficial before ophthalmologist.
itself and no specific treatment needed. HBsAg
• Assess CVD risk  127. to resolve. wash off. 10am and after • If any skin lesions
Advise strict handwashing practises, results
• Give foot care advice - Often difficult to • May take months for 3pm. develop, especially in
especially before handling food and 120.
after using toilet. Avoid alcohol and 66. treat and may never colour to return. Absence sun-exposed areas,
paracetamol whilst ill. • If ulcer 75. completely resolve. of scale indicates adequate refer to exclude skin
• Check HBsAg results 120. • If not responding to above treatment. cancer.
• If nausea/vomiting and unable to and intolerable, refer. • Recurrence is common. Re-
tolerate fluids, refer. treatment may be needed.

If diagnosis uncertain, discuss/refer.

1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer. 2If on atazanavir  116.
79
 SCALP SYMPTOMS
• If hair loss with no rash/itch 81.
• Is there a rash or only an itch?

Itch without rash Rash with or without itch

Severe itch with lice or white Fine, white flakes Scaly patches Redness, swelling and burning/ Red pimples, pustules
eggs. May have small red bites on hair and itching after recent use of hair or nodules around
on back of neck. clothing Red/pink patches with fine Well-defined, raised plaques product. May have blisters. hair follicles
greasy scales. May also covered with silvery scale. Often
Lice likely Dandruff likely occur between eyebrows, on knees, elbows, lower back,
• Apply permethrin 5% lotion to • Apply selenium in nose folds, behind ears. scalp. May have pitted nails.
towel-dried or dry hair: sulphide 2.5% Usually itchy.
- Using normal comb, comb suspension:
into hair to ensure whole - Lather on
scalp is covered and hair is scalp.
saturated. - Rinse off after
- Then using fine lice comb, 10 minutes.
© University of Cape Town
remove lice and eggs from - Use weekly
hair in sections, combing until better, © BMJ Best Practice
away from scalp. then every Contact dermatitis likely
© University of Cape Town • Identify and advise patient to
- Rinse lice comb in hot water second week. Folliculitis likely
in white bowel or wipe on © University of Cape Town avoid cause.
• Advise to wash with soap
white tissue between strokes Seborrhoeic dermatitis likely • Moisturise skin with emulsifying
twice a day.
to identify black lice. • If extensive, test for HIV  110. Psoriasis likely ointment (UE) twice a day.
• Wash scalp with
- Rinse off after combing (up to • Apply selenium sulphide 2.5% • Refer to specialist to confirm • Apply betamethasone 0.1%
chlorhexidine scrub once
1 hour). suspension: diagnosis. ointment twice a day. Once
a day until lesions resolve.
- Repeat every 5 days for - Lather on scalp. • While waiting for appointment: improving, apply instead
• If infection deep,
3 weeks. Lice should get - Rinse off after 10 minutes. - Moisturise skin with emulsifying hydrocortisone 1% cream twice
extensive, recurrent or
smaller with each treatment. - Use weekly until better, then ointment (UE) twice a day. a day, then reduce to once a
no response to above
If not, check patient is every second week. - Apply betamethasone 0.1% day. Stop as soon as better.
treatment:
applying permethrin • For skin: apply hydrocortisone ointment twice a day. Once • If pus or yellow crusts, treat for
- Give flucloxacillin
correctly. 1% cream twice a day. Once improving, apply instead infection:
500mg 6 hourly or
- Avoid broken skin/eyes. improved, reduce to once or hydrocortisone 1% cream twice - Give flucloxacillin 500mg
cefalexin 500mg
• Wash clothes and linen used in twice a week as needed. a day, then reduce to once a 6 hourly or cefalexin 500mg 6
6 hourly for 5 days.
past 2 days in very hot water. - If poor response or severe, day. Stop as soon as better or hourly for 5 days.
- If severe penicillin
• Treat household contacts. apply instead betamethasone apply liquor picis carbonis (LPC) - If severe penicillin allergy¹, give
allergy1, give instead
• Consider shaving head only if 0.1% ointment once a day BP 5% ointment once a day. instead azithromycin 500mg
azithromycin 500mg
acceptable to patient. for 7 days (avoid face, neck - Encourage to expose skin to daily for 3 days.
daily for 3 days
and creases). sunlight before 10am or after 3pm • If no better, refer.
- Test for HIV  110.
• If no response within 2 months, for up to 30 minutes per day.
refer.

If diagnosis uncertain, discuss/refer.

1
History of angioedema, anaphylaxis or urticaria.
80
 HAIR LOSS
• If rash on scalp 80.
• Are hair follicle openings visible in area/s of hair loss?

Yes No
Is hair loss patchy or generalised?
Scarring
Patchy Generalised alopecia
likely
• Test for syphilis. If positive  53. • Ask about recent possible causes:
• Does patient wear tightly-pulled ponytails, buns, braids or weaves, with hair loss along hairline or in area of braids/weave? - Major illness or surgery Refer.
- Major stress
Yes No - Childbirth
- Poor diet
- Significant weight loss
Are patches well-defined with healthy underlying scalp? • Review medication: sodium
valproate, simvastatin and
Yes No: is patient a woman with thinning of hair over top of head? hormonal contraceptives can
cause hair loss. Discuss with
Yes No doctor.
• Test for syphilis. If positive
 53.
• Refer if: • Check TSH and ferritin. If
© University of Cape Town - Syphilis negative abnormal, refer to doctor.
- Syphilis positive and • Check Hb: if< 12 (woman) or
Traction alopecia likely no improvement < 13 (man)  27.
• Explain cause. 3 months after • Reassure that hair will grow again
• Advise to avoid tight or syphilis treatment. once cause treated/resolved.
© University of Cape Town
painful hairstyles. © University of Cape Town • Refer if:
• Reassure that hair will - Cause unclear
Alopecia areata likely
usually grow again Female pattern hair loss likely - Woman with abnormal hair
• Apply betamethasone 0.1%
once cause removed. • Check TSH and ferritin. If abnormal, refer to doctor. growth on face or body,
cream twice a day for 3 months.
• If no better after • Check Hb: if< 12 (woman) or < 13 (man)  27. irregular periods, infertility or
• Check TSH. If abnormal, refer to
3 months, refer. • Advise to use hair styles that may hide hair loss. severe acne.
doctor.
• Refer if: - No improvement 12 months
• Advise that hair may take up to
- Abnormal hair growth on face or body after cause treated/resolved.
2 years to regrow.
• Refer if: - Irregular periods or infertility in woman of child
- Extensive/multiple patches bearing age
- No better with treatment - Severe acne
- Recurrent - Causing severe distress

If causing patient distress, refer for counselling.

If diagnosis uncertain, discuss/refer.

81
 NAIL SYMPTOMS
• If nails long and dirty and patient unkempt, screen for mental health problem and abuse/neglect  86.
• Manage according to type of nail problem:

Disfigured nail with swollen nail Pain, redness and swelling of White/yellow disfigured Blue/brown/black discolouration of nail Transverse dents in
bed and loss of cuticle nail folds, there may be pus. or crumbling nails nails (Beau’s lines)

• Check for
paronychia
in adjacent
columns
• If above
excluded,
reassure likely
due to previous
© University of Cape Town © University of Cape Town
illness/injury and
CDC Public Health Image Library will grow out
with nail.
Chronic paronychia likely © BMJ Best Practice Fungal infection likely
Has there been recent trauma to nail?
Usually associated with excessive • Test for HIV  110
exposure to water and irritants like and diabetes  17.
nail cosmetics, soaps and chemicals. Acute paronychia likely • Fungal nail infection is Yes No
Often with history of trauma, difficult to treat.
such as nail biting, pushing the • If very distressing to
• Advise to avoid water and irritants cuticle or cutting nails too short. patient, refer. Haematoma likely • Psoriasis may discolour nails. If
or to wear gloves if unavoidable. • Reassure patient. psoriasis on skin  70.
Keep hands clean and dry. • Treat if injury < 2 days • Review medication: fluconazole,
• After washing hands, massage • Advise to avoid trauma to nail. old and painful: ibuprofen, lamivudine,
betamethasone 0.1% cream into • If any pus, incise and drain. - Clean nail with phenytoin and zidovudine can
nailfold at night. • Give flucloxacillin 500mg povidone iodine 10% cause discolouration of nails.
• If nailfold painful or pus, treat for 6 hourly or cefalexin 500mg solution. Discuss with doctor.
infection: 6 hourly for 5 days. If severe - Hold finger secure and • Refer same week to exclude
- Give flucloxacillin 500mg penicillin allergy1, give instead gently twist a large bore melanoma (picture above) if:
6 hourly or cefalexin 500mg azithromycin 500mg daily for needle into nail over - New dark spot on 1 nail which
6 hourly for 5 days. 3 days. centre of haematoma. is getting bigger quickly and
- If severe penicillin allergy1, give • If no response, refer. Stop when blood drains no recent trauma
instead azithromycin 500mg through hole. - Discolouration extends into
daily for 3 days - Cover with sterile gauze nail folds
• If no better, refer. dressing. - Band on nail that is:
• > 4mm wide
• Getting darker or bigger
• Has blurred edges
• Nail is damaged

1
History of angioedema, anaphylaxis or urticaria.
82
 SELF-HARM OR SUICIDE
Give urgent attention to the patient who has attempted or considered self-harm or suicide:
Has patient attempted self-harm or suicide?

Yes No
• First assess and manage airway, breathing, circulation and level of consciousness  14. Does patient have current thoughts or plans to commit suicide?
• If oral overdose of harmful substance in past 1 hour and patient fully conscious, give
activated charcoal 50g in 100mL water1. Avoid if paraffin, petrol, corrosive poisons (acids), Yes No
iron, lithium or alcohol. If overdose of > 200mg/kg or 10g of paracetamol and delay in Has patient had thoughts or plans of self-harm or suicide in past month or
referral expected, give N-acetylcysteine 140mg/kg, then 70mg/kg 4 hourly. performed act of self-harm or suicide in past year?
• If exposed to carbon monoxide (exhaust fumes): give 100% face mask oxygen.
• If opioid (morphine/codeine) overdose and respiratory rate < 12: connect bag valve mask Yes No
to oxygen and slowly deliver each breath with patient. Also give naloxone 0.4mg IV/IM2 Patient agitated, violent, distressed or uncommunicative?
immediately. Reassess every 2 minutes: if respiratory rate still < 12, give increasing doses
of naloxone every 2 minutes: 0.8mg, 2mg, 4mg, up to a total of 10mg. Naloxone wears off Yes No
quickly, monitor closely and give further doses later if needed.
• If no response, or overdose/poisoning with other or unknown substance, discuss with High risk of self-harm or suicide Low risk of self-harm
specialist or local poison helpline  178. or suicide

• Avoid leaving patient alone. Remove any possible means of self-harm (firearms, knives, pills). Manage patient
• If aggressive or violent, ensure safety: assess patient with other staff, use security personnel or police if needed. Sedate only if necessary  84. as below.
• Refer urgently: while awaiting transport, monitor closely. If patient refuses admission, consider involuntary admission  140.

Assess the patient whose risk of self-harm or suicide is low

Assess When to assess Note
Depression Every visit If known depression, give routine care  144, otherwise ask: in the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things?
If yes to either  143.
Alcohol/drug use Every visit In the past year, has patient: 1) drunk ≥ 4 drinks1/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.
Other mental illness Every visit • If hallucinations, delusions, disorganised speech, disorganised or catatonic behaviour, discuss with specialist same day. If memory problem, screen for dementia  148.
Stressors Every visit • If not known with a mental illness, assess for stress and anxiety  86.
• Help identify psychosocial stressors. Ask about trauma, sexual abuse/violence  88, family or relationship problems, financial difficulty, bereavement, chronic ill-health.
Chronic condition Every visit • If chronic pain, assess and manage pain  60 and underlying condition. Link patient with helpline or support group  178.
• If patient has a life-limiting illness, also consider giving palliative care  170.

Advise the patient whose risk of self-harm or suicide is low

• Discuss with patient reasons to stay alive. Encourage carers to closely monitor patient as long as risk persists and to bring patient back if any concerns.
• Advise patient and carers to restrict access to means of self-harm (remove firearms from house, keep medications and toxic substances locked away) as long as risk persists.
• Suggest patient seeks support from close relatives/friends and offer referral to counsellor or local mental health centre or helpline  178.

• Discharge into care of family, if possible. Review patient at least weekly for 2 months: involve a counsellor, psychiatric nurse/psychologist or social worker if possible.
• If self-harm or suicide risk is still low follow up monthly. If thoughts or attempts of self-harm or suicide recur, reassess suicide risk above.
1
If able, give this charcoal mixture via nasogastric tube if the airway is protected and patient co-operative. Charcoal may be useful if these poisons are taken in overdose: carbamazepine, barbiturates, phenytoin, dapsone, quinine, theophylline, salicylates,
mushroom poisoning, slow release preparations, digoxin, beta-blockers, NSAIDs. 2Give naloxone IM only if IV not possible.
83
 AGGRESSIVE/DISRUPTIVE PATIENT
Give urgent attention to the aggressive/disruptive patient with any of:
• Angry behaviour • Challenging, insulting or provocative behaviour • Tense posturing like gripping arm rails tightly, clenching fists
• Loud, aggressive speech • Frequently changing body position, pacing • Aggressive acts like pounding walls, throwing objects, hitting
Management:
• Ensure the safety of yourself, the patient and those around you: ensure security personnel present, call police if needed. They should disarm patient if s/he has a weapon. Assess in a safe room
with other staff. Ensure exit is not blocked.
• Try to verbally calm the patient:
- Avoid direct eye contact, sudden movements and approaching patient from behind. Stand at least two arm's lengths away.
- Use an honest, non-threatening manner. Avoid talking down to the patient, arguing or commanding him/her to calm down. Use a friendly gesture like offering a drink or food.
- Listen to patient, identify his/her feelings and desires and offer choices. Take all threats seriously.
• Consider involuntary admission if signs of mental illness and refuses treatment or admission and a danger to self, others, own reputation or financial interest/property  140.
• Restrain and/or sedate only if absolutely needed: imminent harm to self/others, disruption of important treatment, damage to environment, verbal attempts to calm patient failed.
- If possible, before sedation: assess and manage possible causes of abnormal thoughts or behaviour  85.
- If restraints used, check restraint sites every 30 minutes.
Try to avoid IM or IV medication to sedate the aggressive/disruptive patient, especially if > 65 years. Will patient accept oral medication?

Yes No

• Give buccal1 midazolam 7.5-15mg or diazepam 5mg orally.

• Assess response after 30 minutes:

Patient calm Patient still aggressive/disruptive after 30 minutes

Decide which medication to use according to likely cause:

Exact cause unknown Alcohol/drug withdrawal Stimulant drug intoxication Delirium Alcohol intoxication Psychosis2

Give midazolam 7.5-15mg IM. Give haloperidol 5mg IM (2.5mg IM if > 65 years) and promethazine 25mg IM.

Assess response after 30 minutes:

Patient calm Partial response only. No response

Repeat same dose of IM • If midazolam used above, give haloperidol 5mg IM (2.5mg IM if > 65 years) and promethazine 25mg IM.
medication used above. • If haloperidol/promethazine used above, give midazolam 7.5-15mg IM.

• Monitor and record temperature, BP, respiratory and pulse rate, level of consciousness every 15 minutes for first hour, then every 30 minutes until patient referred, or alert and walking.
• If haloperidol used and painful muscle spasms, acute dystonic reaction likely, give biperiden 2.5mg IM. Repeat every 30 minutes, until spasms resolve, up to 3 doses in 24 hours.
• Once patient is calmer, reassess for underlying cause if not already done, and manage further  85.
• Refer the mentally ill aggressive patient same day to hospital3: document history, and time and dose of medication given. If emergency admission needed without patient consent, fill in MHCA 01
form. If restraints used, complete MHCA 48 form.

1
Buccal: use IV formulation of midazolam, use syringe to draw up correct dose, remove needle and give midazolam between the cheek and gum. 2Psychosis likely if patient not aware s/he acting abnormally and has ≥ 1 of: Hallucinations (seeing/ hearing
things); Delusions (unusual/ bizarre beliefs); Disorganised speech or behaviour. 3If delay in transport: try to move patient to most calm/quiet area and enlist help of a family member to monitor patient.
84
 ABNORMAL THOUGHTS OR BEHAVIOUR
Give urgent attention to the patient with abnormal thoughts or behaviour and any of:
• Sudden onset of abnormal thoughts or behaviour
• Recent onset of abnormal thoughts or behaviour
Management:
• If just had a fit 19.
• If aggressive/disruptive 84.
• If new sudden asymmetric weakness or numbness of face/arm/leg, difficulty speaking or visual disturbance: consider stroke or TIA 136.
• If recent head injury 18.
• If suicidal thoughts or plans  83.
• If difficulty breathing, respiratory rate > 30, oxygen saturation < 94% or oxygen saturation machine not available, give face mask oxygen.
• Check glucose: if < 3 or ≥ 11.1  17 or if diabetes and < 4  130.
• If thirst, dry mouth, poor skin turgor, sunken eyes, decreased urine: give oral rehydration solution. If unable to drink or BP < 90/60, give sodium chloride 0.9% 500mL IV over 30 minutes, repeat
until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens.
• Consider involuntary admission if signs of mental illness and refuses treatment or admission and a danger to self, others, own reputation or financial interest/property  140.
• If HIV positive with recent positive cryptococcal antigen test, refer for urgent lumbar puncture (LP).
• Look for delirium, mania, psychosis, intoxication, withdrawal or poisoning and manage before referral:

Varying levels of Abnormally Lack of insight with ≥ 1 of: Dilated pupils, Smells of alcohol, Known alcohol/drug user who has Exposure via
consciousness happy, • Hallucinations (seeing/ restlessness, paranoia, slurred speech, stopped/reduced intake with tremor, ingestion/
over hours/days energetic, hearing things) nausea, sweating incoordination, sweating, nausea, severe restlessness/ inhalation/
and temperature talkative, • Delusions (unusual/ or pulse ≥ 100, unsteady gait agitation or hallucinations absorption of
≥ 38°C irritable or bizarre beliefs) BP ≥ 140/90 medication/
reckless • Disorganised speech or Alcohol intoxication Alcohol/drug withdrawal likely unknown
Delirium likely behaviour Stimulant drug likely • If no other sedation given, give substance
Give ceftriaxone Mania likely intoxication likely • Give thiamine diazepam 10mg orally.
2g IV1/IM. Psychosis likely If pulse irregular, chest 100mg IV/IM. • If alcohol withdrawal, also give Poisoning likely
Avoid injecting pain or BP ≥ 140/90, • Give sodium chloride thiamine 100mg IV/IM and oral Discuss urgently
> 1g IM at one do ECG and discuss 0.9% 1L 6 hourly. rehydration solution. with specialist
injection site. with specialist or local • Check for head injury. • If ≥ 8 hours since last alcohol, or local poison
poison helpline  178. start alcohol detoxification helpline
programme 142.  178.
Refer urgently unless:
• Patient with known schizophrenia who is otherwise well: give routine schizophrenia care  146.
• Patient with diabetes and low glucose, not on glicazide/insulin: if abnormal thoughts/behaviour resolve with dextrose, no need to refer, give routine diabetes care  130.
• Patient with known alcohol use who is otherwise well: if abnormal thoughts/behaviour resolve once sober, no need to refer  142.

Approach to the patient with abnormal thoughts or behaviour not needing urgent attention:
• If for at least 6 months ≥ 1 of: memory problems, disorientation, language difficulty, less able to cope with daily activities and work/social function: consider dementia 148.
• If unsure of diagnosis, refer for further assessment.

1
Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone.
85
 LOW MOOD, STRESS OR ANXIETY
Give urgent attention to the patient with suicidal thoughts or behaviour  83.

Assess the patient with low mood, stress or anxiety. If patient known with depression, rather give routine depression care 144.
Assess Note
Anxiety • If excessive worry causes impaired function/distress for at least 6 months with ≥ 3 of: muscle tension, restlessness, irritability, difficulty sleeping, poor concentration, tiredness: generalised anxiety
disorder likely  144.
• If anxiety is induced by a particular situation/object (phobia) or is repeated sudden fear with physical symptoms and no obvious cause (panic), discuss/refer.
• If anxiety > 1 month linked to a bad experience, with ≥ 3 of: 1) nightmares or flashbacks 2) avoids situations/people 3) constantly on guard, or easily startled 4) feels numb or detached from
others/ surroundings, post-traumatic stress disorder (PSTD) likely, discuss/refer.
Depression If not already done: in the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either 143.
Alcohol/drug use In the past year, has patient: 1) drunk ≥ 4 drinks1/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.
Abuse If patient is being abused  88.
Stressors • Help identify psychosocial stressors. Ask about family or relationship problems, infertility, financial difficulty, bereavement, chronic ill-health. If sexual problems  58.
• If patient has a life-limiting illness, also consider giving palliative care  170.
• If older person: ask about loneliness and if available, refer to nearest social club for older people in the area.
Women’s health • If recent delivery: give postnatal care  164 and if available, refer to mother's support group.
• If woman > 40 years, ask about menopausal symptoms: hot flushes, night sweats, vaginal dryness, mood changes, difficulty sleeping and sexual problems  169.
Medication Review medication: prednisone, efavirenz, metoclopramide, theophylline and contraceptives can cause mood changes. Discuss with doctor. Consider alternative contraceptive  154.
 104
Advise the patient with low mood, stress or anxiety
• Encourage patient to question negative thinking and be realistic if s/he often predicts the worst, generalises, exaggerates problem, inappropriately takes the blame, takes things personally.
• Help the patient to choose strategies to get help and cope:
Get enough sleep Encourage patient to take time to relax:
If patient has difficulty sleeping, Limit alcohol
Find a Do a relaxing Get active
give advice  87. and avoid drugs
creative or breathing Regular exercise might help.
fun activity exercise • Limit alcohol
to do. each day. to ≤ 2 drinks/
Access support day and avoid
Link patient alcohol on at
with helpline or least 2 days/
Spend time with supportive support group week.
friends or family.  178. • Avoid drugs.

• If stressors identified, discuss possible solutions. If needed, refer to available counsellor, psychiatric nurse/psychologist or social worker.
• Deal with bereavement issues if patient or family member has a life-limiting illness or if patient is recently bereaved:
- Acknowledge grief reactions: denial, disbelief, confusion, shock, sadness, bargaining, yearning, anger, humiliation, despair, guilt and acceptance.
- Allow patient/family to share sorrow and talk of memories, the meaning of the patient’s life or religious beliefs. Suggest connecting with a spiritual counsellor as appropriate.
- Identify worrying issues (e.g. child care, will and funeral arrangements) and who can give practical support with these before and after the patient dies.
• For tips on how to communicate effectively  176.

Offer to review the patient in 1 month.

1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer.
86
 DIFFICULTY SLEEPING
Assess the patient with difficulty sleeping
• Confirm that the patient really is getting insufficient sleep. Adults need on average 6-8 hours sleep per night. This decreases with age.
• Determine the type of sleep difficulty: waking too early or frequently, difficulty falling asleep, insufficient sleep.
Exclude medical problems:
• Ask about pain, difficulty breathing, urinary problems. See relevant symptom pages. If persistent snoring, consider obstructive sleep apnoea  38. If restless legs, refer to doctor for further
assessment.
• If patient has a chronic condition, give routine care.
• If pulse ≥ 100, weight loss, palpitations, tremor, dislike of hot weather or thyroid enlargement, check TSH. If abnormal, refer to doctor.
Review medication:
• Over-the-counter decongestants, salbutamol, fluoxetine, efavirenz can cause sleep problems. Discuss with doctor.
• Reassure patient that difficulty sleeping from efavirenz is usually self-limiting and resolves within 6 weeks on ART. If severe or > 6 weeks, discuss with doctor.
Assess alcohol/drug use:
• In the past year, has patient: 1) drunk ≥ 4 drinks1/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.
Screen for possible stressors and mental health problem:
• If stress or anxiety  86.
• Has the patient ever had a bad experience that is causing nightmares, flashbacks, avoidance of people/situations, jumpiness or a feeling of detachment? If yes  88.
• In the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either  143.
• If abnormal thoughts or behaviour  85.
• If for at least 6 months ≥ 1 of: memory problems, disorientation, language difficulty, less able to cope with daily activities and work/social function: consider dementia  148.
Ask about menopausal symptoms:
• If woman > 40 years ask about menopausal symptoms: hot flushes, night sweats, vaginal dryness, mood changes and sexual problems  169.

Advise the patient with difficulty sleeping

• Encourage patient to adopt sensible sleep habits. These often help to resolve a sleep problem without the use of sedatives.
- Get regular exercise.
- Avoid caffeine (coffee, tea, sweetened fizzy drinks), alcohol and smoking for several hours before bedtime.
- Avoid day-time napping.
- Encourage routine: get up at the same time each day (even if tired) and go to bed the same time every evening.
- Allow time to unwind/relax before bed.
- Use bed only for sleeping and sex. Spend only 6-8 hours a night in bed.
- Once in bed, avoid clock-watching. If not asleep after 20 minutes, do a low energy activity (read a book, walk around house). Once tired, return to bed.
- Keep a sleep diary. Review this at each visit.
• Review the patient regularly. A good relationship between practitioner and patient can help.

Refer patient for further assessment if problems with daytime functioning, daytime sleepiness, irritability, anxiety or
headaches that do not get better with 1 month of sensible sleep habits.

1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer.
87
 TRAUMATISED/ABUSED PATIENT
Give urgent attention to the traumatised/abused patient with any of:
• Injuries needing attention  18 • Suicidal thoughts or behaviour  83 • Recent rape or sexual assault
Management of recent rape/sexual assault:
• Arrange same day doctor assessment, ideally at a designated facility for management of rape and sexual assault. Complete required forms and registers. If rape victim pregnant, refer.
• If severe vaginal or anal bleeding, abdominal pain, multiple injuries or history of the use of a foreign object, refer urgently.
• Prevent HIV and hepatitis  108.
• Prevent STIs: give single dose each of ceftriaxone 250mg IM1, azithromycin 1g orally and metronidazole2 2g orally. If severe penicillin allergy3, omit ceftriaxone and increase
azithromycin dose to 2g orally.
• Prevent pregnancy: do pregnancy test. If pregnant  159. If not pregnant, not on reliable contraception and ≤ 5 days since rape, give emergency contraception:
- Give single dose levonorgestrel 1.5mg orally.
• If patient > 80kg, BMI4 ≥ 30, or on efavirenz, rifampicin, phenytoin or carbamazepine, increase dose of levonorgestrel to 3mg or offer IUD instead.
• Give metoclopramide 10mg 8 hourly as needed for nausea/vomiting. If patient vomits < 2 hours after taking levonorgestrel, repeat dose or offer IUD instead.
• Prevent tetanus: if open wound and not immunised in last 5 years, give tetanus toxoid 0.5mL IM within 48 hours of injury.
• Also assess and support the patient as below.

Assess the traumatised/abused patient

Assess When to assess Note
Symptoms Every visit Manage symptoms as on symptom pages. Ask about genital symptoms even if no recent rape or sexual assault  49.
Family planning Every visit Offer to start longterm contraceptive  154. If sexual assault and normal menstruation has not occurred within 4 weeks, repeat pregnancy test. If pregnant  159.
Mental health Every visit • If stress or anxiety  86.
• In the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either  143.
• If patient has ever had an experience so horrible that s/he has had ≥ 3 of the following for > 1 month: 1) Nightmares or involuntary thoughts/flashbacks 2) Avoided certain
situations/people 3) Been constantly on guard, watchful or easily startled 4) Felt numb or detached from other people, activities or surroundings: post-traumatic stress
disorder likely, refer.
Alcohol/drug use Every visit In the past year, has patient: 1) drunk ≥ 4 drinks5/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.
Social Every visit If immediate risk of being harmed and in need of shelter, refer/discuss with social worker same day.
HIV First visit Test for HIV  110.
Syphilis (if sexual assault) First visit If positive  53.

Advise the traumatised/abused patient

• Find a quiet place to talk. Comfort patient, remind him/her that you are there to help. Reassure that s/he is safe and all information is confidential. Allow a trusted friend/relative to stay close.
• Be patient, listen attentively and avoid pressurising the patient. Clearly record patient’s story in his/her own words. Include nature of assault and, if possible, identity of the perpetrator.
• Ask if patient has specific needs/concerns and link with support structures. Refer to available trauma counsellor/psychiatric nurse/psychologist/social worker/helpline  178.
• Refer to police Victim Empowerment office or family violence NGOs for assistance.
• Encourage patient to file a J88 form and to report case to police. Encourage patient to apply for protection order at local magistrate’s court. Respect patient’s wishes if s/he declines to do so.

If rape/sexual assault, review within 3 days  109. Offer to review the traumatised/abused patient who has not been sexually assaulted in 1 month.
1
For ceftriaxone 250mg IM injection: dissolve 250mg in 0.9mL lidocaine 1% without epinephrine (adrenaline). 2Advise no alcohol until 24 hours after last dose of metronidazole. 3History of angioedema, anaphylaxis or urticaria.
4
BMI = weight (kg) ÷ height (m) ÷ height (m). 5One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer.
88
 TB tests changing from

ASSESS AND MANAGE TB INFECTION

'Xpert Ultra' to 'TB NAAT'
(NAAT = nucleic acid
amplification test and includes
Xpert as well as newer TB tests).

‘TB infection’ is different from ‘TB disease’. TB infection refers to TB bacteria that has entered the body but is not yet making the body sick – often called latent TB, which means hidden/inactive TB.

Assess the need for TB preventive treament (TPT)

Is patient a TB contact: has s/he shared an enclosed space at work, socially, or in a household, for ≥ 1 night or for frequent/extended daytime periods, with an adult/adolescent with lung TB ("index patient")?

Yes No
Did patient share this space during the 3-month period before the index patient started their TB treatment?

Yes No
• Check for active TB disease: send 1 sputum sample for TB NAAT, regardless of
symptoms  92. Where needed, arrange CXR and do urine LAM test  92. Any of:
• Assess clinically: if TB symptoms1, discuss/refer for investigation. • HIV positive • Known immunocompromise or taking
• Known with silicosis4 immunosuppressive medications5
If no TB symptoms, clinically well and investigations negative2, active TB disease unlikely.
Give TPT. If patient has had previous TPT, repeat course with every new exposure. One or more of above None of above
• Check for active TB disease: send 1 sputum sample for TB NAAT, regardless of
Choose what TPT to give: start by checking drug sensitivity results of index patient3: symptoms  92. Where needed, arrange CXR and do urine LAM test  92. TB preventive
• Assess clinically: if TB symptoms1, discuss/refer for investigation. treatment (TPT)
Resistance to rifampicin or INH Susceptible to rifampicin or INH (or unknown) is not needed.
If no TB symptoms, clinically well and investigations negative2, active TB disease unlikely.
If patient has had TPT previously, no need to repeat TPT. If no previous TPT, give TPT. Continue routine
• If resistance to INH only, give 4R.
• If resistance to rifampicin, arrange care.
chest x-ray and doctor review: Choose TPT regimen according to age and HIV status:
- If chest x-ray normal, check index
patient’s INH resistance result: Child < 25kg Adult, adolescent or child ≥ 25kg
• If no resistance to INH on
phenotypic DST: give 6H  90.
• If resistance to INH (or unknown): If newborn exposed to TB, or newborn tests positive HIV positive HIV negative
check fluoroquinolone for HIV, assess and manage 167.
resistance and discuss with TB • If patient on ART (even TLD) with VL < 50 in last • Give 3HP 90.
specialist/refer. HIV exposed infant HIV 6 months: give 3HP 90. If 3HP unavailable:
- If chest x-ray abnormal: avoid unexposed • If any of the following, give instead 12H 90: give instead 3RH
giving TPT. Send 1 sputum sample Infant on Infant on Infant no infant - Pregnant or 6H.
for TB NAAT, TB microscopy, ART PEP longer on PEP - Newly diagnosed HIV and starting TLD • If pregnant, give
culture and DST. Refer to TB - Already on ART with VL ≥ 50 3RH or 6H 90.
specialist same week. - 3HP unavailable.
Give 6H 90. Give 3RH or 6H 90.

6H – 6 months isoniazid; 12H – 12 months isoniazid; 3RH – 3 months rifampicin and isoniazid; 3HP – 3 months isoniazid and rifapentine; 4R – 4 months rifampicin

1
TB symptoms in adults may include: current cough, weight loss, drenching night sweats, fever or coughing up blood. TB symptoms in children may include: current cough, poor weight gain/failure to thrive, fever, lethargy or decreased playfulness, visible
neck mass. 2If investigations are not available, continue to give TPT if patient has no symptoms of TB. 3If drug susceptibility results of index patient unknown, ask where index patient receives TB treatment and contact clinic for treatment details. 4Sillicosis
is a chronic lung disease caused by breathing in silica dust while working in mining or construction. 5Cancer, those waiting/received blood/organ transplant or receiving chemotherapy, dialysis or corticosteroids, diabetes). 5Cancer, uncontrolled diabetes,
those awaiting/received blood/organ transplant or receiving chemotherapy, dialysis or long term corticosteroids.
89
TB
 At TPT initiation, decide patient category
• If never had TPT before or took TPT < 4 weeks, document as new.
• If completed TPT before or took TPT ≥ 4 weeks and stopped (due to adverse event, developed TB or was lost to follow up), document as previously treated.

Treat the patient needing TPT according to chosen regimen and weight
• Give pyridoxine together with TPT.
• If severe peripheral neuropathy, active liver disease or known alcohol use disorder, defer TPT.
Rifapentine and isoniazid (3HP): Isoniazid (6H and 12H): Rifampicin and isoniazid (3RH): Rifampicin (4R):
• 3HP is weekly rifapentine and isoniazid for • 6H is daily isoniazid for 6 months. • 3RH is daily dosing rifampicin and isoniazid for 3 months. • 4R is daily dosing rifampicin
3 months. • 12H is daily isoniazid for 12 months. • Rifampicin interacts with ART2: adjust doses or TPT regimen. for 4 months.
• Give with or immediately after eating. • Rifampicin interacts with
Isoniazid (Daily) RH (Daily)
• Rifapentine decreases levels of protease Weight ART2: adjust doses or TPT
100mg tablet 300mg tablet Weight 75/50 (use mL if
inhibitors (lopinavir/atazanavir/ritonavir), (kg) regimen.
(daily) (daily) (kg) 300/150 150/75 tablet dispersed in
nevirapine, and dolutegravir (when starting):
2 – 3.4 ¼ tablet - water) < 10 years 15mg/kg daily
use instead 12H.
• Rifapentine decreases levels of oral 3.5 – 4.9 ½ tablet - 2-2.9 - - ½ tablet 5mL ≥ 10 years 10mg/kg daily
contraceptive and subdermal implant: use 5 – 7.4 ¾ tablet - 3-3.9 - - ¾ tablet 7.5mL
instead barrier method and injectable or IUD 7.5 – 9.9 1 tablet - 4-5.9 - - 1 tablet 10mL Pyridoxine
contraceptive. 10 – 14.9 1 ½ tablet - 6-7.9 - - 1 ½ tablet 15mL • Give pyridoxine whenever
Isoniazid Rifapentine 15 – 19.9 2 tablets - 8-11.9 - - 2 tablets 20mL using isoniazid to prevent
Weight (weekly) (weekly) ≥ 20 3 tablets 1 tablet 12-15.9 - - 3 tablets 30mL peripheral neuropathy.
(kg) 300mg tablets 150mg tablets 16-24.9 - - 4 tablets 40mL < 5 years 12.5mg daily
(weekly) (weekly) 25 – 37.9 - 2 tablets - - ≥ 5 years 25mg daily
25 – 29.9 2 tablets 4 tablets 38 – 54.9 - 3 tablets - -
≥ 30 3 tablets 6 tablets ≥ 55 2 tablets - -

• Review monthly while on TPT: check for TB symptoms and side effects. Adjust dose according to weight, if needed. If peripheral neuropathy develops while on TPT  66. Advise to avoid alcohol/smoking.
• Explain possible side effects to patient: low appetite, nausea, abdominal discomfort, fatigue/weakness, dark urine, pale stools.
• If sudden new vomiting, upper abdominal pain, jaundice, hives, wheeze, difficulty breathing, BP < 90/60 or dizziness/collapse, stop TPT, refer and report ADR2.
• If TB symptoms develop: send 1 sputum sample for TB NAAT  92.
• If patient interrupts TPT:
- Explore reasons for treatment interruption, address individual concerns. Educate on the importance of adherence and provide adherence support  173.
- Screen clinically for TB symptoms:
• If symptoms of TB are present, check for TB  92.
• If no symptoms TB, continue treatment including missed doses.
- If individual interrupts for the second time, avoid restarting treatment.

Once TPT complete, decide on treatment outcome

• If completes full duration of TPT, document as treatment completed. • If stops TPT due to serious adverse event or developed TB, document as treatment stopped.
• If on 3HP, 3RH or 4R: if interrupts treatment for ≥ 4 weeks, document as lost to follow-up. • If died during TPT, document as died.
• If on 6H or 12H: if interrupts treatment for 3 consecutive months, document as lost to follow-up.

1
Rifampicin decreases levels of protease inhibitors (lopinavir/atazanavir/ritonavir), efavirenz and nevirapine: use instead 12H. If on dolutegravir: offer 12H or increase dolutegravir dose to 50mg 12 hourly. Continue until 2 weeks after TPT completed.
Discuss if unsure. 2Email or fax adverse drug reaction (ADR) form to [email protected] or (012) 842 7609/10.
90
 HOW TO COLLECT A GOOD SPUTUM SPECIMEN FOR TB TESTING
Aim to collect sputum in the early morning. This improves the chance of an accurate result. However, avoid missing the opportunity to collect sputum anytime during a consultation.

• Explain that a good quality sputum specimen is important to make an accurate diagnosis of TB.
• Advise to avoid putting saliva or nasal secretions into specimen jar. Sputum is the secretion that comes from deep within the lungs and a forceful cough is needed to bring it up for collection.
• If observing sputum collection, health worker to use mask (N95/FFP2) in well ventilated area. Stand behind patient and check air stream (fan, air conditioner) is coming from behind back to avoid exposure.
• Explain how to collect a good sputum specimen:

1 2 3 4 5 6
• Ensure collection area is well • Rinse mouth with water to • Breathe in and out deeply • On the third breath, give a • Replace lid and screw on • Wash your hands after
ventilated and private. remove food, mouth wash or two times. strong cough. tightly to prevent leaking. sputum collection.
• Use a designated sputum medication. • Have an open specimen • Cough 5-10mL (1-2 teaspoons) • Give to health worker.
collection area if available. jar ready. sputum into the jar.
• Keep the jar sterile (clean), • You may need several coughs to
avoid touching inside it. get at least 5mL.
• Avoid putting saliva/nasal
secretions into jar.

If patient unable to produce sputum, use nebuliser to induce sputum

• Health worker to wear a N95/FFP2 respirator mask in a well ventilated area. Explain process to patient: follow same steps as above only use nebuliser to help produce sputum.
• Add 5mL 3% saline to nebuliser and nebulise at 8L/min for 10 minutes or until sputum coughed up. While nebuliser runnng, ask patient breathe in and out deeply 2-3 times, followed by a strong
cough to try and bring up sputum from deep within the chest. If able to generate sputum, ask patient to remove mask and cough it into the specimen jar, then continue with nebulisation. Repeat until
at least 5mL sputum collected.
• If no sputum coughed up by 10 minutes, repeat nebulisation once.

Prepare specimens for transport to the laboratory:

• Check specimens are adequate: if patient unable to produce 5mL (1 teaspoon) but quality of sputum is still good, still send specimens to laboratory. If quality of specimen is inadequate, see below.
• Ensure lid is closed tightly and correctly, and that the specimen jar is correctly labelled as above. Wash hands after handling specimens.
• If room temperature is > 25°C or transport delayed for > 24 hours, store in refrigerator (2-8°C). Keep cool but do not freeze.
• Complete request form and advise patient to return for results in 2 days. If patient HIV-positive, indicate this on request form.

If specimen inadequate:
• If specimen is inadequate and of poor quality after repeated attempts, discard used jar in medical waste bin and give patient new labelled specimen jar. Instruct on how to collect sputum at home:
- Collect sputum specimen early in the morning after waking up, before eating or taking any medications. Collect sputum specimen outside home. Follow the same steps tried above.
- Once collected, protect sputum specimen sample from heat and light. Keep at room temperature and bring to the clinic as soon as possible.
• If specimen from home is adequate, prepare for transport to laboratory (above). If still not adequate, refer to hospital for further investigation or to a doctor for chest x-ray and review.

91
TB
 TB tests changing from
TUBERCULOSIS (TB): DIAGNOSIS 'Xpert Ultra' to 'TB NAAT'
(NAAT = nucleic acid
amplification test and includes
Xpert as well as newer TB tests).
• Check for TB if any TB symptoms: current cough, weight loss, drenching night sweats, fever or coughing up blood.
• Also routinely check for TB, even if no TB symptoms, if:
- Patient completed TB treatment in last 2 years: check for TB yearly, for 2 years after completing TB treatment. - Excluding TB disease during TB preventive treatment (TPT) work up.
- Patient HIV positive: at HIV diagnosis, then yearly (when viral load checked) and if pregnant at first antenatal visit. - Abnormal TB screening chest x-ray, even if no known TB exposure.

Give urgent attention to the patient with suspected TB and any of:
• Respiratory rate ≥ 30 • Prominent use of breathing muscles • Coughs up ≥ 1 tablespoon of fresh blood • Persistent vomiting
• Breathless at rest or while talking • Drowsy/confused • Neck stiffness • New weakness of arm/leg
Manage and refer urgently:
• If breathing difficulty, give face mask oxygen and ceftriaxone 1g IV1/IM to treat for suspected severe pneumonia.
• If able, send 1 sputum sample for TB NAAT. If HIV positive with CD4 ≤ 200 or WHO clinical stage 3 or 4, also do a rapid urine LF-LAM test.

Start the workup to diagnose TB in the patient not needing urgent attention
Test sputum Test blood Test urine
• Send 1 sputum sample for TB NAAT: demonstrate how to give sputum sample  91. Test for HIV • If HIV positive and CD4 ≤ 200 or WHO stage 3 or 4 disease, also do
• If unable to produce sputum: induce sputum  91. If unsuccessful, arrange chest x-ray  93.  110. rapid urine LAM test (only if TB symptoms):
• Ask patient to return for results in 2 days. Manage according to results: if TB NAAT positive - If LAM positive, diagnose TB and start DS-TB treatment same day
(or trace), manage below. If TB NAAT negative  93.  94 and follow up TB NAAT result (see below).
- If LAM negative, ask patient to return for TB NAAT results in 2 days.

TB NAAT positive or trace (MTB detected)

Patient has had TB in last 2 years. Patient has not had TB in last 2 years.

Trace result Rifampicin Rifampicin susceptible Rifampicin resistance detected Rifampicin Rifampicin Rifampicin Trace result
unsuccessful resistance susceptible unsuccessful
• Send sputum for Send sputum for smear: Did patient have RR-TB previously? detected Do chest
TB culture and • Send sputum • If smear positive: start Diagnose • Send x-ray, where
DST. for smear, TB DS-TB treatment 94. Yes. Send sputum for smear. No DS-TB sputum available,
• If no TB culture and • If smear negative: • Send for smear, and assess
symptoms: DST. do chest x-ray, where sputum for culture and clinically
wait for results • Defer TB available, and assess Smear negative Smear smear. DST and 93.
93. treatment. clinically  93. If chest Do chest x-ray, where available, positive • Start DS-TB follow up
• If TB symptoms: • Follow up x-ray suggestive of TB or and assess clinically  93. If treatment and DST
start DS-TB culture and TB symptoms and signs chest x-ray suggestive of TB or TB same day results
treatment DST result present: symptoms and signs present: 94.  93.
 94 and 93. • Start DS-TB
follow up results Start DS-TB treatment Diagnose RR-TB treatment
93. same day 94. • Send a 2nd sputum sample for DR-TB reflex testing. 94.
• Refer or start RR-TB treatment 99.
1
Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone.
92
 TB NAAT negative (MTB not detected)
• If no TB symptoms and testing for TB using TB NAAT negative, consider TB unlikely. Continue to assess need for TPT  89.
• If TB symptoms, manage symptom/s as on symptom page, especially if cough  38, if weight loss  23, if fever  24. Continue to assess and manage according to HIV status:

HIV negative HIV positive

• Review in 1 week: At this visit, also:

- If TB symptoms resolve: no further follow-up needed. Advise to return if symptoms recur. Assess need for TPT  89. • Send sputum for TB culture and DST.
- If TB symptoms persist: send sputum for TB culture and DST and arrange chest x-ray, assess clinically and review as below. If • Arrange chest x-ray, assess clinically and review as below.
chest x-ray unavailable, refer and follow up culture and DST results.

Doctor to review the chest x-ray, where available, and clinically assess the patient:
Compare with previous chest x-rays, if available. Especially look for: upper lobe cavitation, any lung opacification in HIV positive patient,
pleural effusion/s, hilar lymphadenopathy, miliary TB, pericardial effusion.

Chest x-ray abnormal Chest x-ray normal

Pleural or pericardial effusion No effusion Assess clinically: does patient have persistent symptoms or
• If bilateral pleural effusions or pericardial effusion, refer. • If unsure, discuss/refer. signs suggestive of TB?
• If pleural effusion, aspirate fluid and send 2 samples: • If history of mining or
- If clear: request TB culture, DST, ADA and cell count. working in construction, Yes No
- If pus: request TB NAAT, microscopy, TB culture and DST. Refer same day. consider silicosis.
TB disease unlikely
If not yet done, send sputum sample for TB culture and DST if able to produce sputum and assess clinically, looking for other causes.
• Continue routine care.
• If previous TB in the last 2 years with positive TB NAAT 91. • Assess eligibility for TPT  89.
• If no previous TB in the last 2 years, start DS-TB treatment  93 if: • If done, follow up TB culture and DST
- TB NAAT trace. results below.
- TB NAAT negative in HIV positive patient. • Advise to return if symptoms develop.
- Chest x-ray suggestive of TB in a patient with persistent TB symptoms and signs.
• Consider extrapulmonary TB:
- If abdominal pain, swelling, hepatosplenomegaly, or diarrhoea, refer for abdominal ultrasound.
- If severe headache/s, refer for CT scan/lumbar puncture.
- If back pain, arrange spinal x-ray or refer.
- If lymph node ≥ 2cm, aspirate lymph node for TB microscopy and cytology  25.

Follow-up culture and DST results every 1-2 weeks until available and review:

Culture positive (MTB confirmed) Culture negative

No resistance to rifampicin and INH detected Resistance to INH only detected Resistance to rifampicin detected TB unlikely
Diagnose DS-TB: start treatment 94. Diagnose INH mono-resistant TB: Diagnose RR-TB: start or refer to start • If TB symptoms resolved, continue routine care.
start treatment 95. RR-TB treatment 99. Advise to return if symptoms recur.
• If TB symptoms persist, refer.

93
TB
 TB tests changing from
DRUG-SENSITIVE TB (DS-TB): ROUTINE CARE 'Xpert Ultra' to 'TB NAAT'
(NAAT = nucleic acid
amplification test and includes
Xpert as well as newer TB tests).
Assess the patient with DS-TB
Assess When to assess Note
Registration At diagnosis Ensure patient record completed and captured on TIER.net.
TB contacts At diagnosis Advise that all TB contacts1 visit the clinic for TB screening and testing or ensure CHW does a home visit for TB screening and testing.
Alcohol/drug use At diagnosis In the past year, has patient: 1) drunk ≥ 4 drinks3/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.
Symptoms Every visit • If respiratory rate ≥ 30, breathless at rest or while talking, prominent use of breathing muscles, drowsy/confused, coughs up ≥ 1 tablespoon fresh blood, neck
stiffness, persistent vomiting or new weakness of arm/leg, give urgent attention 92.
• Expect gradual improvement on TB treatment. If symptoms worsen or do not get better, refer to doctor.
Adherence Every visit Request patient brings all medication to each visit. Check adherence on the TB card. If poor adherence, manage the patient who interrupts TB treatment  98.
Side effects Every visit Ask about side effects of treatment  97.
Family planning Every visit • Encourage patient to avoid pregnancy during treatment, assess patient's contraceptive needs  154. If pregnant  159.
• Avoid oral contraceptive and subdermal implant2 on TB treatment, use instead injectable or IUD plus condoms. No need to change interval between injectable.
Depression Every visit In the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either  143.
Palliative care If advanced TB disease If patient is in bed or chair for 50% or more of the day or dependent on others for most care, also give palliative care  170.
Weight and BMI Every visit • Expect weight gain on treatment and adjust TB treatment dose  96. If losing weight, refer to doctor/hospital same week.
• BMI = weight (kg) ÷ height (m) ÷ height (m). If < 18.5, refer for nutritional support.
Glucose At diagnosis • If known diabetes, assess glucose control more often  130.
• If not known with diabetes, check glucose  17.
HIV At diagnosis and every visit If > 3 months since last HIV test, test for HIV  110. If HIV positive, give routine HIV care and start ART  111. If on ART, adjust medication/dosing  97.
TB NAAT result At diagnosis Register patient as MTB detected, RIF sensitive/ RIF resistant; MTB not detected; Trace. If LAM was used to diagnose TB, review TB NAAT result  92.
TB microscopy At diagnosis If TB NAAT positive at diagnosis, send sputum for smear microscopy. Record smear microscopy result in the patient's file. Register as smear negative or smear positive.
(smear)4 Week 7 • Do only if smear positive pulmonary TB at diagnosis/registration:
- If week 7 smear positive: send 1 sputum for DST, prolong intensive phase for 1 month and manage further as per positive week 7 smear algorithm  97.
- If week 7 smear negative and clinically improving: change to continuation phase for further 4 months.
Week 23 • Do only if smear positive pulmonary TB at diagnosis.
• Use week 23 smear result to decide treatment outcome  98.
TB culture and • If sent during diagnostic workup • If both TB culture and TB NAAT negative at diagnosis, refer to hospital for further investigation or discuss with experienced TB doctor or specialist.
DST result • At 8 weeks: if still smear positive • If MTB (Mycobacterium tuberculosis) on culture, check DST result:
• If HIV positive and TB NAAT negative - If susceptible to rifampicin and INH, continue treatment.
• At 24 weeks: if still smear positive - If resistant to INH only, diagnose INH mono-resistant TB and give routine care 95.
- If resistant to rifampicin, diagnose rifampicin-resistant TB (RR-TB) and give routine care 98.
• If culture contaminated, repeat. If culture shows NTM (Nontuberculous mycobacteria), continue treatment and refer to doctor.
Treatment At completion of TB treatment Decide on treatment outcome  98.
outcome
Advise, counsel and treat the patient with DS-TB 96.
1
A TB contact refers to a patient who shared an enclosed space (at work, socially, in a hostel, or in a household setting), for ≥ 1 night or for frequent/extended daytime periods, with an adult/adolescent with pulmonary TB ("index patient"), during the 3-month
period before the index patient started their TB treatment. 2If patient already has subdermal implant, advise additional non-hormonal method (copper IUD or condoms) until 4 weeks after completing TB treatment. 3One drink is 1 tot of spirits, or 1 small glass
(125mL) of wine or 1 can/bottle (330mL) of beer. 4Make every effort to obtain sputum. If difficulty, try in early morning or arrange for induced sputum.
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 TB tests changing from
INH MONO-RESISTANT TB: ROUTINE CARE 'Xpert Ultra' to 'TB NAAT'
(NAAT = nucleic acid
amplification test and includes
Xpert as well as newer TB tests).
Assess the patient with INH mono-resistant TB
Assess When to assess Note
Registration At diagnosis Ensure patient record completed and captured on TIER.net.
TB contacts At diagnosis Advise that all TB contacts1 visit the clinic for TB screening and testing or ensure CHW does a home visit for TB screening and testing.
Alcohol/drug use At diagnosis In the past year, has patient: 1) drunk ≥ 4 drinks3/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.
Symptoms Every visit • If respiratory rate ≥ 30, breathless at rest or while talking, prominent use of breathing muscles, drowsy/confused, coughs up ≥ 1 tablespoon fresh blood, neck
stiffness, persistent vomiting or new weakness of arm/leg, give urgent attention 92.
• Expect gradual improvement on TB treatment. If symptoms worsen or do not get better, refer to doctor.
Adherence Every visit Request patient brings all medication to each visit. Check adherence on the TB card.
Side effects Every visit Ask about side effects of treatment  97.
Family planning Every visit • Encourage patient to avoid pregnancy during treatment, assess patient's contraceptive needs  154. If pregnant  159.
• Avoid oral contraceptive and subdermal implant2 on TB treatment, use instead injectable or IUD plus condoms. No need to change interval between injectable.
Depression Every visit In the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either  143.
Palliative care If advanced TB disease If patient is in bed or chair for 50% or more of the day or dependent on others for most care, also give palliative care  170.
Weight and BMI Every visit • Expect weight gain on treatment and adjust TB treatment dose  96. If losing weight, refer to doctor.
• BMI = weight (kg) ÷ height (m) ÷ height (m). If < 18.5, refer for nutritional support.
Glucose At diagnosis • If known diabetes, assess glucose control more often  130.
• If not known with diabetes, check glucose  17.
HIV At diagnosis and every visit If > 3 months since last HIV test, test for HIV  110. If HIV positive, give routine HIV care and ART  111. If on ART, adjust medication/dosing  97.
TB microscopy At diagnosis Register as smear negative or smear positive depending on result.
(smear) and culture4
Monthly • If still culture positive at 3 months, request DST on that same positive specimen.
• If still culture positive at 4 months, discuss with specialist or refer to drug-resistant TB unit.
• If negative smear/culture becomes positive, request DST on that same positive specimen.
DST • At diagnosis • If resistant to INH only: if still culture positive at 4 months, discuss with specialist or refer to drug-resistant TB unit.
• If culture positive at 3 months • If resistant to rifampicin, diagnose rifampicin-resistant TB (RR-TB) and give routine care 99.
• If negative smear/culture
becomes positive
TB NAAT If needed If INH resistance detected > 28 days after start of DS-TB treatment, send 1 further sputum sample for TB NAAT to confirm that there is no resistance to rifampicin.
Treatment outcome At completion of TB treatment Decide on treatment outcome  98.

Advise and treat the patient with INH mono-resistant TB 96.

1
Close TB contact: any person who shared an enclosed space (social/work/congregate/household setting) with an adolescent or adult with pulmonary TB (index patient) for > 15 minutes in 24 hours during the 3 months before index patient started TB
treatment. 2If patient already has subdermal implant, advise additional non-hormonal method (copper IUD or condoms) until 4 weeks after completing TB treatment. 3One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of
beer. 4Make every effort to obtain sputum. If difficulty, try in early morning or arrange for induced sputum.
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 Advise the patient with DS-TB or INH mono-resistant TB
• Provide TB counselling and refer for community or workplace adherence support.  78
• Educate about TB treatment side effects  97 and advise to return promptly should they occur.
• Educate about infection control: adequate ventilation/open windows (if area is not well ventilated, to wear a face mask), cough/sneeze into upper sleeve or elbow. Wash hands with soap regularly.
• If patient smear positive, advise to stay home from work for the first 2 weeks of treatment.
• Alert to the risks of smoking  141 and alcohol/drugs and support patient to change  177. If patient chooses to continue, advise safe alcohol use  142 and to continue taking TB medication daily.
• Give enhanced adherence support to the patient with poor adherence  173:
- Educate on the importance of adherence and the risks of resistance.
- Ask about alcohol/drug use  142, stress/anxiety/depression  86 and side effects  97.
- Refer for support: adherence counsellor, support group, treatment partner, community health worker.

Treat the patient with drug-sensitive or INH mono-resistant TB

• If drug-sensitive TB (DS-TB):
- Treat the patient (whether a new or retreatment case) 7 days a week for 6 months: Dose according to weight and
• Give intensive phase rifampicin/isoniazid/pyrazinamide/ethambutol (RHZE) for 2 months. Prolong for 1 month if 7 week smear positive  97. adjust as weight increases
• Then, if clinically improving (and 7 week smear negative if done), change to continuation phase rifampicin/isoniazid (RH) for a further 4 months.
RHZE
• If TB meningitis, TB bones/joints or miliary TB, extend treatment to 9 months (2 months RHZE/7 months RH) or as guided by a specialist.
(150/75/400/275mg)
- If patient pregnant, misuses alcohol, or has diabetes, epilepsy or BMI < 18.5: also give pyridoxine 25mg daily. Stop on completion of TB treatment.
25-37kg 2 tablets
• If INH mono-resistant TB: 38-54kg 3 tablets
- Give daily 7 days a week: rifampicin 10mg/kg + pyrazinamide 25mg/kg + ethambutol 15mg/kg + levofloxacin 750-100mg, until TB treatment completed. 55-70kg 4 tablets
To ensure adherence, give fixed dose combination tablets RHZE even though isoniazid (H) may not be active and add levofloxacin (see table).
- If inhA mutation only, consider giving high-dose isoniazid (up to total of 10mg/kg/day in total). If unsure, present to NCAC1. ≥ 71kg 5 tablets
- Give pyridoxine 50mg daily until TB treatment completed.
RH
• Decide treatment duration: 25-37kg 2 tablets (150/75mg)
Pulmonary TB Extrapulmonary TB 38-54kg 3 tablets (150/75mg)
≥ 55kg 2 tablets (300/150mg)
INH mono-resistant TB DS-TB • Hilar lymphadenopathy • Pericardial TB • TB meningitis
• TB lymphadenitis • Abdominal TB • TB spine/bone/joint Levofloxacin
• Give treatment for 6 months • Pleural effusion • Miliary TB < 33kg 15-20mg/kg
from date levofloxacin added. 33-50kg 750mg
• If extensive disease, refer to Give total of 6 months TB treatment. Give a total of 9 months
drug-resistant TB health facility. treatment as guided by specialist. ≥ 51kg 1000mg

• If HIV positive: if on ART, adjust medication/dosing  97. If not on ART  114.

• Check that patient is up to date with his/her COVID-19 vaccination.

Review the patient with drug-sensitive or INH mono-resistant TB

• If stable, review monthly during intensive phase, then arrange for treatment collection through RPCs2. Avoid treatment collection through RPCs if patient has TB and HIV.
• Review again at week 23.
• Advise to return sooner if worsening or side effects develop.
• Assess patient for TB preventive treatment (TPT)  89 and check for TB yearly for 2 years after completing TB treatment  92.

1
National Clinical Advisory Committee. 2RPCs - repeat prescription collection strategies make it easier and quicker for patient to collect their chronic medications and include ‘facility pick-up points’ (FAC-PUPs), ‘external pick-up points’ (EX-PUPs) and clubs.
Medications are pre-dispensed by Central Dispensing Unit (CDU) or Central Chronic Medicine Dispensing and Delivery (CCMDD).
96
 Treat the patient with TB1 and HIV
• If already on dolutegravir-based ART regimen and starting TB treatment: increase dolutegravir (DTG) dose to 50mg 12 hourly2. Continue this dose until 2 weeks after TB treatment completed.
• If already on TB treatment and starting ART (patient has never been on ART): consider TEE (TDF + FTC + EFV). Switch to DTG-based regimen 2 weeks after TB treatment complete.
• Avoid atazanavir with rifampicin. If already on atazanavir, discuss with HIV expert, infectious disease specialist or HIV hotline  178.
• If on lopinavir/ritonavir, increase lopinavir/ritonavir dose gradually:
- After 1 week of TB treatment, increase lopinavir/ritonavir to 600/150mg (3 tablets) 12 hourly for 1 week.
- Then increase lopinavir/ritonavir to 800/200mg (4 tablets) 12 hourly. Continue this dose until 2 weeks after TB treatment completed.
- Monitor for liver problem (jaundice, abdominal pain, vomiting) and check ALT monthly. If symptomatic with ALT > 120, or asymptomatic with ALT ≥ 200, refer.
- Aim to switch to a dolutegravir-based regimen 2 weeks after TB treatment completed.

Look for and manage TB treatment side effects

Side effect Likely cause Management
Jaundice Most TB medications Stop all medications and refer to hospital same day.
Nausea, vomiting, abdominal Most TB medications • Check ALT and review result within 24 hours:
pain - If ALT > 120, stop all medications and refer to hospital same day.
- If ALT 50-120, assess for possible causes, consider interrupting treatment and repeat ALT within 1 week. If unsure, discuss or refer.
• If nausea/vomiting: advise to take treatment at night. If significant nausea/vomiting, give metoclopramide 10mg 30 minutes before TB medication.
Skin rash/itch Most TB medications Assess and manage  67.
Seizures Levofloxacin, isoniazid Manage seizure  19 and refer to hospital same day.
Psychosis Levofloxacin, isoniazid Manage psychosis  85 and discuss/refer to hospital same day.
Change in vision Ethambutol Stop ethambutol and refer to eye specialist same day.
Joint pain Pyrazinamide, levofloxacin Give ibuprofen 400mg 8 hourly as needed with food for up to 5 days (avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease).
Orange urine Rifampicin Reassure this is normal while taking rifampicin.
Pain/numbness of feet Isoniazid Peripheral neuropathy likely  66.

Manage the patient with DS-TB and a positive week 7 smear

• Look for explanation for result: if poor adherence, give enhanced adherence support  173, alcohol/drug use  142, stress  86 or treatment side effects (see above).
• Send 1 sputum for culture and DST and continue intensive phase treatment for a month.
• Follow up culture and DST result every 1-2 weeks until available and review:

Sensitive to rifampicin and INH Resistant to INH only Resistant to rifampicin

• Change to continuation phase  96 and monitor clinically. Diagnose INH Diagnose RR-TB
• Repeat TB microscopy (smear) at week 11: mono-resistant TB • Stop DS-TB treatment:
• Start treatment - If resistant to rifampicin only, give outcome of "rifampicin resistant TB"
same day 95. in patient folder.
Smear positive Smear negative
• Register patient - If resistant to rifampicin and INH, give outcome of "multidrug-
as INH mono- resistant TB" in patient folder.
• Assess clinically: • Continue treatment and monitor clinically. resistant TB. • Give routine RR-TB care and start treatment same day 99.
- If patient improving, change to continuation phase • Continue treatment for a total of 6 months. • Register in drug-resistant TB register.
and continue treatment for a total of 6 months. • If RR-TB care not available, refer to drug-resistant TB initiation facility.
- If patient deteriorating, refer.
1
This includes drug-sensitive TB (DS-TB) and INH-monoresistant TB. 2If on fixed dose combination, tenofovir/lamivudine/dolutegravir (TLD): continue this and add dolutegravir 50mg 12 hours after TLD dose.
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 TB tests changing from
Manage the patient who interrupts DS-TB treatment 'Xpert Ultra' to 'TB NAAT'
• Look for explanation for treatment interruption and give enhanced adherence support  96. If alcohol/drug use  142, stress  86 or treatment side effects  97. (NAAT = nucleic acid
amplification test and includes
• Manage according to duration of interruption: Xpert as well as newer TB tests).

Interrupted for Interrupted for 1-2 months Interrupted for ≥ 2 months

< 1 month
Send 1 sputum sample for TB NAAT. Continue DS-TB • Do not restart DS-TB treatment.
treatment and review result after 2 days: • Register patient as loss to follow up.
• Send 1 sputum sample for TB NAAT and review result after 2 days:
TB NAAT negative TB NAAT positive
Rifampicin resistant Rifampicin sensitive
Rifampicin sensitive Rifampicin resistant
Stop DS-TB treatment. • Restart full course of DS-TB
• Continue DS-TB treatment. treatment 94.
• Extend treatment phase by the number of missed doses. Diagnose RR-TB • Register as re-treatment
• Give routine care RR-TB care and start treatment same day 99. after loss to follow up.
• Register in drug-resistant TB register.
• If RR-TB care not available, refer to drug-resistant TB initiation facility

Once TB treatment complete, decide on treatment outcome

Drug sensitive TB (DS-TB) INH mono-resistant TB

Pulmonary TB Extrapulmonary TB Pulmonary TB

Was TB diagnosed on either TB NAAT or culture? • If two

consecutive
Yes No negative cultures
30 days apart,
register as cured.
Smear positive at diagnosis Smear TB diagnosed • If culture
negative on chest x-ray or negative but
Smear negative at week 23 Smear positive at week 23 (or culture other by other means does not meet
positive) at (clinically diagnosed TB) criteria for
diagnosis cured, register
Smear Smear • Stop treatment and register as treatment failure.
negative at positive at • Send 1 sputum specimen for culture and DST. Decide on as treatment
week 7 week 11 further treatment according to results: Is patient well and has s/he gained weight? completed.
(or week 11)
Stop Sensitive to Resistant to Resistant to Yes No
Stop treatment rifampicin and INH INH only rifampicin
treatment and Stop treatment and register as Stop treatment.
and register register as Re-start DS-TB treatment Diagnose INH Diagnose treatment completed. Register as treatment
as cured. treatment and register as mono-resistant RR-TB 99. failure and refer for further
completed re-treatment after failure. TB 95. investigation.

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 RIFAMPICIN-RESISTANT TB (RR-TB): ROUTINE CARE
• RR-TB refers to TB that is resistant to rifampicin, with or without resistance to other TB medications. If patient has INH mono-resistant TB 95. • If newly diagnosed with RR-TB or pre-XDR TB: if pretomanid
available, consult the updated 'Clinical Management of RR-TB,
• If RR-TB care not available, refer to closest drug-resistant TB unit. September 2023' guideline to start patient on new short 6-mth
BPaLL (or BPaL if pre-XDR) regimen.
• Note: 1st and 2nd LPA tests are being replaced with Xpert
Assess the patient with RR-TB MTB/XDR assays for rapid detection of resistance to isoniazid,
Assess When to assess Note fluoroquinolones, amikacin and ethionamide.

Registration Every visit Enter patient's details at diagnosis. Update register (EDR.web) with latest sputum results at every visit.
Symptoms Every visit • If respiratory rate ≥ 30, breathless at rest or while talking, prominent use of breathing muscles, drowsy/confused, coughs up ≥ 1 tablespoon fresh blood, neck stiffness,
persistent vomiting or new weakness of arm/leg, give urgent attention 92. If persistent episodes of coughing blood, consider referral for surgical review.
• Expect gradual improvement. If not improving, assess adherence  173 and review LPA and DST results.
• If still no improvement at 4 months, request 1st and 2nd line LPA and extended phenotypic DST and present to NCAC1 to advise on rescue regimen.
Adherence Every visit Check patient is attending clinic daily for treatment (or on appointment day if receiving supply of medications).
Side effects Every visit • Ask about side effects of treatment  105. Manage promptly as side effects are common cause of treatment interruption.
• If intolerance to any medication, present to PCAC2/NCAC for medication substitution. Email or fax adverse drug reaction (ADR) form to [email protected] or (012) 842 7609/10.
TB contacts At diagnosis • Ask if patient is a TB contact3 of index patient with RR-TB. If yes, check contact’s LPA and DST results to help decide patient's RR-TB treatment regimen.
• Advise that all TB contacts3 visit the clinic for TB screening/prevention.
Family planning Every visit • Advise to avoid pregnancy during treatment, assess patient's contraceptive needs  154. If on injectable contraceptive, no need to change interval between doses.
• If pregnant  159 and present to NCAC. Avoid delaying treatment, start while awaiting response.
Depression Every visit In the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either  143.
Alcohol/drug use At diagnosis, 4 months In the past year, has patient: 1) drunk ≥ 4 drinks4/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.
Palliative care If deteriorating If patient breathless at rest, unable to walk unaided or failing treatment, also consider giving palliative care  170.
Weight (BMI ) 5
Every visit Expect weight gain on treatment and adjust treatment doses. If losing weight on treatment, discuss with specialist/refer. If BMI < 18.5, refer for nutritional support.
BP At diagnosis If known hypertension  133. If not, check BP: if ≥ 140/90  132.
Check routine tests according to table and review results 100:
At diagnosis At 2 weeks At 4 weeks and then monthly At 3 months At 6 months At 12 months Other
• 1 sputum for DR-TB reflex DST testing (smear, culture, 1st and 2nd • If on linezolid: • If pulmonary TB: 1 sputum for TB • HIV  110 • Chest x-ray • HIV  110 • If on amikacin: baseline
line LPA, phenotypic DST) FBC, differential microscopy and culture • If on • If HIV: CD4, • If HIV: CD4, audiometry (hearing test)
• ECG, chest x-ray count • If on bedaquiline, clofazimine, ethionamide viral load viral load • Once bedaquiline stopped:
• Vision (Snellen chart) moxifloxacin or delamanid: ECG or PAS: TSH ECG 3 monthly
• Pregnancy test • If on linezolid: FBC, differential • If HIV: viral load 6 monthly
• HIV  110 count, vision (Snellen chart) • If on ethionamide or PAS:
• Fingerprick glucose • If on amikacin: audiometry, TSH 3 monthly
• FBC, differential count, ALT, creatinine, potassium, magnesium, TSH creatinine, potassium, magnesium • If unwell: chest x-ray, ALT,
• If HIV: CD4, viral load Creat, K+, Mg

Review results 100.

1
National Clinical Advisory Committee: [email protected]. 2Provinical Clinical Advisory Committee. 3A TB contact refers to a patient who shared an enclosed space (at work, socially, in a hostel, or in a household setting), for ≥ 1 night or for frequent/extended
daytime periods, with an adult/adolescent with pulmonary TB ("index patient"), during the 3-month period before the index patient started their TB treatment. 4One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer. 5BMI = weight
(kg) ÷ height (m) ÷ height (m).
99
 Review test results and manage accordingly:
Assess Note
TB microscopy (smear) and culture If month 4 smear/culture positive or smear/culture becomes positive after being negative: assess adherence  173, review all previous sputum results and request LPA and extended
phenotypic DST on latest culture positive specimen. Present to NCAC as soon as possible to advise on rescue regimen. Consider referral for surgical assessment.
LPA and DST results (drug • 1st and 2nd line LPA will be done when reflex DST testing is requested at diagnosis:
susceptibility) - If LPA is sensitive to INH, INH phenotypic DST will be automatically tested by laboratory.
- If LPA is sensitive to fluoroquinolones, fluoroquinolone phenotypic DST will be automatically tested by laboratory.
- If LPA is resistant to fluoroquinolones or injectables, or both inhA and katG mutations present, 2nd line phenotypic DST will be automatically tested by laboratory.
Chest x-ray If chest x-ray worse despite treatment, discuss with specialist.
ECG Calculate QTcF1. If ≥ 450ms:
• If symptoms (chest pain, palpitations, dizziness or faintness), discuss with specialist or refer to hospital same day.
• If no symptoms:
- If QTcF < 470ms: continue treatment and routine ECG monitoring.
- If QTcF 470-499ms: repeat ECG at rest same day to confirm. Check potassium, magnesium and TSH and treat if abnormal. Check for medications that prolong QT interval2 and discuss
with experienced TB doctor or specialist. Repeat ECG weekly until < 470ms.
- If QTcF ≥ 500ms: repeat ECG at rest same day to confirm. Check potassium, magnesium and TSH and treat if abnormal. Stop all medications that prolong QT interval2 including RR-TB
medications (moxifloxacin, delamanid, clofazimine, bedaquiline). Discuss with experienced TB doctor or specialist same day.
Audiometry (hearing test) If on amikacin and any changes to hearing, stop amikacin and discuss possible medication substitutions3 with PCAC/NCAC.
Vision If any change in visual acuity, stop linezolid and ethambutol and refer to eye specialist same day. Discuss possible medication substitutions3 with PCAC/NCAC.
Pregnancy test If pregnant  159 and present to NCAC. Avoid delaying treatment, start while awaiting response.
Glucose If known diabetes, assess glucose control more often  130. If not known with diabetes, check glucose  17.
HIV If HIV positive, give routine care  111. If on ART, check if ART regimen needs adjusting  101. If not on ART, start or re-restart  101.
FBC and differential count If Hb < 8, neutrophils < 0.75 or platelets < 50, stop linezolid and discuss with PCAC/NCAC or refer for admission.
ALT • If ALT ≥ 200 or jaundice, stop all medications and refer same day.
• If ALT 50-199: if symptoms (nausea/vomiting/abdominal pain)  105.
- If no symptoms: continue medications and monitor for symptoms. If ALT 120-199, also repeat ALT weekly until < 120.
Creatinine (eGFR) If eGFR ≤ 50, avoid amikacin. If on amikacin, stop amikacin and discuss possible medication substitutions3 with PCAC/NCAC.
Potassium • If potassium ≤ 2.5, refer same day.
• If potassium 2.6-3.5, do ECG:
- If any arrhythmia on ECG or if patient has muscle weakness or vomiting, refer same day.
- If neither, give potassium chloride 2 tablets 12 hourly and repeat potassium within 1 week. Manage again according to result.
Magnesium If magnesium < 0.6, give magnesium chloride 500-1000mg orally 12 hourly for 1 month. If < 0.4, refer for IV magnesium.
TSH (thyroid function) If TSH raised, check FT4. If FT4 low, hypothyroidism likely:
• Give levothyroxine 100mcg daily and repeat TSH and FT4 after 2 months, unless:
- If ≥ 60 years: give instead levothyroxine 50mcg daily and repeat TSH and FT4 after 1 month.
- If known ischaemic heart disease: give instead levothyroxine 25mcg daily and repeat TSH and FT4 after 1 month.
• If repeat FT4 still low, increase levothyroxine by 25mcg every 4 weeks until FT4 within normal range.
• Once RR-TB treatment completed, continue levothyroxine for 2-3 months, then wean while continuing to monitor TSH and FT4.
Continue to review results 101.
1
QTCF is QT interval corrected for heart rate: online calculator (Fridericia's formula) can be accessed via https://www.mdcalc.com/corrected-qt-interval-qtc or calculate manually: QTcF = QT/(60/heart rate)0.33. 2Medications that may prolong QT interval
include: anti-arrhythmics (e.g amiodarone), psychotropics (e.g haloperidol), macrolide antibiotics (e.g erythromycin, azithromycin, clarithromycin), fluoroquinolone antibiotics (e.g ciprofloxacin, levofloxacin, moxifloxacin) and antifungal drugs (e.g
fluconazole, ketoconazole). 3Continue other medications while awaiting response from PCAC/NCAC.
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 CD4 Use CD4 to guide co-trimoxazole preventive therapy (CPT), see table 113.
Viral load • If VL < 50, continue ART.
• If VL ≥ 50, assess adherence to ART  173 and discuss with experienced TB doctor or specialist.

 65
Advise the patient with RR-TB
• Provide RR-TB counselling and arrange community health worker home visit. Refer to support group if available.
• Explain that duration of treatment will depend on previous treatment, site of disease and extent of drug resistance. Duration may need to be extended depending on response to treatment.
• Educate on the importance of adherence  173 and dangers of further resistance. Educate about treatment side effects  105, and advise to return promptly should they occur.
• Educate about infection control: cough hygiene, adequate ventilation/open windows, avoid close contact with children/those with HIV. Give surgical mask for use in poorly ventilated areas. Advise to
avoid sharing a bedroom if possible.
• Advise that TB contacts1 need to visit the clinic for TB screening/prevention.
• If pulmonary TB, advise to return to work only when culture conversion2 occurs.
• Alert to the risks of smoking  141 and alcohol/drugs and support patient to change  177. If patient chooses to continue, advise safe alcohol use  142 and to continue taking TB medication daily.

Treat the patient with RR-TB

• Give pyridoxine 50mg daily until TB treatment completed.
• Ensure COVID-19 vaccination is up to date.

If not on RR-TB treatment: If on RR-TB treatment:

• Start treatment using steps 1-3  102. • Check outstanding LPA and DST results3 and adjust regimen using step 2  102.
- Shorter regimen is 9-11 months treatment (4-6 months intensive and 5 months continuation phase). • If patient has gained weight, check if medication doses need adjusting  104.
- Longer regimen is 18-20 months treatment (6-8 months intensive and 12 months continuation phase).
- If unsure of initial regimen choice, discuss with PCAC/NCAC. • Decide when to change intensive phase to continuation phase:
- If on shorter regimen: decide at end of month 4  103.
- If on longer regimen: decide at end of month 6  103.

Treat the patient with RR-TB and HIV

Avoid EFV while on bedaquiline and AZT while on linezolid. Choose ART regimens according to the following scenarios:
Already on ART Starting ART Re-starting ART after ART interruption
If already on ART when RR-TB treatment • If starting ART after RR-TB treatment has been started, decide when to start ART  115. Provide adherence support  173.
started, check if ART regimen needs changing • Then choose most appropriate ART regimen: ideally choose TLD (TDF + 3TC + DTG). If eGFR < 50, Choose most appropriate ART regimen
according to latest viral load results  112. choose instead ABC + 3TC + DTG. to re-start  114.
ABC – abacavir; TDF – tenofovir; 3TC – lamivudine; TLD – tenofovir + lamivudine + dolutegravir

Review the patient with RR-TB

• Assess patient at diagnosis, 2 weeks, 4 weeks and then monthly. Review sooner if not improving or any problems.
• Once RR-TB treatment complete, follow up 6 monthly (or earlier if any symptoms recur) for 2 years: at each visit check symptoms, do chest x-ray and send sputum for TB microscopy and culture.

Decide when to stop RR-TB treatment

• If on shorter regimen: stop treatment 5 months after changing to continuation phase if patient well and cultures remain negative. If unwell or cultures become positive, present to NCAC.
• If on longer regimen: stop treatment 12 months after changing to continuation phase if patient well and cultures remain negative. If unwell or cultures become positive, present to NCAC.
• Record treatment outcome  103.

1
A TB contact refers to a patient who shared an enclosed space (at work, socially, in a hostel, or in a household setting), for ≥ 1 night or for frequent/extended daytime periods, with an adult/adolescent with pulmonary TB ("index patient"), during the
3-month period before the index patient started their TB treatment. 2Culture conversion: 2 consecutive negative culture results one month apart. 2If sample contaminated/inadequate/leaked or LPA results inconclusive, send another sample to laboratory.
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 How to start/adjust RR-TB treatment
ABC – abacavir; AZT – zidovudine; BDQ – bedaquiline; CFZ – clofazimine; DTG – dolutegravir; EFV – efavirenz; FLQ – fluoroquinolone; FTC - emtricitabine; LPVr – lopinavir/ritonavir; LZD – linezolid; TDF – tenofovir; 3TC - lamivudine

STEP 1: If any of the following, refer to hospital for admission

• Respiratory rate > 20 • Suspected TB meningitis or brain tuberculoma • Difficulty with adherence
• Hb < 8 • Unable to walk unaided • Patient requests admission
• BMI < 18 • Unstable social circumstances • Infection control challenges at home

STEP 2: If starting treatment as outpatient or hospital admission not possible, decide which RR-TB regimen to give
Does patient have any of:
• Hb < 8 • Previous RR-TB treatment for > 1 month • Patient is a TB contact2 of index patient with resistance to FLQ,
• Complicated EPTB1 • Both inhA and KatG mutations on LPA injectables, BDQ, LZD or CFZ
• Extensive bilateral cavitations on chest x-ray • Patient is a TB contact2 of index patient with both inhA and katG mutations • Patient is a TB contact2 of index patient failing treatment

None of above One or more of above

Start shorter regimen  104. Does patient have any of:

• Hb < 8
• QTcF ≥ 450ms
• Patient is a TB contact2 of index patient failing treatment
• CNS disease (TB meningitis or brain tuberculoma)
• Patient is a TB contact2 of index patient with resistance to FLQ, BDQ, LZD or CFZ

No Yes

Start basic longer regimen  104. • Discuss

individualised
Review LPA and phenotypic DST results: longer regimen with
• If discordance3 or heteroresistance4: continue same regimen and discuss with laboratory and PCAC/NCAC. PCAC/NCAC.
• Does patient have both inhA and katG mutations on LPA, or resistance to FLQ, BDQ, LZD or CFZ? • Follow up LPA and
phenotypic DST
results and discuss.
No Yes

• Continue same regimen. • If resistance to FLQ, BDQ, LZD or CFZ: discuss individualised longer regimen with PCAC/NCAC.
• If on shorter regimen and INH susceptible on both LPA and • Otherwise continue/change to basic longer regimen  104.
phenotypic DST, reduce high dose INH to normal dose INH  104.

STEP 3: If on ART, adjust ART regimen

• Avoid giving EFV and BDQ or, AZT and LZD, together because of overlapping toxicities.
• Check if patient eligible to switch same day to TDF + 3TC + DTG (TLD)  117.
1
TB meningitis or brain tuberculoma/TB spine/bone/joint or miliary, pericardial, abdominal or urogenital TB. 2A TB contact refers to a patient who shared an enclosed space (at work, socially, in a hostel, or in a household setting), for ≥ 1 night or for
frequent/extended daytime periods, with an adult/adolescent with pulmonary TB ("index patient"), during the 3-month period before the index patient started their TB treatment. 3Discordance here refers to instance where TB NAAT result is rifampicin-
resistant and DST result is rifampicin-sensitive. 4Heteroresistance here refers to both rifampicin-susceptible and rifampicin-resistant strains of TB in the same sputum sample.
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 Decide when to change intensive phase to continuation phase
• If patient on shorter regimen:
At end of month 4, assess clinical condition and check sputum results:

Month 4 smear negative Month 4 smear positive

Clinically improving Clinically not improving

Change to continuation phase for 5 months • Assess adherence  173 and side effects  105.
• Select medications according to regimen and dose according to • Optimise management of chronic conditions: if HIV  111, if diabetes  130, if hypertension  133.
weight  104. • Review all previous sputum results. Request 1st and 2nd line LPA and extended phenotypic DST on latest culture
• Ensure bedaquiline given for at least 6 months. positive specimen.
- If slow clinical response, extensive bilateral cavitations on chest
x-ray or fluoroquinolone sensitivity not confirmed, consider • Present to PCAC.
extending bedaquiline to 9 months: present to PCAC/NCAC. • Extend intensive phase to 6 months and bedaquiline to 9 months.
• If patient on longer regimen:
At end of month 6, assess clinical condition and check sputum results:

Month 4 culture negative Month 4 culture positive

Are there any of: • Assess adherence  173 and side effects  105.
• Slow clinical response1 • Fluoroquinolone sensitivity • Optimise management of chronic conditions: if HIV  111,
• Extensive bilateral cavitations on chest x-ray not confirmed if diabetes  130, if hypertension  133.

No Yes Consider possible treatment failure

Consider extending intensive phase to 8 months and BDQ to 9 months,
Change to continuation phase for 12 months Consider extending intensive or changing to rescue regimen: present to PCAC/NCAC.
Select medications according to regimen phase to 8 months and BDQ to
and dose according to weight  104. 9 months: present to PCAC/NCAC.

Decide on treatment outcome

Record treatment outcome based on culture conversion, number of consecutive negative cultures, duration of minimum treatment and clinical status.
Cure Treatment completed (success) Treatment failure
• TB culture converted • TB culture converted • Failure of month 4 TB culture to convert by month 6
• ≥ 3 consecutive2 negative cultures in continuation phase • < 3 consecutive2 negative cultures in continuation phase • ≥ 2 cultures positive in continuation phase and clinically worsening
• If shorter course: ≥ 9 months of treatment • If shorter course: ≥ 9 months of treatment • Treatment stopped on clinical grounds or by instruction from PCAC
• If longer course: ≥ 18 months of treatment • If longer course: ≥ 18 months of treatment • ≥ 2 new drugs added to regimen due to poor clinical response
• Not clinically worsening • Not clinically worsening
• Other outcomes include: ‘Loss to follow up’ (treatment interruption for ≥ 2 months), ‘Moved’, ‘Transferred out’, ‘Died’, ‘Still on treatment’, ‘Not evaluated’.

1
Slow clinical response: poor weight gain, ongoing TB symptoms, poor improvement on chest x-ray or delayed smear/culture conversion. 2Cultures need to have been done in a row, at least 30 days apart.
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 Select RR-TB medications according to chosen RR-TB regimen
Regimen Intensive phase Continuation phase
Shorter regimen • Bedaquiline (at least 6 months) • High dose isoniazid1 • Bedaquiline (for 6 months in total) • Pyrazinamide
• Linezolid (2 months only) • Pyrazinamide • Levofloxacin • Ethambutol
• Levofloxacin • Ethambutol • Clofazimine
• Clofazimine
Longer regimen • Bedaquiline • Clofazimine • Levofloxacin
This longer regimen is for uncomplicated cases as chosen in step 2  102. Avoid and • Linezolid • Terizidone • Clofazimine
discuss instead if any of: • Levofloxacin • Terizidone
• Hb < 8
• CNS disease (TB meningitis or brain tuberculoma)
• Resistance to FLQ, BDQ, LZD or CFZ
• Patient is a TB contact2 of index patient with resistance to FLQ, BDQ, LZD or CFZ or
failing treatment Note: manage the patient with
RR-TB at a health facility that
Dose RR-TB medications according to weight has reliable access to RR-TB
medications and monitoring
Medication Daily dose Note equipment available.
30-35kg 36-45kg 46-70kg > 70kg
Bedaquiline (BDQ) • 400mg daily for first 2 weeks If previous cardiac ventricular arrhythmias, severe coronary artery disease, known or family history of
• Then 200mg 3 days a week (Mon/Wed/Fri) prolonged QT syndrome, previous intolerance to bedaquiline, or on other QT-prolonging medications
(anti-arrhythmics, tricyclic antidepressants and antipsychotics), discuss with PCAC/NCAC.
Linezolid (LZD) 600mg 600mg 600mg 600mg Avoid starting if Hb < 8, neutrophils < 0.75 or platelets < 50: discuss instead with PCAC/NCAC.
Levofloxacin (LFX) 750mg 750mg 1000mg 1000mg
Clofazimine (CFZ) 100mg 100mg 100mg 100mg If on other QT-prolonging medications (anti-arrhythmics, tricyclic antidepressants and antipsychotics),
discuss with PCAC/NCAC.
Isoniazid High dose (hdINH) 450mg 450mg 600mg 600mg If phenotypic DST confirms sensitivity to INH, reduce to normal dose INH.
Normal dose (INH) 200mg 300mg 300mg 300mg
Pyrazinamide (Z) 1000mg 1500mg 1500mg 2000mg
Ethambutol (E) 800mg 800mg 1200mg 1200mg
Terizidone (TRD) 500mg 750mg 750mg 750mg If previous psychosis, avoid terizidone and present to PCAC/NCAC3.
Delamanid (DLM) 100mg 12 hourly 100mg 12 hourly 100mg 12 hourly 100mg 12 hourly
PAS 8g 8g 8g 8g
Ethionamide (ETO) 500mg 500mg 750mg 750mg
Moxifloxacin (MFX) 400mg 400mg 400mg 400mg If on other QT-prolonging medications (anti-arrhythmics, tricyclic antidepressants and antipsychotics),
discuss with PCAC/NCAC.
Amikacin (Am) (15-20mg/kg) 625mg 750mg 750-1000mg 1000mg Ensure audiometry (hearing test) done at baseline and then monthly.
Rifabutin 300mg 300mg 300mg 300mg • Give for 6 months if heteroresistance confirmed by laboratory and approved by PCAC/NCAC.
• If on lopinavir or atazanavir, reduce rifabutin dose to 150mg daily.

BDQ – bedaquiline; CFZ – clofazimine; FLQ – fluoroquinolone (e.g levofloxacin or moxifloxacin); LZD – linezolid;
If phenotypic DST confirms sensitivity to INH, reduce to normal dose INH. 2A TB contact refers to a patient who shared an enclosed space (at work, socially, in a hostel, or in a household setting), for ≥ 1 night or for frequent/extended daytime periods,
1

with an adult/adolescent with pulmonary TB ("index patient"), during the 3-month period before the index patient started their TB treatment. 3Start other medications while awaiting response from PCAC/NCAC.
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 Look for and manage RR-TB treatment side effects
Report adverse events via the MedSafety App, the reporting website, or complete adverse reporting form and email to [email protected] or fax to (021) 448 6181 or (012) 842 7609/10.
Side effect TB medication likely to cause side effect Management : consult latest NDoH guideline or discuss with PCAC/NCAC.
Chest pain, palpitations Bedaquiline, clofazimine, delamanid, moxifloxacin Do ECG and discuss with PCAC/NCAC same day.
Faintness Bedaquiline, clofazimine, delamanid, moxifloxacin Do ECG and discuss with PCAC/NCAC same day.
Dizziness Bedaquiline, clofazimine, delamanid, moxifloxacin, • Do ECG and discuss with PCAC/NCAC same day.
amikacin • If on amikacin, stop amikacin and present to PCAC/NCAC for medication substitution1.
Jaundice Most RR-TB medications Stop all medications and refer same day.
Nausea, vomiting, abdominal pain Most RR-TB medications • Check ALT and review result within 24 hours:
- If ALT ≥ 100, stop all medications and refer same day.
- If ALT 50-99, doctor to assess for possible causes, consider interrupting treatment and repeat ALT within
1 week. If unsure, discuss with specialist.
• If nausea/vomiting:
- Reassure that this usually improves after a few weeks.
- Advise to eat a non-fatty meal before taking medication.
- If no better, give metoclopramide 10mg to take 30 minutes before taking RR-TB medication.
- If still no better and on ethionamide, give ethionamide in divided doses.
Skin rash/itch Most RR-TB medication Assess and manage  67.
Seizures Terizidone, levofloxacin, high dose INH Manage seizure  19 and refer same day.
Psychosis Terizidone, high dose INH, levofloxacin, ethionamide Manage psychosis  85 and discuss/refer same day.
Change in vision Change in visual acuity Linezolid, ethambutol • Stop linezolid and ethambutol and refer to eye specialist same day.
• Discuss possible medication substitution1 with PCAC/NCAC.
Painful/red eyes, blurred Rifabutin Stop rifabutin and refer to eye specialist same day.
vision, sensitive to light
Hearing loss/ringing in ears Amikacin Stop amikacin and discuss possible medication substitution1 with PCAC/NCAC.
Diarrhoea Ethionamide, PAS, delamanid, bedaquiline, linezolid • Reassure that this usually improves and advise to increase fluid intake.
• Assess further  46. Give loperamide 4mg initially, then 2mg after each loose stool, up to 12mg/day.
• If severe and not resolving, discuss with PCAC/NCAC. Consider taking blood for Na, K+ and creatinine.
Joint pain Pyrazinamide, levofloxacin, delamanid, bedaquiline • Give ibuprofen 400mg 8 hourly as needed with food for up to 5 days (avoid if peptic ulcer, asthma,
hypertension, heart failure or kidney disease).
• If available, refer for physiotherapy.
• If no improvement, discuss possible withdrawal of pyrazinamide with PCAC/NCAC.
Pain/numbness of feet Terizidone, high dose INH, linezolid Peripheral neuropathy likely, discuss with PCAC/NCAC.
Headaches Linezolid, delamanid, bedaquiline • Give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) as needed for up to 5 days.
• Also consider other cause of headache  30.
Skin darkening Clofazimine Reassure that this will improve after treatment completed.
Low mood or anxiety Terizidone, high dose isoniazid Assess low mood or anxiety  86. If antidepressant started, avoid amitriptyline (prolongs QT interval).
Dry skin Clofazimine • Wash with aqueous cream (UEA) instead of soap. Avoid using aqueous cream as moisturiser (emollient).
• Moisturise skin with emulsifying ointment (UE) twice a day.
1
Continue other medications while awaiting response from PCAC/NCAC.
105
 HIV: PRE-EXPOSURE PROPHYLAXIS (PrEP)
If a HIV negative patient is at high risk of HIV infection or requests PrEP, use daily Pre-Exposure Prophylaxis (PrEP) to prevent patient from getting HIV. Continue to give condoms and lubricants as well.

Assess need for PrEP: is patient requesting PrEP?

Yes No: assess risk of HIV infection. Ask patient if s/he is having sex:
• Without a condom • With an HIV-positive partner (especially if partner not on ART/not virally suppressed) • While under the influence of alcohol and drugs
• With more than one partner • With a partner whose HIV status is unknown • With a partner who is more than 5 years older than him/her

Yes to one or more No to all

Has patient been recently or frequently diagnosed with STI/s?

Yes No: consider as low risk for HIV infection - no need to give PrEP.
• Discuss safe sex: use condoms reliably, only 1 partner, partner testing for HIV. Offer referral for male circumcision.
Consider as high risk for HIV infection • If sexually active, advise to re-test for HIV 6-12 monthly. Educate about availability of post-exposure prophylaxis.
• Encourage prompt treatment of STI for patient and partner.
Continue to advise and assess eligibility

Advise and assess eligibility of the patient needing or requesting HIV PrEP
• Explain that HIV PrEP is two medications in one tablet and needs to be taken every day to be effective. It helps to prevent HIV-negative people from getting HIV.
• Advise that HIV PrEP should be used together with other prevention methods (condoms, lubricants, male circumcision and contraception).
• Explain that regular HIV testing is needed: HIV test will be before starting PrEP, after 1 month and then 3 monthly.
• If pregnant or breastfeeding, explain that benefits of taking PrEP outweigh risk of any possible harm to mother or baby.

Is patient willing and ready to start HIV PrEP, to adhere to medication and to return for follow-up visits and 3-monthly HIV tests?

Yes No
Test for HIV  110 (if not already done at this visit). Manage according to result: • Encourage
patient to
HIV negative HIV positive follow safe sex
Was patient at risk of HIV infection in the past 6 weeks (new or multiple sexual partner/s, or unprotected sex)? • Avoid giving practices.
HIV PrEP. • Advise patient
• Explain the and partner to
No Yes test regularly
Does patient have any of: unwell, poor appetite, body pain, headache, sore throat, enlarged tender lymph nodes, rash, fever, sweating? benefits of
starting ART. for HIV (at least
• Give routine 6 monthly).
No Yes HIV care • Advise patient
Acute HIV infection unlikely Acute HIV infection possible  111. to return once
willing and
• If < 30kg or on medications that affect the kidneys (e.g. amikacin, gentamicin), discuss with doctor or HIV hotline  178. • Manage as on symptom pages. ready to start
• If history of kidney disease, do creatinine before starting PrEP: if abnormal, avoid starting PrEP. • Repeat HIV test after 4 weeks. HIV PrEP.
• Take blood for creatinine and hepatitis B surface antigen and continue to assess for HIV PrEP  107. • Delay giving HIV PrEP until
- Results do not have to be available to start patient on PrEP. Ensure correct contact details. confirmed HIV negative at 4 weeks.
106
 HIV PRE-EXPOSURE PROPHYLAXIS (PrEP): ROUTINE CARE
Assess the patient starting HIV PrEP at baseline, within 28 days and then 3 monthly.
Assess When to assess Note
Symptoms Every visit Manage symptoms as on symptom pages. If cough or fever ≥ 2 weeks, unexplained weight loss or night sweats, exclude TB  92.
STI symptoms Every visit Screen for STI: if discharge, rash, itch, lump/s, ulcer/s  49.
Adherence Every visit Ask about pill taking pattern and missed doses. If difficulty with adherence  173. If needed, align visits with baby's routine care or EPI visit.
Side effects Every visit Ask about side effects of medication (see below). Reassure these usually resolve within a few weeks.
Alcohol/drug use Every visit In the past year, has patient: 1) drunk ≥ 4 drinks1/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.
Sexual health Every visit If risky sexual behaviour: new or multiple partner/s, uses condoms unreliably, has sex under influence of alcohol/drugs, give safe sex advice.
Family planning Every visit • Exclude pregnancy  157. Assess patient's contraceptive needs  154. There are no interactions between PrEP and hormonal contraception.
• Align contraception visit with PrEP visit, if possible.
HIV test Baseline2, at 1 month, then every 3 months • If positive, stop HIV PrEP and give routine HIV care  111. If negative, continue HIV PrEP.
HBsAg Baseline • If positive, continue PrEP, take blood for ALT and refer doctor to monitor liver function: if ALT > 2 times upper limit of normal, refer.
• If negative, continue PrEP, consider giving hepatitis B vaccine  120.
Creatinine (eGFR) • If ≥ 30 years: baseline • If not pregnant: if eGFR < 30, refer same day. If eGFR < 50, repeat creatinine (eGFR) on a separate day: if repeat eGFR is ≥ 50, continue PrEP.
• If diabetes/hypertension: baseline, then - If repeat eGFR still < 50, stop PrEP and discuss with doctor/HIV hotline 178.
yearly • If pregnant: if creatinine > 85, repeat creatinine on a separate day: if repeat creatinine is ≤ 85, continue PrEP.
• If pregnant: baseline, at 3 and 6 months. - If repeat creatinine still > 85, stop PrEP and discuss with doctor/HIV hotline  178.
Syphilis At baseline Rapid tests are preferable, as results are immediately available. If positive  53.

Advise the patient on/starting HIV PrEP

• If starting, advise that daily HIV PrEP is only effective after taking it for at least 7 days. Emphasize importance of condom use until PrEP effective.
• Advise that HIV PrEP can be started and stopped according to risk. Discuss with nurse/doctor before stopping. Advise patient that HIV PrEP is not treatment for HIV and to avoid sharing medication.
• Emphasize that HIV PrEP does not prevent pregnancy or other STIs. Advise to avoid unprotected sex. Encourage reliable use of condoms and supply male and female condoms and lubricants. Offer
referral for male circumcision. Explain the need for regular HIV testing and advise partner/s to test for HIV. Help patient to plan and set goals for behavior changes that may reduce his/her risk.
• Support adherence: advise that s/he needs to take the PrEP medication every day for it to be effective in preventing HIV infection.
- Suggest patient uses a weekly pillbox and/or reminders like cell phone alarms or calendar checklist
- If missed pill, advise to take it as soon as s/he remembers within 24 hours and not take more than 1 pill in one day.
- Encourage patient to identify friends/family who can support adherence. Refer patient to local/online support group or adherence club, if available.

Treat the patient on/starting HIV PrEP

• If starting, give medication for 1 month. If already on HIV PrEP, give medication for 3 months. Complete PrEP Clinical Form at each visit.
Medication Dose Side effects
Tenofovir/emtricitabine (TDF/FTC) 300/200mg once daily Nausea, headache, tiredness, diarrhoea, depression, abnormal dreams, vomiting, rash, problems sleeping, changes in appetite.

Review after 1 month, sooner if side effects develop. Then 3 monthly: for HIV test and prescription of medications.

Decide when to stop HIV PrEP

If patient is no longer at high risk of HIV and wishes to stop PrEP, plan with patient to stop PrEP at least 7 days after last potential HIV exposure. If HBsAg-positive, avoid stopping PrEP and refer instead.
1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer. 2If starting PrEP is delayed, repeat HIV test on same day that PrEP is started  110.
107
HIV
 HIV: POST-EXPOSURE PROPHYLAXIS (PEP)
Body fluids transmit infection through sexual contact (assault or consensual, burst condom), occupational exposure (sharps injury, splash to eye, mouth, nose or broken skin), sharing
needles, contact with used condom and exposure to blood in sport or at accident scene. Tears, saliva (non-bloodstained), sweat, urine and stool are considered non-infectious fluids.

Give urgent attention to the patient exposed to infectious fluid:

• Exposure to blood, blood-stained fluid/tissue, pleural/pericardial/peritoneal/amniotic/synovial/cerebrospinal fluid, vaginal secretions, semen or breast milk
• Human bite severe enough to cause bleeding

Yes No
Was there sexual contact, sharps injury, splash to eye/open wound/mouth/nose?

Yes No
STEP 1. Give exposed patient immediate attention:
• If broken skin, clean area immediately with soap and water. • If human bite severe
• If splash to eye, mouth or nose, immediately rinse mouth/nose or irrigate eye thoroughly with water. enough to cause
bleeding, prevent
STEP 2. Assess need for HIV PEP and give immediately if ≤ 72 hours since exposure: hepatitis B only. Risk
of HIV transmission
Patient Patient HIV negative or unknown: give first dose of HIV PEP (as below), obtain consent and do HIV rapid test  110. negligible and there is
known HIV no need for HIV PEP.
positive Positive Negative One positive and one negative Patient refuses HIV rapid test • For all other exposures,
reassure that HIV and
Avoid giving HIV PEP, give instead Give HIV PEP only if ≤ 72 hours since exposure (ideally within 1 hour) for 28 days: hepatitis transmission
routine HIV care  111. • Give TDF 300mg + 3TC 300mg + DTG 50mg once daily for 28 days as a fixed combination tablet (TLD). If kidney is unlikely, avoid
disease, give instead AZT 300mg + 3TC 150mg 12 hourly plus DTG 50mg once daily. giving PEP.
• Check for medication interactions and adjust doses if needed  118, especially TB and epilepsy treatment, • If unsure, discuss with
contraceptives and other common medications like: calcium, iron, zinc, antacids, metformin. HIV hotline  178 or
• If source is failing 2nd line ART, discuss PEP with HIV hotline  178. specialist.

STEP 3. Take blood from exposed patient: if giving TDF, do creatinine (eGFR). If giving AZT, do FBC + differential count.

Send exposed patient’s blood for HBsAb titre (unless occupational exposure with documented HBsAb titre ≥ 10).

STEP 4. Take blood from source, if possible and source consents:

• Do rapid HIV test  110 and send blood for HBsAg and hepatitis C antibody. If case of human bite, only do HBsAg. If sexual exposure, also do syphilis.
• If source HIV rapid negative, no need to continue PEP unless signs of acute HIV infection (history of flu-like symptoms - fever, sore throat, headache). If unsure, discuss PEP with HIV hotline  178.

STEP 5. Give hepatitis B PEP if needed:

If exposed patient has not previously had 3 doses of hepatitis B vaccine or unsure, give 1st dose of hepatitis B vaccine 1mL IM. If sharps injury, give within 7 days. If sexual exposure, within 14 days.

STEP 6. Continue to assess and manage the patient:

If sexual assault  88. If emergency contraception needed  154. Review patient and blood results within 3 days 109.
AZT – zidovudine; DTG – dolutegravir; FTC – emtricitabine; TDF – tenofovir; 3TC – lamivudine; HBsAg – Hepatitis B surface antigen; HBsAbs – Hepatitis B surface antibody

108
 REVIEW THE PATIENT ON POST-EXPOSURE PROPHYLAXIS (PEP)
Review patient within 3 days, at 4 weeks and 4 months.
• Check adherence and ask about side effects from HIV PEP  116. Advise patient of side effects and to return promptly if they occur. Advise patient to use condoms for 4 months until results confirmed.
• If sexual assault  88. If case of human bite: repeat only HBsAg (at 4 months) from table below, use HBsAbs results to continue to give only hepatitis B prophylaxis below.
• Check bloods according to table and review results as below:
Assess When to assess Note
HIV rapid test Repeat HIV rapid test at 4 weeks and 4 months • Encourage to test for HIV  110.
- If HIV negative, assess the need for PrEP  106.
- If HIV positive, give routine HIV care  111.
Hepatitis B surface antigen (HBsAg) At 4 months If positive  120.
Hepatitis C antibody Do only if source hepatitis C antibody positive: first visit If positive, refer. If negative, do hepatitis C PCR at 6 weeks.
Hepatitis C PCR If exposed hepatitis C antibody negative and source positive: at 6 weeks If positive, refer.
Syphilis (if sexual exposure) Do only if source syphilis positive/unknown: first visit, 4 months If positive  53.
Creatinine (eGFR) result Check baseline results at 3-day follow up If eGFR ≤ 50, stop TDF + 3TC (or TDF + FTC), give instead AZT 300mg + 3TC 150mg 12 hourly and
check FBC and differential count.
Full blood count If on AZT: repeat at 2 weeks If Hb ≤ 8 or neutrophils ≤ 1.0, discuss with HIV hotline  178 or specialist.
Source blood results (if done) - If source HBsAg or hepatitis C antibody positive, refer source patient. If syphilis positive  53.
AZT – zidovudine; FTC – emtricitabine; TDF – tenofovir; 3TC – lamivudine.

Continue to give hepatitis B prophylaxis according to vaccination status

Has exposed patient/health worker previously received 3 doses of hepatitis B vaccine?

Yes No or unsure

Check exposed patient/health worker’s HBsAb titre result: Check source HBsAg result:

HBsAb titre ≥ 10 HBsAb titre < 10 or unknown Source HBsAg Source HBsAg
Check source HBsAg result: positive or unknown negative
• No need to give hepatitis B PEP.
• Reassure patient that s/he is Source HBsAg Source HBsAg positive or unknown
protected from hepatitis B negative
infection.
Give exposed patient/health worker hepatitis B immunoglobulin1 500IU IM.

• Give 3 doses of hepatitis B vaccine 1mL IM: if not already given, give 1st dose now and then dose 2 at 1 month.
- If source HBsAg positive or unknown: give dose 3 at 2 months.
- If source HBsAg negative: give dose 3 at 6 months.

1
If giving both hepatitis B vaccine and immunoglobulin, give at different sites. If immunoglobulin not available, refer to secondary care within 7 days but ideally within 24-72 hours after exposure. 2If health worker, repeat HBsAb titre 1-2 months after the
last vaccine dose to ensure HBsAb ≥ 10.
109
HIV
 HIV: DIAGNOSIS
• Encourage patient and his/her partner/s and children to test for HIV.
• If HIV self-screening test done, confirm results with routine tests below.

Obtain informed consent

• Educate about HIV, methods of HIV transmission, risk factors, treatment and benefits of knowing one’s HIV status.
• Explain test procedure and that it is completely voluntary.
• Obtain consent (children < 12 years need parental, guardian or caregiver consent). If consent is granted, test using the ‘three-test kit HIV test’ approach:

Do first HIV rapid screening test on fingerprick blood.

Screening test reactive Screening test

Using a different rapid test, do confirmatory HIV test 1 on fingerprick blood. non-reactive

Confirmatory test 1 reactive Confirmatory test 1 non-reactive

Do confirmatory HIV test 2 on fingerprick blood. Immediately repeat the screening rapid HIV test only:

Confirmatory HIV test 2 Confirmatory HIV test 2 non-reactive Second screening test reactive Second
reactive screening test
Discrepant results. Report as HIV inconclusive1. non-reactive
Send blood for an HIV ELISA test and advise patient to return for result within 7 days.

ELISA Reactive ELISA results ELISA non-reactive

inconclusive
Report HIV test result as positive. Patient has HIV. Report HIV test result as negative. Patient does not have HIV.
• Give routine HIV care at this visit  111. • HIV cannot be confirmed or Has patient been at risk of HIV infection in past 6 weeks (had new/multiple partners or
• Encourage HIV testing for partner/s and children. excluded at this time. unprotected sex with partner who has HIV/is HIV unknown)?
• Use HIV index testing forms, if available. • Advise patient to repeat
rapid HIV tests in 6 weeks. Yes No
• Explain that s/he may still be • Encourage patient to remain negative and
in window period2. Advise to advise when to re-test:
repeat HIV test after 6 weeks. - If sexually active: 6-12 monthly
• Consider need for PrEP  106. - If pregnant: at every antenatal visit.
- If on PrEP or breastfeeding, retest 3 monthly.

Offer referral for male circumcision to decrease risk of HIV infection.

Support
• Ensure patient understands test result and knows where and when to access further care.
• Encourage patient to follow safe sex practices. Demonstrate and give male/female condoms.

1
If pregnant in labour, manage baby as high-risk until mother's status confirmed. 2The window period is the time between HIV infection and the point when a test can accurately pick up HIV in the blood.
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 HIV: ROUTINE CARE
Assess the patient with HIV
Assess When to assess Note
Symptoms Every visit Manage patient’s symptoms as on symptom pages. If genital discharge/ulcer or partner has been treated for an STI in past 8 weeks, manage for STI  49.
TB Every visit Test for TB (send 1 sputum sample for TB NAAT): at HIV diagnosis, yearly with VL tests, and if any TB symptoms develop (cough, weight loss, night sweats or fever)  92.
Adherence Every visit Check record of patient's adherence to treatment and facility visits. If difficulty with adherence, give adherence support  173.
Side effects Every visit • Ask about side effects from ART  116, TB preventive treament (TPT)  89, co-trimoxazole preventive therapy (CPT) and fluconazole  113. Manage promptly. Discuss if unsure.
• If suspected adverse drug reaction, report via the MedSafety app or fill form and submit to pharmacist, or email to [email protected].
Depression Every visit In the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either  143.
Alcohol/drug use Every visit In the past year, has patient: 1) drunk ≥ 4 drinks1/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.
Sexual health Every visit If risky sexual behaviour: new or multiple partner/s, uses condoms unreliably, has sex under influence of alcohol/drugs, give safe sex advice.
Family planning Every visit • If woman of child bearing potential, sexually active and not on reliable contraception, exclude pregnancy  157.
• Assess patient's contraceptive needs. Advise reliable contraception (condoms plus IUD, subdermal implant, injectable or sterilisation)  154.
• Reassure that there are no interactions with DTG. If on other ART regimen, assess eligibility to switch to DTG  117 or adjust contraception  118.
• If planning pregnancy: start folate 5mg daily and advise to defer pregnancy until viral load < 50. Check for syphilis  53.
Vertical transmission Pregnant/ • If not on ART, start ART same day. If pregnant, also give antenatal care  159.
prevention (VTP) breastfeeding • If breastfeeding, check that HIV-exposed infant has received correct PEP and PCR results  168.
Palliative care If deteriorating If failing 3rd line ART and deteriorating, also give palliative care  170.
Weight Every visit • At diagnosis, measure height and weight to calculate BMI. BMI = weight (kg) ÷ height (m) ÷ height (m):
- If BMI < 18.5, refer for nutritional support. If BMI ≥ 25, assess CVD risk below.
• If weight loss ≥ 5% of body weight in 4 weeks  23.
Chronic conditions At diagnosis • If known hypertension, check control  133. If not known with hypertension, check BP: if ≥ 140/90  132.
and CVD risk • If known diabetes, check glucose control and adjust doses of metformin if taking together with dolutegravir  130. If not known with diabetes, check glucose  17.
• If known with epilepsy, check seizure control and for possible medication interactions  149.
• Assess CVD risk  127. If CVD risk > 20% or known CVD2, and on LPVr or ATV/r, switch to DTG  117. If unable to switch to DTG, switch to ATVr and change simvastatin to
atorvastatin 10mg at night.
WHO Clinical Stage Every visit to check if • Check weight, mouth, skin, previous and current problems. Once on ART, the aim is for patient to be WHO Clinical Stage 1.
stage has worsened • Use WHO Clinical Stage to decide when to start co-trimoxazole  113. If not on ART, use most advanced stage even if recovered. If on ART, use stage done at this visit.
WHO Clinical Stage 1 WHO Clinical Stage 2 WHO Clinical Stage 3 WHO Clinical Stage 4
• No symptoms • Recurrent sinusitis, tonsillitis, otitis media, • Pulmonary TB within past year • Extrapulmonary TB within past year • Kaposi’s sarcoma, lymphoma, invasive
• Persistent painless pharyngitis • Oral candida • Weight loss ≥ 10% and diarrhoea cervical cancer
swollen glands • Papular pruritic eruption (PPE) • Oral hairy leukoplakia or fever > 1 month • Cytomegalovirus infection
• Fungal nail infections • Unexplained weight loss ≥ 10% body weight or BMI < 18.5 • Pneumocystis pneumonia (PJP) • Toxoplasmosis
• Herpes zoster (shingles) • Unexplained diarrhoea > 1 month • Recurrent severe bacterial • HIV-associated dementia, encephalopathy
• Recurrent mouth ulcers • Unexplained fever > 1 month pneumonia • Cryptococcal disease (including
• Angular cheilitis/stomatitis • Severe bacterial infections (pneumonia, meningitis) • Herpes simplex of mouth or genital meningitis)
• Unexplained weight loss < 10% body weight • Unexplained anaemia < 8, neutropaenia < 0.5 or chronic area > 1 month • Cryptosporidium or Isospora belli diarrhoea
thrombocytopaenia < 50 • Oesophageal candida
Continue to assess the patient with HIV 112.

1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer. 2Cardiovascular disease (CVD) includes ischaemic heart disease, peripheral vascular disease and stroke/TIA.
111
HIV
 Check tests according to table and review results below. Results do not have to be available to start patient on ART same day. Record correct contact details in case of abnormal results to recall patient.
At diagnosis Starting/changing ART After 1 month After 3 months on ART After 10 months 6 monthly Yearly Also
on ART on ART
• Urine: dipstick and pregnancy test1 • Changing to TDF: AZT: FBC + diff • Viral load • Viral load If previous • Viral load • Check viral load more often :
• Sputum: TB NAAT creatinine • TDF: creatinine • CD4 CD4 < 200 • TDF: creatinine - Pregnant: at 1st antenatal visit
• Blood: creatinine, Hb, HBsAg, CD4 • Changing from TDF: HBsAg • AZT: FBC + diff • TDF: creatinine or not on • Sputum: TB NAAT and delivery
(and CrAg2 if CD4 < 100) • Starting AZT: Hb • ATVr or LPVr: total ART: CD4 - Breastfeeding: 6 monthly
• Cervical screening cholesterol, triglycerides - RR-TB: 6 monthly
• Cervical screen 3 yearly
ABC - abacavir ATVr - atazanvir/ritonavir AZT – zidovudine CrAg - cryptococcal antigen Diff - differential white cell count EFV - efavirenz FBC – full blood count FTC - emtricitabine
Hb - haemoglobin HBsAg – hepatitis B surface antigen LPVr – lopinavir/ritonavir RR-TB – rifampcin-resistant TB TDF – tenofovir TEE - TDF + FTC + EFV TLD - TDF + 3TC + DTG 3TC - lamivudine
Urine dipstick • If proteinuria, check creatinine (eGFR) if not already done. Interpret result below. If pregnant, recheck urine dipstick, do BP and manage further  161.
• If glucose in urine: check random fingerprick glucose  17. TB tests changing from
'Xpert Ultra' to 'TB NAAT'
Urine pregnancy • If pregnancy test positive, give antenatal care  159 and if not on ART, start same day. (NAAT = nucleic acid
test • If pregnancy test negative, advise to use reliable contraception (IUD, subdermal implant or sterilisation, plus condoms). amplification test and includes
Xpert as well as newer TB tests).
TB sputum test Interpret sputum TB NAAT results  92. Repeat TB sputum test yearly, at same time as yearly viral load done.
CD4 If CD4 < 100, check CrAg result. If CD4 < 200 or WHO stage 2, 3 or 4 disease at HIV diagnosis, start co-trimoxazole prophylaxis therapy (CPT)  113 and do a rapid urine LAM test for TB if TB symptoms  92.
CrAg2 If cryptococcal antigen (CrAg) positive, refer for lumbar puncture (LP). If symptomatic (headache, confusion) or pregnant, refer urgently.
Hb (FBC + • If Hb < 12 (woman) or < 13 (man), anaemia likely, do FBC and differential count if not already done  27. If difficulty breathing, chest pain or dizziness, refer same day.
differential count) • If Hb ≤ 8 or neutrophils ≤ 1.0: avoid zidovudine. If already on zidovudine, switch to TDF or ABC. If on AZT because of kidney problem and ABC hypersensitivity, discuss with HIV hotline  178.
Hepatitis B • If HBsAg positive, TDF should form part of ART regimen  120.
(HBsAg) • If HBsAg negative, check immune response and give 3 doses of hepatitis B vaccine if needed  120.
Cervical screen Interpret result  55. Repeat 3 yearly if normal.
Creatinine (eGFR) • If eGFR < 30, refer/discuss with HIV hotline  178.
• If eGFR ≤ 50 (or creatinine > 85 in pregnant patient): recall patient. Switch ART according to HbsAg result:
- If HBsAg negative: stop TDF, use ABC instead. If on TLD or TEE: switch to ABC + 3TC + DTG. If previous hypersensitivity to ABC, use AZT instead of ABC.
- If HBsAg positive: discuss management with experienced ART clinician or HIV hotline  178.
• Check if other medication doses need adjusting: eGFR can be used as acceptable estimate of creatinine clearance (CrCl). Check for proteinuria and repeat eGFR after 1 month. If repeat eGFR ≤ 50, refer
to doctor to check BP, glucose, urine dipstick, send urine for protein/creatinine ratio and arrange kidney ultrasound.
ALT • If ALT ≥ 200 or jaundice, stop medications and discuss/refer same day.
• If ALT < 200:
- If no symptoms, continue medications and monitor for symptoms. Also repeat ALT weekly until < 120.
- If symptoms (nausea/vomiting/abdominal pain):
• If ALT 120-199 (or total bilirubin > 40, if done): stop all medications and discuss/refer same day.
• If ALT 50-120: doctor to assess for causes (check HBsAg; consider alcohol or drug-induced liver injury), consider interrupting/delaying ART. Repeat ALT within 1 week. If unsure, discuss with specialist.
Total cholesterol, • If triglycerides ≥ 10, discuss/refer same day.
triglycerides • If total cholesterol > 6 or triglycerides > 5, and on LPVr or ATV/r, switch to DTG  117. If unable to switch to DTG, switch to ATVr and change simvastatin to atorvastatin 10mg at night. Repeat fasting
total cholesterol and triglycerides after 3 months: if still raised, discuss/refer.
Viral load (VL) • If VL < 50, continue routine VL monitoring (see table above). If not yet on TLD, switch ART  117. Check if eligible to collect medications from a repeat prescription collection point  113.
• If VL ≥ 50, manage unsuppressed viral load  119.
Advise and treat the patient with HIV 113.

1
Only do pregnancy test if woman of child bearing potential has missed period and is not on contraception. 2CrAg - cryptococcal antigen. Laboratory will usually automatically do this if CD4 < 100.
112
 Advise the patient with HIV  74
• Encourage disclosure to supportive partner, family member or friend and refer to counsellor/support group. Advise patient’s partner/s and children be tested for HIV.
• Encourage safe sex even if partner has HIV or patient on ART. Advise correct and consistent use of condoms with all partners. Demonstrate and give male/female condoms.
• Explain that HIV is treatable but not curable and needs lifelong adherence to treatment to stay well and to prevent resistance.
• Explain the benefits of starting ART early, regardless of CD4 or stage but especially if CD4 ≤ 200, stage 3 or 4, pregnant or breastfeeding.
• If patient chooses not to start ART: identify barriers, link to counselling and review blood results and ART readiness in 1 week. If remains unwilling to start, re-educate about importance of early
treatment, refer to wellness programme, and advise to return immediately if s/he becomes unwell.

Treat the patient with HIV

If patient not on ART If patient on ART
Plan to start or restart TDF + 3TC + DTG (TLD)1, same day if • If not on a DTG-based regimen, check if eligible to switch same day  117.
possible (or within 7 days). Follow Steps 1-5  114. • Ask about any new medications: especially TB and epilepsy treatment, contraceptives and other common
medications like: calcium, iron, zinc, antacids, metformin. If needed, adjust ART or dosing  118.
• Give influenza vaccine 0.5mL IM yearly. Avoid if CD4 ≤ 100. Check that patient is up to date with his/her COVID-19 vaccination.
• Give prophylaxis: TB preventive treatment (TPT), co-trimoxazole preventive therapy (CPT) and fluconazole as needed:
Medication When to give/avoid What to give Side effects When to stop
TB preventive • Start TPT if not already had TPT and no current TB symptoms. • If already on ART with VL < 50 in last 6 months, give 3HP • If pain/numbness of feet, peripheral • If on 3HP, stop after
treatment • Avoid if previous RR-TB, neuropathy, liver disease, alcohol misuse. and pyridoxine  89. neuropathy likely  66. 3 months.
(TPT) • If TB contact2: start TPT even if already had TPT. • If starting ART or on ART and viral load ≥ 50, give • If rash  67. • If on 12H, stop after
instead isoniazid for 12 months (12H): give 300mg daily. • If jaundice: refer same day. 12 months.
Also give pyridoxine 25mg daily. • If nausea, vomiting, abdominal pain: check ALT
and review result within 24 hours  112.
Co- Start if: • If CrCl > 50, give co-trimoxazole 160/800mg daily. • If jaundice: refer same day. Stop after at least 1
trimoxazole • CD4 ≤ 200 or • If CrCl 10-50, give co-trimoxazole 80/400mg daily. • If nausea, vomiting abdominal pain: check ALT year once CD4 > 200,
preventive • WHO stage 2, 3 or 4 disease • If CrCl < 10, give co-trimoxazole 80/400mg 3 days a week and review result within 24 hours  112. regardless of stage.
therapy (CPT) (Mon/Wed/Fri). • If nausea/vomiting  45. If started for TB and
• If rash  67. CD4 > 200, stop after
6 months.
Fluconazole • If CrAg3 result positive, refer for lumbar puncture (LP). If delay in • If delay in LP expected, give fluconazole 1200mg. • If jaundice: refer same day. Stop after at least
referral for LP, start fluconazole. • If CCM3: once discharged, give fluconazole 200mg daily • If nausea, vomiting abdominal pain: check ALT 1 year if CD4 > 200
• If pregnant/breastfeeding, liver disease, previous CCM4, discuss to complete at least 1 year. and review result within 24 hours  112. and VL < 50.
with HIV hotline before starting  178. • If no symptoms and LP clear: complete fluconazole • If nausea/vomiting  45.
1200mg daily for 2 weeks, then 800mg daily for 2 months.
Then fluconazole 200mg daily to complete at least 1 year.

Review the patient with HIV

Visit Baseline visit Month 1 Month 3 Month 4 Month 10 6-monthly Yearly
Note • Baseline tests - follow up • Review patient. • Review patient. • Review results. • Review patient. • Repeat medication • Review patient.
results. Recall patient if needed. • If well, give 2 months ART. • Do viral load and other • Assess for repeat • Do viral load and other script. • Do viral load and other
• Start ART. • If unwell, review more often. monitoring blood tests. prescription (below). monitoring blood tests. • Do CD4 if needed. monitoring blood tests.
• Patient eligible to use repeat prescription collection point (RPC)5 if: 1) Viral load < 50, 2) Clinically well with no infections, 3) No other uncontrolled chronic conditions, 4) Not pregnant.
• If not eligible or RPC5 refused: if patient well enough, give more than 1 month of medication at a time.
1
TDF – tenofovir; 3TC – lamivudine; DTG – dolutegravir; TLD – fixed combination dose tablet of TDF + 3TC + DTG. 2A TB contact refers to a patient who shared an enclosed space (at work, socially, in a hostel, or in a household setting), for ≥ 1 night or for
frequent/extended daytime periods, with an adult/adolescent with pulmonary TB ("index patient"), during the 3-month period before the index patient started their TB treatment. 3CrAg - cryptococcal antigen. 4CCM - Cryptococcal meningitis. 5Repeat
prescription collection points (RPC) include ‘facility pick-up points’ (FAC-PUP), ‘external pick-up points’ (EX-PUP), clubs. Medications are pre-dispensed by Central Dispensing Unit (CDU) or Central Chronic Medicine Dispensing and Delivery (CCMDD).
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 Start or restart ART
STEP 1. Decide what ART regimen to start or restart

Patient starting ART Patient restarting ART after treatment interruption

Is patient known with kidney disease • Explore and address reasons for treatment interruption and try to resolve issues  173.
(eGFR ≤ 50 or if pregnant creatinine > 85)? • If on third-line ART, discuss with experienced ART doctor, HIV expert or HIV hotline  178.
• If not on third-line ART, check if previously taking LPVr or ATVr for 2 or more years?
No Yes
No Yes
Choose: Choose: Previously on: LPVr or ATVr for < 2 years, or a NVP-, EFV- or DTG-based regimen, or unknown. First check
tenofovir (TDF) + abacavir (ABC) + eligibility to
lamivudine (3TC) lamivudine (3TC) • Restart TDF + 3TC + DTG same day. Fixed combination dose tablet known as TLD. Record as TLD1 if patient never failed a previous ART restarting ART
+ dolutegravir + dolutegravir regimen and TLD2 if patient failed a previous ART regimen. and switching
(DTG). The fixed (DTG). The fixed - If known kidney disease (eGFR ≤ 50 or creatinine > 85 in pregnant woman), use instead ABC + 3TC + DTG. Fixed combination dose tablet to TLD same day
dose combination dose combination known as ALD. Record as ALD1 if patient never failed a previous ART regimen and ALD2 if patient failed a previous ART regimen.  117.
known as TLD1. known as ALD1. - Only if previous hypersensitivity reaction to ABC, use instead AZT + 3TC + DTG.

Then decide where patient will continue to collect medications and when to repeat viral load according to duration of interruption:

Patient has Patient has interrupted treatment for ≥ 28 days

interrupted
treatment for Any of:
< 28 days
• Patient unwell with symptoms • Interrupted for 90 days (3 months) or more • High VL before interruption
• Known with CD4 < 200 or TB or stage 4 illness • Pregnant • Switching regimen to TLD today

No Yes

• Do VL as per routine yearly schedule. • Manage any symptoms as on symptom page.

• Enrol patient in RPC1. • If no TB test done in past year, send sputum for TB NAAT.
• Give a 3-month medication refill. • Do CD4 at this visit, and repeat VL after 3 months if restarting ART.

STEP 2. Check for possible medication interactions and adjust ART or dosing if needed.
Ask about other medications patient is taking: especially TB and epilepsy treatment, contraceptives and other common medications like: calcium, iron, zinc, antacids, metformin  118.

STEP 3. Take bloods according to chosen ART regimen  112.

STEP 4. Check if there is a reason to delay ART  115.

ABC – abacavir; ATVr - atazanavir/ritonavir; AZT – zidovudine; DTG – dolutegravir; EFV – efavirenz; NVP – nevirapine; LPVr – lopinavir/ritonavir; TDF – tenofovir; 3TC – lamivudine

1
Repeat prescription collection points (RPC) include ‘facility pick-up points’ (FAC-PUP), ‘external pick-up points’ (EX-PUP), clubs. Medications are pre-dispensed by Central Dispensing Unit (CDU) or Central Chronic Medicine Dispensing and Delivery
(CCMDD).
114
 STEP 4. Check if there is a reason to delay ART
Aim to start same day but first check if there is a reason to delay ART:

If any of: difficulty breathing, respiratory rate ≥ 30, temperature ≥ 38°C, pulse > 100, BP < 90/60, confusion or agitation, or unable to walk unaided, delay starting ART and refer same day.

Is patient known with TB1?

No Yes

Does patient have cough, weight loss, night sweats, fever, chest pain or blood-stained sputum? Known with TB meningitis or brain tuberculoma?

No Yes No Yes

Is patient known with cryptococcal meningitis1? • Exclude TB Does patient have any of: • Start ART after
 92. • CD4 < 50 4-8 weeks of TB
No Yes • Plan to start • RR-TB treatment.
ART within • Pregnant/breastfeeding • If pregnant or
Is CD4 result available? Start ART 1 week once breastfeeding,
after TB excluded. No Yes start ART
4-6 weeks 4-6 weeks after
No Yes starting TB
of Start • If DS-TB and
meningitis ART after CD4 < 50, start ART treatment.
If CD4 < 100, check cryptococcal antigen (CrAg) result.
treatment. 8 weeks within 2 weeks of
of TB TB treatment as
CrAg not done (CD4 ≥ 100) CrAg negative CrAg positive treatment. soon as tolerating
TB treatment.
Does patient have jaundice, signs of meningitis (severe headache with Delay ART and • If RR-TB, start ART
neck stiffness/vomiting), or signs of other acute illness (like COVID-19, refer for lumbar after 2 weeks of TB
pneumonia or PJP)? puncture (LP). treatment if stable
If symptomatic and tolerating TB
No Yes (headache, treatment.
confusion) or • If pregnant or
• Start ART same day. • If jaundice, check ALT and total pregnant, refer breastfeeding,
• Follow-up blood results bilirubin and manage according to urgently. start ART within
when available. results before starting ART  112. 2 weeks of starting
• If signs of meningitis, refer urgently. If no cryptococcal TB treatment,
• If other severe acute illness, treat for meningitis when patient's
1-2 weeks before starting ART. on LP and no symptoms are
• Follow up blood results. symptoms, start improving, and
• If unsure, discuss with experienced ART after 2 weeks of TB treatment is
ART doctor or HIV hotline  178. fluconazole. tolerated.

STEP 5. Dose ART correctly according to chart 116.

1
If patient has TB and cryptococcal meningitis, discuss with experienced ART clinician about when to start ART.
115
 STEP 5. Dose ART correctly according to chart
• Give 3 antiretrovirals (1 from each of the 3 sections in the table below) according to chosen ART regimen and blood results, if available.
• Where available, use fixed dose combination tablets. Prescribe in full (e.g. for TLD (TDF + 3TC + DTG): write tenofovir, oral, 300mg daily + lamivudine, oral, 300mg daily + dolutegravir, oral, 50mg daily.
Short-term side effects that usually
Urgent side effects (stop Long-term side
Medication Dose When to avoid resolve. If persists ≥ 6 weeks,
antiretroviral and refer same day) effects
discuss/refer.
1 Tenofovir • CrCl > 50: give 300mg daily. • Kidney disease: Kidney failure: Nausea, vomiting
(TDF) • CrCl ≤ 50: avoid. eGFR or CrCl ≤ 50 • If CrCl < 30, refer same day.
• If pregnant: • If CrCl 30-50 and unwell, refer same day.
creatinine > 85 • If CrCl 30-50 and well, refer to doctor.
Abacavir • 300mg 12 hourly or 600mg daily Previous AHR AHR likely if ≥ 2 of: 1) Fever 2) Rash 3)
(ABC) • Give "alert card" found in packaging warning of Abacavir Fatigue/body pain 4) Nausea, vomiting,
Hypersensitivity Reaction (AHR). diarrhoea or abdominal pain 5) Sore
throat, cough or difficulty breathing.
Zidovudine • Use only if TDF and ABC not suitable. • Hb ≤ 8 (Hb ≤ 7, if Anaemia (pallor) with respiratory rate ≥ 30, Headache, nausea, muscle pain, fatigue Lipoatrophy (fat loss
(AZT) • CrCl ≥ 10: give 300mg 12 hourly. pregnant) dizziness/faintness or chest pain. (if Hb ≤ 8 doctor to switch ART  117). in face, limbs and
• CrCl < 10: give 300mg daily. • Neutrophils ≤ 1.0 buttocks): switch to
• On linezolid TDF or ABC.
2 Lamivudine • CrCl > 50: give 150mg 12 hourly or 300mg daily. Uncommon Uncommon Uncommon
(3TC) • CrCl 10-50: give 150mg daily.
• CrCl < 10: give 50mg daily.
Emtricitabine • CrCl > 50: give 200mg daily. Uncommon Uncommon Darkening of palms/
(FTC) • CrCl 30-50: give 200mg every 2 days. soles
• CrCl < 30: discuss.
3 Dolutegravir • 50mg daily Uncommon • Headache, nausea, diarrhoea
(DTG) • If also on any of these medications, adjust medications/ • Insomnia: advise to take treatment in
dosing  118: rifampicin (DS-TB), iron, calcium, the morning.
magnesium or aluminium, metformin, carbamazepine,
phenytoin.

Efavirenz • ≥ 40kg: give 600mg daily. • Active psychiatric • Rash  67. Jaundice. Psychosis. • Rash  67. Gynaecomastia
(EFV) • < 40kg: give 400mg daily. illness • Nausea/vomiting/abdominal pain: check • Headache, dizziness, sleep problems (breast enlargement):
• On bedaquiline ALT and review results within 24 hours • Low mood  86. switch to DTG
 112.  117.
Lopinavir/ • 400/100mg 12 hourly (with food). If never taken LPVr or ATVr • Chronic diarrhoea • Jaundice Diarrhoea: if intolerable or > 6 weeks, Dyslipidaemia: if
ritonavir in past, give 800/200mg daily. • Cholesterol/ • Nausea/vomiting/abdominal pain: check switch to DTG  117. total cholesterol
(LPVr) • If also on any of these medications, adjust medications/dosing triglycerides raised ALT and review results within 24 hours > 6 or triglycerides
 118: rifampicin, carbamazepine, phenytoin, lamotrigine, • CVD risk > 20%  112. > 5, switch to ATVr
oral contraceptive, fluticasone/budesonide.  112.
Atazanavir/ • 300mg/100mg daily (with food) • On rifampicin • Jaundice with other symptoms • Headache
ritonavir • If also on any of these medications, adjust medications/ • On lansoprazole • Nausea/vomiting/abdominal pain: • Jaundice without other symptoms:
(ATVr) dosing  118: rifampicin, carbamazepine, phenytoin, check ALT and review results within check ALT, review result within 24
lamotrigine, oral contraceptive, fluticasone/budesonide. 24 hours  112. hours. ATVr can cause jaundice without
hepatitis. Discuss with ART doctor or
HIV hotline  178.

116
 Switch ART
Aim to switch all patients to dolutegravir (DTG). Resistance to DTG is rare and DTG provides rapid VL suppression and has minimal side effects.

Check if patient eligible to switch, or restart, DTG-based regimen same day:

Does patient’s ART regimen include LPVr or ATVr?

No Yes

• Patient on one of following: Has patient been on LPVr or ATVr for 2 or more years?
- TDF + FTC + EFV (TEE)
- ABC + 3TC + EFV No Yes
- AZT + 3TC + EFV Manage further according to last two VL results, taken at least 2 years after starting LPVr or ATVr (if VL unknown, discuss):
- AZT + 3TC + DTG
- NVP-based regimen
• If patient on regimen other than above, Both VL Latest VL result ≥ 1000 Both VL
discuss with doctor, HIV expert or HIV results • Continue same regimen and assess and support adherence  173. results
hotline  178. < 1000 • Repeat VL in 3 months: ≥ 1000

Switch to DTG-regimen today, regardless of VL. VL < 1000 VL ≥ 1000

• Check VL result done in last 12 months: Virological failure confirmed

- If VL ≥ 50: continue to switch but assess and • If pregnant, discuss with HIV expert/hotline  178.
support adherence  173. • Assess adherence in last 6-12 months by checking script for pharmacy refills and notes
- If VL not done in last 12 months, do it at this visit. for clinic appointment attendance1.
No need to wait for results before switching. • Have refills been collected > 80%2 of time or has patient attended > 80%3 clinic visits?

• Switch to TDF + 3TC + DTG same day. Fixed combination dose tablet known as TLD Record as No Yes
TLD1 if patient never failed a previous ART regimen and TLD2 if patient failed a previous ART • Adherence considered poor. Resistance test is not indicated.
regimen. • Switch to TDF + 3TC + DTG same day. This is available in a fixed combination • Adherence
- If known kidney disease (eGFR ≤ 50 or creatinine > 85 in pregnant woman), use instead ABC dose tablet called TLD2. considered good.
+ 3TC + DTG. Fixed combination dose tablet known as ALD. Record as ALD1 if patient never - If known kidney disease (eGFR ≤ 50 or creatinine > 85 in pregnant woman), • Discuss need for
failed a previous ART regimen and ALD2 if patient failed a previous ART regimen. use instead ABC + 3TC + DTG. Fixed combination dose tablet known as ALD2. resistance testing
- Only if previous hypersensitivity reaction to ABC, use instead AZT + 3TC + DTG. - Only if previous hypersensitivity reaction to ABC, use instead AZT + 3TC + and choice
• If unsure, discuss with experienced ART doctor, HIV expert or HIV hotline  178. DTG (2nd-line). of new ART
• If unsure, discuss with ART doctor, HIV expert or HIV hotline  178. regimen with HIV
• If restarting ART, manage further 116. expert, infectious
• If VL done in last 12 months < 50, continue routine viral load monitoring  112. • Repeat VL in 3 months.
• If VL done in last 12 months ≥ 50, repeat VL in 3 months (or 4-6 weeks if pregnant). disease specialist,
third line ART
committee or HIV
• Ask about other medications: especially TB or epilepsy treatment, contraceptives and calcium, iron, zinc, antacids, metformin. Check if ART needing adjusting  118. hotline  178.
• Check if bloods needed  112: if starting TDF, take baseline creatinine. If stopping TDF, check HBsAg before switching ART. If starting AZT, check Hb.
• Dose ART correctly according to chart  116.

ABC – abacavir; ATVr - atazanavir/ritonavir; AZT – zidovudine; DTG – dolutegravir; EFV – efavirenz; FTC – emtricitabine; NVP – nevirapine; LPVr – lopinavir/ritonavir; TDF – tenofovir; VL – viral load; 3TC – lamivudine
1
If available, also do drug level on urine or blood specimen: adherence is considered good if medications are detected in patient's urine/blood. 2Calculate adherence % for pharmacy refills: ‘number of actual refills done during period assessed’ ÷ ‘number of
months in period assessed’. Then x by 100. 3Calculate adherence % for clinic attendance: ‘number of scheduled visits actually attended by patient during period assessed’ ÷ ‘number of scheduled visits during period assessed’. Then x by 100.
117
 Manage ART medication interactions
• Ask patient if s/he is taking any over-the-counter or herbal/traditional medications.
• If on or needing contraception: reassure that there are no interactions with DTG. If on other ART regimen, assess eligibility to switch to DTG  117, otherwise manage below.
• For other interactions: check SAMF, EMGuidance app, Liverpool HIV iChart app, use web-based interaction checker (see QR code) or discuss with HIV expert/hotline  178.
Check for HIV
Assess and manage common medication interactions: medication
interactions
If on this ART medication Check for interacting medications Adjust medications and/or doses
Dolutegravir (DTG) Rifampicin • Increase DTG dose to 50mg 12 hourly. If on TLD or ALD fixed dose combination tablet, add DTG 50mg 12 hours after TLD or ALD dose. Continue
this dose until 2 weeks after TB treatment completed, or
• If already on TB treatment and starting ART (patient has never been on ART): consider TEE (TDF + FTC + EFV). Switch to DTG-based regimen
2 weeks after TB treatment complete.
Anticonvulsants: • Avoid giving carbamazepine or phenytoin together with DTG:
• Carbamazepine - Switch to lamotrigine  149. If unable to use lamotrigine, consider valproate  149. Avoid valproate if woman of child-bearing potential.
• Phenytoin - If unable to switch anticonvulsant and patient to remain on carbamazepine, increase dose of DTG to give 50mg 12 hourly.
Iron and/or calcium • If taking iron only, advise to take iron and DTG together with food.
• If taking calcium only, advise to take calcium and DTG together with food.
• If taking iron and calcium, advise to take DTG and calcium together with food, then to take iron at least 4 hours later.
Zinc Advise to take zinc at least 6 hours before or 2 hours after DTG.
Magnesium/aluminium (antacids) Advise to take antacid at least 6 hours before or 2 hours after DTG.
Metformin Avoid giving more than 500mg metformin 12 hourly. If diabetes uncontrolled, move to step 2 (start glimepiride)  131.
Lopinavir/ritonavir (LPVr) Rifampicin • Assess eligibility to switch to DTG  117. If not eligible for DTG switch, gradually increase dose of LPVr according to ALT  97.
Anticonvulsants: • Assess eligibility to switch to DTG  117. If switching to DTG, continue to manage as above (see dolutegravir row).
• Carbamazepine • If not eligible for DTG switch, avoid giving carbamazepine or phenytoin together with LPVr:
• Phenytoin - Switch anticonvulsant to lamotrigine and double lamotrigine dose  149. If unable to use lamotrigine, consider valproate  149. Avoid
valproate if woman of child-bearing potential. If unsure, discuss with HIV expert/hotline  178.
Oral contraceptive Avoid with LPVr. Assess eligibility to switch to DTG  117. If not eligible to switch to DTG, use instead an IUD, subdermal implant or injectable and condoms.
Fluticasone/budesonide Avoid with LPVr. Assess eligibility to switch to DTG  117. If not eligible to switch to DTG, use instead beclomethasone 12 hourly.
Atazanavir/ritonavir (ATVr) Rifampicin • Avoid ATVr. Assess eligibility for switch to DTG  117.
• If not eligible for DTG switch, discuss with TB expert/hotline to switch rifampicin to rifabutin or switch ATVr to LPVr  178.
Carbamazepine or phenytoin • Assess eligibility to switch to DTG  117. If switching to DTG, also adjust choice of anticonvulsant as for LPV/r above.
• If unable to switch to DTG, discuss with HIV hotline  178
Oral contraceptive Avoid with ATVr. Assess eligibility to switch to DTG  117. If not eligible to switch to DTG, use instead an IUD, subdermal implant or injectable and condoms.
Fluticasone/budesonide Avoid with ATVr. Assess eligibility to switch to DTG  117. If not eligible to switch to DTG, use instead beclomethasone 12 hourly.
Efavirenz (EFV) Bedaquiline Avoid EFV. Switch to DTG  117.
• Oral contraceptive • Avoid giving these contraceptives together with EFV. Assess eligibility to switch to DTG  117.
• Subdermal implant • If not eligible to switch to DTG, use instead IUD or injectable and condoms.
Zidovudine (AZT) Linezolid Avoid AZT. Discuss with HIV expert/hotline  178.

ATVr - atazanvir/ritonavir; AZT – zidovudine; EFV - efavirenz; FTC - emtricitabine; LPVr – lopinavir/ritonavir; TDF – tenofovir; TEE - TDF + FTC + EFV; TLD - TDF + 3TC + DTG; 3TC - lamivudine

118
 Manage the patient with an unsuppressed viral load (VL ≥ 50)
Assess and manage possible causes of unsuppressed viral load (VL ≥ 50):
• If pregnant or breastfeeding 166.
• Check for underlying causes of unsuppressed VL, especially adherence issues and medication interactions  173.
• Emphasise condom use and contraception, especially while VL is unsuppressed

• If patient is not on TLD (or ALD), check if same day ART switch is appropriate  117.
• If patient is on DTG-based regimen, continue below.

Repeat VL in 3 months:

Second viral Second viral load result ≥ 50

load result < 50 • Increase efforts to resolve adherence1 issues and address possible drug-drug interactions  173.
• Manage further according to duration:
Continue routine
VL monitoring Patient has been Patient has been on DTG-based regimen for at least 2 years.
 112. on DTG-based • Assess adherence in last 6-12 months by checking script for pharmacy refills and notes for clinic appointment attendance2.
regimen for less • Have refills been collected > 80%3 of time or has patient attended > 80%4 clinic visits?
than 2 years
No Yes

Adherence Adherence considered good.

considered
poor. Has patient had 2 or more VL results ≥ 1000 after starting DTG-based regimen?

No Yes

Has patient had at least one VL ≥ 1000 with either: CD4 < 200, or an opportunistic infection5? Virological
failure confirmed.
No Yes

Has patient failed previous regimen before s/he started DTG-based regimen (on TLD2 or ALD2/2nd-line)?

No Yes

• No resistance testing needed. If drug interactions suspected, then • Discuss need for resistance testing and choice of new individualised regimen with HIV
discuss with HIV expert or HIV hotline  178. expert, infectious disease specialist, third line ART committee or HIV hotline  178.
• Continue to address adherence and possible interactions. • If VL ≥ 1000, monitor CD4 6 monthly. If CD4 ≤ 200, restart co-trimoxazole  113.
• Repeat VL at next scheduled routine VL. • Repeat VL 3 months after starting new regimen.

1
Resistance to a DTG-based regimen is rare – the most probable cause for VL non-suppression is poor adherence. 2If available, also do drug level on urine or blood specimen: adherence is considered good if medications are detected in patient's
urine/blood. 3Calculate adherence % for pharmacy refills: ‘number of actual refills done during period assessed’ ÷ ‘number of months in period assessed’. Then x by 100. 4Calculate adherence % for clinic attendance: ‘number of scheduled visits actually
attended by patient during period assessed’ ÷ ‘number of scheduled visits during period assessed’. Then x by 100. 5Examples of opportunistic infections include TB, Cryptococcal disease, Pneumocystis jirovecii pneumonia (PJP), Cryptosporidium, Isospora belli
(Cystoisospora belli).
119
 HEPATITIS B (HBV)
Test for hepatitis B: send blood for hepatitis B surface antigen (HBsAg) if:
• Jaundiced (yellow skin/eyes) • HIV positive starting ART • Contact1 of person known with hepatitis B
• ALT raised • As part of post/pre-exposure prophylaxis (PEP/PrEP) workup • Pregnant (at booking visit)

• If patient has yellow skin or eyes, jaundice likely, assess and manage  79.
• If not done already, also test for for HIV  110 and syphilis  53. Manage further according to HBsAg result:

HBsAg positive HBsAg negative

Patient has hepatitis B infection Patient does not have hepatitis B.

• Notify. Any of:
• Educate that infection requires no specific treatment at this stage. Advise to return if jaundice develops. • Health worker3 • Person who injects drugs (PWID)
• Educate that hepatitis B spreads via blood and sexual fluids. Advise patient to: • HIV positive • Man who has sex with men (MSM)
- Reliably use condoms. Advise partners to test. • Contact1 of person known • Sex worker
- Avoid sharing toothbrushes, razors or needles. Advise household contact/s and needle-sharing/sexual contact/s to test. with hepatitis B • Pregnant
• If HIV positive: ensure patient on ART containing tenofovir (TDF) and lamivudine (3TC) or emtricitabine (FTC). If not, discuss
with experienced ART clinician or HIV hotline  178. No Yes
• Also screen for hepatitis C: send blood for anti-HCV (EIA-antibody) or do rapid test, if available, using blood or saliva. If positive,
refer.
• If pregnant and HIV negative: consider need for PrEP (do ALT)  106. Tenofovir/emtricitabine (TDF/FTC) will also function • If not known to be immunised4, send blood for HBsAbs5:
as, treatment to prevent transmission of hepatitis B to baby. If needed, discuss with doctor/specialist. - If HBsAbs ≥ 10: patient is immune, no further
• If able, arrange delivery at facility where hepatitis B immunoglobulin (HBIG) and hepatitis B monovalent vaccine available,  167. management needed.
• Explain that hepatitis B infection can resolve by itself or become a chronic infection. - If HBsAbs < 10: give 3 doses of hepatitis vaccine 1mL
IM at 0, 1 month and 6 months. Re-check HBsAbs
2 months after last vaccine:
Check HBsAg after 6 months:
HBsAbs HBsAbs < 10
HBsAg positive HBsAg negative ≥ 10
• Offer re-vaccination: give 3 doses of hepatitis
Patient has chronic hepatitis B infection Hepatitis B infection vaccine 1mL IM, one month apart.
• Educate that chronic hepatitis B infection can lead to liver disease and cancer. has resolved. • Repeat HBsAbs two months after last
• Advise to avoid/reduce alcohol intake. No further treatment vaccine given:
• Test for HIV: needed.
- If HIV positive:
• Explain that certain medications used in ART will treat hepatitis as well. These will HBsAbs ≥ 10 HBsAbs < 10
If high risk lifestyle2 advise to repeat
lower the hepatitis viral levels so that risk of liver disease is lowered. HBsAg yearly.
• Ensure patient on ART containing TDF + 3TC/FTC. If not, discuss with experienced ART Patient is immune due to previous hepatitis B Repeat HBsAg
clinician or HIV hotline  178. vaccination. No further vaccination needed. test and
- If HIV negative, refer for further tests and management of chronic hepatitis B infection. discuss/refer.

Manage the baby born to mother with hepatitis B infection 167.

1
Contact refers to household contact or needle-sharing/sexual partner of person known with hepatitis B (HBsAg-positive). 2New/multiple sexual partners, unprotected sex, exposure through skin like tattoo, piercing, sharing needles/other sharps.
3
This includes student health care workers, clinic support staff (cleaners) and laboratory staff. 4Patient has no documentation of hepatitis B vaccination (e.g. Road to health booklet) or was born before April 1995 when hepatitis B vaccine was introduced
into expanded programme on immunisation (EPI). 5HBsAbs - hepatitis B surface antibodies.
120
 LONG COVID: ROUTINE CARE
A patient is considered to have 'Long COVID' if s/he has ongoing symptoms for 2 or more months following acute COVID-19 infection (usually 3 months from the onset of COVID-19 symptoms).

Assess the patient with Long COVID

Assess When to assess Note
Symptoms Every visit • Ask about symptom/s: specifically ask about difficulty sleeping and ongoing pain. Manage as on symptom pages.
• If patient was hospitalised for COVID-19 and breathlessness lasts > 6 weeks after discharge, refer to physiotherapist, if available, for assessment/home programme.
• If persistent dry cough ≥ 8 weeks, consider referral to a speech and language therapist, if available.
• If symptoms still present and troubling after 12 weeks, or uncommon (like palpitations, skin rash), refer/discuss with doctor/specialist.
TB Every visit Follow up TB sputum results. If no TB sputums sent during 'Long COVID' work-up, send 1 sputum sample for TB NAAT at this visit  92.
Daily activities Every visit If patient not able to cope with activities of daily living (like bathing, dressing, grooming, homemaking), consider referral to available rehab team member.
Chronic conditions Every visit If patient has chronic condition, check control and give routine care. Check that routine bloods have been done.
Mental health Every visit If stress, anxiety or low mood, assess and manage further  86.
Family planning At diagnosis If patient had severe COVID-19 and is on combined oral contraceptive (COC), doctor to discuss risks of thrombosis and consider switch to progestogen-only pill,
copper IUD or subdermal implant. Assess family planning needs  154.
Carer/family Every visit Ask how carer/family is coping.
CVD risk At diagnosis Assess CVD risk at diagnosis  127.
Weight Every visit If weight loss, assess further  23.
Chest x-ray If cough/breathlessness ≥ 12 weeks If chest x-ray abnormal, refer/discuss.
Thyroid Tiredness ≥ 12 weeks Check TSH. If abnormal, refer to doctor.

Advise the patient with Long COVID

• Reassure that many people with COVID-19 have ongoing symptoms, even in mild cases. Explain that, normally, symptoms slowly resolve without specific treatment.
• Advise that symptoms may fluctuate and to expect good days and bad days. Advise to rest and pace activity. Set achievable targets and gradually increase activity according to symptom severity.
• Advise to look after general health: eat a healthy diet, get enough sleep, limit alcohol and caffeine and avoid illicit drugs.
• Extend sick leave as needed. Suggest patient speaks to employer about options to return to work more slowly. If unemployed, refer to SASSA to apply for COVID-19 Social Relief of Distress Grant.
• If needed, discuss what can be done to support carer/s and family. Identify local resources, social worker, counsellor, NGO, community action networks. Refer to occupational therapy if available.

Treat the patient with Long COVID

• Treat pain with paracetamol 1g 4-6 hourly (up to 4g in 24 hours) or ibuprofen 400mg 8 hourly with food for up to 2 weeks. Review need for pain medications after 2 weeks.
• Chronic overuse may cause headaches: if using painkillers > 2 days/week for ≥ 3 months, advise to reduce or stop pain medication.
• Encourage patient to get vaccinated unless unwell and being actively investigated, then discuss with specialist.
• Help patient to manage ongoing symptoms of tiredness, breathlessness and cough  122. Avoid prescribing inhalers used for asthma to treat breathlessness unless patient known with asthma.

Review the patient with Long COVID

• If TB sputums sent at this visit: review in 2 days, otherwise review 2-4 weekly as needed. Expect gradual improvement.
• If no gradual improvement, refer/discuss. Advise to return urgently if breathlessness worsens, new or worsening confusion or unable to wake patient, chest pain or pressure that won’t go away, new
sudden weakness or numbness in face, leg or arm: refer.

121
 Support the patient with ‘Long COVID’ to manage his/her symptoms at home
• Explain that symptoms may differ between patients (no typical presentation) and may vary from day to day. S/he may find normal activities difficult (like washing/dressing/doing housework).
• Invite patient to look at the below and help him/her to choose lifestyle changes that may help to manage his/her symptoms. Explore what might hinder or support this.
Pace yourself, plan and prioritise tasks Keep a diary to track Get enough sleep
• Build a regular routine. Plan each day so important tasks improvement • Tiredness feels much worse if sleep patterns are disturbed. If difficulty sleeping:
are done first. Learn your patterns: - Establish a routine: try to get up at the same time each day (even if tired) and go
• Avoid overdoing things on a good day. This may cause learn what brings on to bed the same time every evening. Avoid day time napping if able.
exhaustion the next day. utter exhaustion or other - Avoid caffeine and smoking for several hours before bedtime.
• Allow enough time to complete activities and to rest in symptoms, and try to - Allow time to unwind/relax before bed.
between. Break tasks down into smaller ones. avoid these. - Use bed only for sleeping and sex.
• Ask others to help with the less important tasks. Think - Once in bed, avoid clock-watching. If not asleep after
about how others can help you save your energy, Eat well 20 minutes, do a low energy activity (read a book, walk
like helping with groceries, cleaning and cooking. • Where possible, eat regular around house). Once tired, return to bed.
Keep active healthy meals that include
• Start with light exercise (walking) for around fruit and vegetables. Get help when you need it
4-6 weeks. Gradually increase intensity to aim • Drink plenty of water. • Discuss your worries with someone you trust. Join a support group, if available.
for 150 minutes per week (moderate intensity - • Limit alcohol and caffeine. • Consider speaking to your employer about options to return to work more slowly.
working in garden). Monitor immediate symptoms • If you have financial worries, arrange to see a social worker.
(like fatigue/breathlessness) as well as delayed Look after your mental health
symptoms and adapt as needed. • Find time to relax: relaxing activities can help sleep and mental well-being– try deep breathing
• Before returning to sport, ensure you are able exercises, yoga, reading or having a relaxing bath or shower.
to complete activities of daily living and walk • Find a creative or fun activity that you enjoy.
500m on the flat without excessive fatigue • Set small achievable goals that will give you a sense of accomplishment.
or breathlessness. Ensure you have at • Stay connected: spend time with supportive family and friends.
least 10 days’ rest and be symptom-free • Talk to your family/family or friends: share/explain the impact that symptoms are having on your life.
for a minimum of 7 days before starting. It can be hard for them to understand.

Help the patient to manage ongoing breathlessness and cough

• Advise patient to do the following when feeling breathless:
- Stay calm, relax your neck and shoulders and choose a position that eases your work of breathing (see pictures). Think about your breathing: breathe in slowly through your nose, as if you are smelling
roses. Breathe out through your mouth, pursing your lips as if you are blowing out a candle and try to relax rather than forcing it. Slowly count to 2 when inhaling and 3 counts during relaxation.
- Wipe a cool wet cloth over your nose and cheeks, this can help to relieve the feeling of breathlessness.

• Sit on a chair • Lean forward • Lean against a wall for

• Lean forward
and lean forward with elbows support and rest your hand
with hands
with elbows resting on the on your thigh or tuck your
resting on knees.
resting on knees. back of a chair. hand into your pocket.

• Advise the patient with ongoing dry cough:

- Avoid breathing through your mouth as dry air irritates the airways and causes a cough. Try to interrupt cough cycle by closing your mouth, swallowing repeatedly and gently breathing through your
nose until the urge to cough goes away. Sip drinks regularly (hot or cold). Suck boiled sweets or lozenges.
• If productive cough, arrange physiotherapist for further techniques.

122
 ASTHMA AND COPD: DIAGNOSIS
Asthma and chronic obstructive pulmonary disease (COPD) both present with cough, wheeze, tight chest or difficulty breathing. Distinguish asthma from COPD:

Asthma likely if several of: COPD likely if several of:

• Onset before 20 years of age • Onset after 40 years of age
• Associated hayfever, allergic conjunctivitis or eczema, other allergies • Symptoms are persistent and worsen slowly over time
• Intermittent symptoms with normal breathing in between • Cough with sputum starts long before difficulty breathing
• Symptoms worse at night, early morning, with cold or stress • History of heavy smoking or worked in dusty environment
• Patient or family have a history of asthma • Previous diagnosis of TB
• PEFR1 response to inhaled beta-agonist (e.g. salbutamol) improves ≥ 20% (see below). • Previous doctor diagnosis of COPD
Give routine asthma care  125. Give routine COPD care  126.

Doctor to confirm diagnosis. If doctor not available, treat as asthma 125 and refer to doctor within 1 month.

How to measure peak expiratory flow rate (PEFR) How to assess response to inhaled beta-agonist
Calculate % PEFR response to inhaled beta-agonist to help diagnose asthma
• Measure 'initial PEFR’. Use the highest reading of 3 results.
• Give inhaled salbutamol 200mcg (2 puffs via a spacer) and wait for 15 minutes.
• Repeat PEFR - this is the 'repeat PEFR'
4 • Calculate % PEFR response = (repeat PEFR – initial PEFR)
1 2 3 x 100
Initial PEFR
Move marker • Stand up and take a full, Breathe out as • Read the result. • If % PEFR response is ≥ 20%, asthma likely.
to bottom of deep breath. hard and as fast as • Move marker back to
numbered scale. • Hold breath and place possible (keeping bottom and repeat
mouthpiece between teeth. fingers clear of twice. Use the highest
• Form a seal with lips. scale). of the 3 readings.

Using inhalers and spacers2

• If patient unable to use an inhaler correctly, add a spacer to increase drug delivery to lungs, especially if using inhaled corticosteroids. This may also reduce the risk of oral candida.
• Clean the spacer before first use and weekly: remove the canister and wash spacer with soapy water. Allow to drip dry. Avoid rinsing with water after each use.

Shake inhaler Stand up and breathe Press pump once • Then take 4 breaths keeping
and insert into out. Then form a to release one spacer in mouth.
spacer. seal with lips around puff into spacer. • Repeat step 3 and 4 for
mouthpiece. each puff.
• Rinse mouth after using
2 inhaled corticosteroid.
1 3 4
1
Peak expiratory flow rate. 2If no spacer available, explain how to use inhaler without spacer: take off cap and shake inhaler. Stand up and breathe out. Then form seal with lips around inhaler mouthpiece. Breathe in slowly. As breathing in, press pump
once and keep breathing in slowly. Close mouth and hold breath for 10 seconds. Breathe out.
123
CHRONIC RESPIRATORY
DISEASE
Calculate % of predicted PEFR
Calculate % of predicted PEFR to help provide routine asthma/COPD care
e.g. 60 year old man with asthma who is 188cm tall. Peak expiratory flow rate - normal values
For use with EU/EN13826 scale PEF meters only
Step Measure patient’s PEFR  123. Use the highest of 3 results - this is the

1 'observed PEFR'.
e.g. his PEFR readings are: 450; 420; 400. Use 450 as the 'observed PEFR'.

Step Plot the patient on the adjacent PEFR graph using Step 4
height, sex and age.
2 Men

Step If patient a man, look at group of lines next to 'Men'. Height

190cm
If patient a woman, look at group of lines next
3 to 'Women'.
183cm
175cm
167cm
Women
e.g. this patient is a man, look at group of lines next to 'Men'. 160cm

Predicted PEFR (L/min)

Step Identify the patient's height and choose the coloured Step 5 Men
line closest to that height.
4 e.g. this patient's height is 188cm, choose the red line. Men

PEF (L/min)
Height
190cm

Identify the patient's age on the bottom axis and

183cm

Step
175cm

Height
Women 167cm
160cm

draw a line up until it meets the coloured height line

5 identified in step 4. Height
190cm
183cm
183cm
175cm

e.g. this patient is 60 years old

167cm
160cm
152cm

Age (years)
175cm
Step From this point on the coloured line, draw a straight 167cm
Step 6 Women
line left until you reach the left axis (labelled Predicted 160cm
6 PEFR). The closest number is the 'predicted PEFR'. ± 590

e.g. this patient's 'predicted PEFR' is ± 590 L/min. Men

PEF (L/min)

Height

Calculate % of predicted PEFR:

190cm

Step
183cm
175cm
Women 167cm

observed PEFR ÷ predicted PEFR x 100

7
160cm

e.g. 450 ÷ 590 x 100 = 76%. Height

183cm
Height
183cm
175cm
167cm
160cm
152cm

Age (years)
175cm
Step Interpret result: 167cm
• If known asthma and PEFR is < 80% of predicted, 160cm
8 asthma is not controlled. 152cm
• If known COPD and PEFR is 50-80% of predicted PEFR, COPD is moderate. If PEFR
is < 50% of predicted PEFR, COPD is severe.
Age (years)
e.g. this patient whose PEFR is 76% of his predicted PEF has asthma that is
not controlled. Adapted by Clement Clarke for use with EN13826 / EU scale peak flow meters from Nunn AJ Gregg I, Br Med J 1989:298;1068-70

124
 ASTHMA: ROUTINE CARE
Ensure that a doctor confirms the diagnosis of asthma within 1 month. Refer the patient with newly diagnosed asthma for community health worker support, if available.

Assess the patient with asthma

Assess When to assess Note
Asthma symptoms to Every visit • If wheeze, tight chest or difficulty breathing and no response to salbutamol inhaler, manage acute exacerbation  39.
determine control • Any of the following indicate that the patient's asthma is not controlled:
- Daytime cough, difficulty breathing or wheeze > 2 times a week
- Night-time cough, wheeze, tight chest or difficulty breathing > once a month
- Limitation of daily activities due to asthma symptoms
• If none of above then asthma is controlled.
Other symptoms Every visit • Manage symptoms as on symptom pages. Ask about and manage allergic rhinitis  34 and dyspepsia  44.
• If using inhaled corticosteroid and white patches on cheeks/gums/tongue/palate, oral candida likely  35.
Adherence and inhaler technique Every visit Check adherence and that patient is using inhaler and spacer correctly  123. If not adherent, give adherence support  173.
Peak expiratory flow rate (PEFR) At diagnosis, if symptoms worsening, if Calculate % of predicted PEFR  124. If < 80%, asthma is not controlled.
change to medication at last visit
 116
Advise the patient with asthma
• Advise to avoid triggers that may worsen asthma/hayfever (e.g. animals, cigarette smoke, dust, chemicals, pollen, grass), aspirin/NSAIDs (e.g. ibuprofen) and beta-blockers (e.g. atenolol).
• If patient smokes, encourage to stop  141. Support the patient to make a change  177.
• Ensure the patient understands medication: beta-agonist inhaler (salbutamol) relieves symptoms but does not control asthma. Inhaled corticosteroid (beclomethasone or fluticasone) prevents but
does not relieve symptoms and it is the mainstay of treatment.
• Inhaled corticosteroids can cause oral candida: advise patient to rinse and gargle after each dose of inhaled corticosteroid.

Treat the patient with asthma

• Give influenza vaccine 0.5mL IM yearly. Check that patient is up to date with COVID-19 vaccine.
• Give inhaled salbutamol 100-200mcg (1-2 puffs) 6-8 hourly, as needed. If exercise-related symptoms, advise patient to use salbutamol 200mcg (2 puffs) before exercise.
• If acute exacerbation was managed at this visit:
- Give prednisone 40mg daily for a total of 7 days. If > 2 courses of oral prednisone given in past 6 months or exacerbation occurs on maximum treatment, also refer to doctor.
- Only give antibiotic if fever or thick yellow/green sputum: give amoxicillin1 500mg 8 hourly for 5 days. If severe penicillin allergy1, give instead azithromycin 500mg daily for 3 days.
• Manage further according to asthma control:
Asthma not controlled or acute exacerbation Asthma controlled
• Before stepping up treatment, ensure adherent and using inhaler/spacer correctly  123 and • Continue inhaled medication at same dose.
check patient is avoiding smoking, allergens and certain medications2. • If controlled and no acute exacerbations for ≥ 6 months, step down treatment:
• Give inhaled beclomethasone 200mcg 12 hourly. If already on it, increase dose to 400mcg - If on salmeterol/fluticasone, stop this and give instead beclomethasone3 400mcg 12 hourly.
12 hourly. - If on beclomethasone, decrease dose to 200mcg 12 hourly. If already on 200mcg, stop
• If still not controlled, doctor to stop beclomethasone and give instead inhaled salmeterol/ beclomethasone.
fluticasone3 50/250mcg, 1 puff 12 hourly. If still not controlled after 3 months, refer. - If symptoms worsen, step up to same medication and dose when patient was controlled.

If asthma controlled, review 3 monthly. If not controlled, review monthly. If acute exacerbation, review after 1 week. Advise to return before next appointment if symptoms persist/worsen.

1
History of anaphylaxis, urticaria or angioedema. 2NSAIDS (aspirin/ibuprofen), beta blockers. 3If on lopinavir/ritonavir or atazanavir/ritonavir, avoid budesonide and fluticasone, and discuss/refer instead.
125
 CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD): ROUTINE CARE
Ensure that a doctor confirms the diagnosis of COPD within 1 month and refer for spirometry if available. Refer the patient with newly diagnosed COPD for community health worker support.

Assess the patient with COPD

Assess When to assess Note
COPD symptoms Every visit • If patient has wheeze/tight chest and breathless at rest or while talking or respiratory rate ≥ 30, manage acute exacerbation  39.
• Assess disease severity: if patient can walk as fast as others of same age, COPD is mild. If not, COPD is moderate or severe.
• Investigate for TB only if patient has other TB symptoms like weight loss, night sweats, blood-stained sputum  92.
Other symptoms Every visit • Manage symptoms as on symptom pages.
• If using inhaled corticosteroid and white patches on cheeks/gums/tongue/palate, oral candida likely  35.
• If swelling in both legs, refer to doctor to consider heart failure.
• If pain ≥ 4 weeks, assess and advise  61.
Adherence and inhaler technique Every visit Check adherence and that patient can use inhaler correctly  123. If not adherent, give adherence support  173.
Depression Every visit In the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either  143.
Palliative care Every visit If severe COPD with breathlessness at rest, > 3 hospital admissions for COPD in 1 year, heart failure or long term oxygen therapy needed  170.
CVD risk At diagnosis The patient with COPD is at increased risk of cardiovascular disease. Assess CVD risk  127.
Peak expiratory flow rate (PEFR) • At diagnosis Calculate % of predicted PEFR  124.
• If symptoms worsening • If 50-80%, COPD is moderate.
• If change to medication at last visit • If < 50%, COPD is severe.

Advise the patient with COPD

• If patient smokes, encourage to stop  141. Stopping smoking is the mainstay of COPD care. Support patient to change  177.
 120
• Encourage the patient to take a walk daily and to increase activities of daily living like gardening, housework and using stairs instead of lifts.
• Inhaled corticosteroids can cause oral candida: advise patient to rinse and gargle after each dose of salmeterol/fluticasone.

Treat the patient with COPD

• Give influenza vaccine 0.5mL IM yearly. Check that patient is up to date with COVID-19 vaccine.
• Give inhaled salbutamol 100-200mcg (1-2 puffs) 6-8 hourly, as needed.
• Before adjusting or starting treatment, ensure patient is adherent and knows how to use an inhaler and spacer correctly  123.
• If patient has moderate or severe COPD and not controlled on salbutamol alone, decide which treatment to add:
- If COPD diagnosis confirmed on spirometry and < 2 exacerbations in past year: add inhaled formoterol 12mcg, 1 puff 12 hourly.
- If spirometry not done, ≥ 2 exacerbations in past year or no better with formoterol: add inhaled salmeterol/fluticasone1 50/250mcg, 1 puff 12 hourly (stop formoterol if on it).
• If acute exacerbation was managed at this visit:
- If patient received prednisone or hydrocortisone, continue prednisone 40mg daily for a total of 7 days.
- If sputum increased or colour changed to yellow/green, give amoxicillin 500mg 8 hourly for 5 days. If severe penicillin allergy2, give instead doxycycline 100mg 12 hourly for 5 days.

• If recent exacerbation, treatment adjustment, symptoms worse than usual or not coping as well as before, review monthly. Otherwise review 3-6 monthly.
• If no better with treatment after 3 months, discuss/refer.
- Refer to Lung Unit to arrange long-term home oxygen therapy if patient is not smoking and still has moderate to severe symptoms (decreased oxygen saturations) despite treatment for ≥ 3 months.
1
If on lopinavir/ritonavir or atazanavir/ritonavir, avoid fluticasone and discuss/refer instead. 2History of anaphylaxis, urticaria or angioedema.
126
 CARDIOVASCULAR DISEASE (CVD) RISK: DIAGNOSIS
CVD risk is the chance of having a heart attack or stroke over the next 10 years

Step Identify if the patient has established CVD:

• If patient has had previous heart attack, stroke or TIA or is known with angina (ischaemic heart disease) or peripheral vascular disease, manage as CVD 129.
1 • If current/recent chest pain, especially on exertion and relieved by rest, consider ischaemic heart disease  137.
• If current/recent leg pain, especially on walking and relieved by rest, consider peripheral vascular disease  139.
• If new sudden asymmetric weakness or numbness of face, arm or leg; difficulty speaking or visual disturbance: consider stroke or TIA  136.

Step Look for modifiable CVD risk factors:

• Ask about smoking: consider the patient who quit smoking in the past year a smoker for CVD risk assessment.
2 • Calculate BMI: weight (kg) ÷ height (m) ÷ height (m). A BMI > 25 is a risk factor.
• Measure waist circumference while standing or breathing out, midway between lowest rib and top of iliac crest. More than 80cm (woman) or 94cm (man) is a risk factor.
• Look for hypertension: check BP. If BP ≥ 140/90 and not known with hypertension  132.
• Look for diabetes: if not known with diabetes, check glucose  17.

Step Calculate the patient’s CVD risk if no established CVD:

• If total and HDL cholesterol results available, calculate the patient's 10-year CVD risk score below or use the EMGuidance app tool.
3 • If cholesterol results are not available, use instead the chart that calculates CVD risk using BMI  128.
If no established CVD and cholesterol available, calculate the patient’s 10-year CVD risk using the scoring system below
• Calculate CVD risk score by adding the points in each of the tables below, using patient's age, sex, total cholesterol, HDL cholesterol, BP, smoking status and diabetes status:
- If man: if score < 11, then CVD risk is < 10%. If score 11-14, then CVD risk is 10-20%. If score ≥ 15, then CVD risk is > 20%.
- If woman: if score < 13, then CVD risk is < 10%. If score 13-17, then CVD risk is 10-20%. If score ≥ 18, then CVD risk is > 20%.

Age (years) Man Woman Total Man Woman HDL Man Woman Systolic BP Man Woman Man Woman
35-39 2 2 cholesterol cholesterol (mmHg) Not on BP On BP Not on BP On BP Smoker 4 3
40-44 5 4 (mmol/L) (mmol/L) treatment treatment treatment treatment Diabetes 3 4
45-49 6 5 < 4.1 0 0 > 1.5 -2 -2 < 120 -2 0 -3 -1
50-54 8 7 4.1-5.19 1 1 1.3-1.49 -1 -1 120-129 0 2 0 2
55-59 10 8 5.2-6.19 2 3 1.2-1.29 0 0 130-139 1 3 1 3
60-64 11 9 6.2-7.2 3 4 0.9-1.19 1 1 140-149 2 4 2 5
65-69 12 10 > 7.2 4 5 < 0.9 2 2 150-159 2 4 4 6
70-74 14 11 ≥ 160 3 5 5 7
75-79 15 12

Step Explain to the patient what his/her risk of heart attack or stroke might be over next 10 years:
• If CVD risk is < 10%, there is a less than 1 in 10 chance that s/he may have a heart attack or stroke over the next 10 years.
4 • If CVD risk is 10-20%, there is a 1-2 in 10 chance that s/he may have a heart attack or stroke over the next 10 years.
• If CVD risk is > 20%, there is a more than 2 in 10 chance that s/he may have a heart attack or stroke over the next 10 years.

Step Use the patient's CVD risk to decide treatment and frequency of follow-up:
• If CVD risk factor or a CVD risk ≥ 10%, manage the CVD risk 129.
5 • If CVD risk < 10% and no CVD risk factors, reassess CVD risk after 5 years.

127
CHRONIC DISEASES
OF LIFESTYLE
 CVD risk: diagnosis if cholesterol not available

Man Woman
Age Systolic
Non-smoker Smoker Non-smoker Smoker
(years) BP
≥ 180
160-179
70-74 140-159
120-139
< 120
≥ 180
If no established CVD and cholesterol not available, calculate the patient’s 160-179
Step 65-69 140-159
10-year CVD risk using the chart based on BMI instead of cholesterol:
3 • Use the patient’s sex, age, BMI, systolic BP and smoking status to work out 120-139
< 120
what colour block they fall into.
≥ 180
160-179
Step Explain to the patient what his/her risk of heart attack or stroke might be 60-64 140-159
over next 10 years:
4 CVD risk is < 5%: this means there is less than a 1 in 20 chance that s/he
120-139
< 120

may have a heart attack or stroke over the next 10 years. ≥ 180
160-179
CVD risk is 5-10%: this means there is between a 1 in 20 and a 1 in 10 55-59 140-159
chance that s/he may have a heart attack or stroke over the next 10 years. 120-139
< 120
CVD risk is 10-20%: this means there is between a 1 in 10 and a 1 in 5
≥ 180
chance that s/he may have a heart attack or stroke over the next 10 years.
160-179
50-54 140-159
CVD risk is > 20%: this means there is more than 1 in 5 chance that s/he 120-139
may have a heart attack or stroke over the next 10 years. < 120
≥ 180
Step Use the patient's CVD risk to decide treatment and frequency of follow-up: 160-179
• If CVD risk factor or a CVD risk ≥ 10%, manage the CVD risk 129.
5
45-49 140-159
• If no CVD risk factors and CVD risk < 10%, reassess CVD risk after 5 years. 120-139
< 120
≥ 180
160-179
40-44 140-159
120-139
< 120
20 - 24
25 - 29
30 - 35

20 - 24
25 - 29
30 - 35

20 - 24
25 - 29
30 - 35

20 - 24
25 - 29
30 - 35
< 20

≥ 35

< 20

≥ 35

< 20

≥ 35

< 20

≥ 35
Body mass index(kg/m2)

1
Adapted from WHO cardiovascular disease risk non-laboratory-based Southern Sub-Saharan Africa. From: HEARTS technical package for cardiovascular disease management in primary health care: risk based CVD management. World Health Organization.
Geneva, 2020.
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 CARDIOVASCULAR DISEASE (CVD) RISK: ROUTINE CARE
Assess the patient with CVD risk
Assess When to assess Note
Symptoms Every visit Ask about chest pain  37, difficulty breathing  38, leg pain  65 and symptoms of stroke/TIA  136.
Modifiable CVD risk factors Every visit Ask about smoking, diet, alcohol/drug misuse, stress, exercise and activities of daily living. Manage as below.
BMI At diagnosis, yearly or 3 monthly if trying to lose weight BMI = weight (kg) ÷ height (m) ÷ height (m). Aim for < 25.
Waist circumference At diagnosis, yearly or 3 monthly if trying to lose weight Measure while standing, on breathing out, midway between lowest rib and top of iliac crest. Aim for < 80cm (woman) and < 94cm (man).
BP Every visit If known hypertension  133. If not, check BP: if ≥ 140/90  132.
CVD risk (if no known CVD1) At diagnosis, then depending on risk If < 10% with CVD risk factors or 10-20%, reassess after 1 year. If > 20%, reassess after 6 months.
Diabetes risk At diagnosis, then depending on result If known diabetes  130. If not known with diabetes, check glucose  17.
Random total cholesterol If early onset2 CVD in patient/family: at diagnosis • If early onset2 CVD in patient or family history of early onset2 CVD or familial hyperlipidaemia, check cholesterol.
• If cholesterol > 7.5, check TSH and refer to doctor.
 92
Advise the patient with CVD risk
• Discuss CVD risk: explore the patient’s understanding of CVD risk and the need for a change in lifestyle. Support the patient to change  177.
• Invite patient to address 1 modifiable CVD risk factor at a time: help plan how to fit the lifestyle change into his/her day. Explore what might hinder or support this. Together set reasonable target/s for next visit.
Physical activity Diet Screen for alcohol/drug misuse
• Aim for at least • Eat a variety of foods in moderation. Reduce portion sizes.Increase fruit, • Limit alcohol intake to ≤ 2 drinks1/day and avoid
30 minutes brisk vegetables, nuts and legumes. alcohol on at least 2 days of the week.
exercise at least • Choose whole grain bread/rice or potatoes rather than white bread/rice. • In the past year, has patient: 1) drunk ≥ 4 drinks3/
5 days/week. • Replace brick margarine/butter with vegetable oil or soft tub margarine. session, 2) used illegal drugs or 3) misused
• Increase activities Remove skin and fat from meat. prescription or over-the-counter medications?
of daily living like • Reduce salty processed foods like gravies, stock cubes, If yes to any
gardening, housework,  19 packet soup. Avoid adding salt to food.  142.  37 and 41
walking instead of • Avoid/use less sugar.
taking transport, using Weight
stairs instead of lifts. Aim for BMI < 25, and waist circumference
Smoking
• Exercise with arms if < 80cm (woman) and < 94cm (man). Any Stress
unable to use legs. If patient smokes, encourage weight reduction is beneficial, even if Assess and manage stress  86.
to stop  141. targets not met.
 27  100
 33  23

• Identify support to maintain lifestyle change: health education officer or dietician/nutritionist, friend, partner or relative to attend clinic visits, a healthy lifestyle group, helpline  178.
• Be encouraging and congratulate any achievement. Avoid judging, criticising or blaming. It is the patient’s right to make decisions about his/her own health. For tips on communicating effectively  176.

Treat the patient with CVD risk

• If known CVD1: give simvastatin4 40mg at night. If on amlodipine, give instead simvastatin4 20mg at night. Avoid simvastatin if pregnant or liver disease.
- If patient develops muscle pain/cramps, reduce dose to 10mg at night.
• If no known CVD: if CVD risk > 20%, give simvastatin4 10mg at night. Avoid if pregnant or liver disease.

Review the patient with CVD risk ≤ 20% yearly. Review the patient with CVD risk >20% 6 monthly. If trying to lose weight, review 3 monthly.
1
Cardiovascular disease (CVD) includes ischaemic heart disease, peripheral vascular disease and stroke/TIA. 2CVD that develops in a woman < 55 years or in a man < 65 years. 3One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle
(330mL) of beer. 4If on lopinavir/ritonavir or atazanavir/ritonavir, avoid simvastatin, give instead atorvastatin 10mg at night. No dose adjustment needed for rosuvastatin, pravastatin, atorvastatin.
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 DIABETES: ROUTINE CARE
Give urgent attention to the patient with diabetes and any of:
• Chest pain 37. • Confusion or unusual behaviour • Sweating • Nausea or vomiting • Temperature ≥ 38°C
• Fitting  19. • Weakness or dizziness • Palpitations • Abdominal pain • Dehydration: dry mouth, poor skin turgor,
• Decreased consciousness, drowsiness • Shaking • Rapid deep breathing • Thirst or hunger BP < 90/60, pulse ≥ 100
Check random fingerprick glucose:
Glucose < 4 with/without symptoms Glucose ≥ 11.1 with symptoms Glucose ≥ 11.1 without symptoms

• If alert: give glucose1 5mL/kg orally. If unable to take orally, give instead glucose1 or Check urine for ketones.
dextrose 10%2 5mL/kg via nasogastric tube.
• If decreased consciousness: give dextrose 10%2 5mL/kg IV. If known alcohol user, give Ketones present No ketones
thiamine 100mg IM/IV before dextrose.
• Recheck glucose after 15 minutes: if still < 4, give further 2mL/kg. For IV: once glucose • Give sodium chloride 0.9% 20mL/kg IV over the first hour, then 10mL/kg/hour Give routine
≥ 4, continue dextrose 5% 1L IV 6 hourly. thereafter. Stop if breathing worsens. diabetes care
• Identify cause and educate about meals and doses  131. • If referral delay > 2 hours: give short-acting insulin 0.1 unit/kg IM (not IV)3. below.
• If incomplete recovery or on glimepiride, glibenclamide or insulin, refer same day. • Refer urgently.

Assess the patient with diabetes not needing urgent attention:

Assess When to assess Note
Symptoms Every visit Manage symptoms as on symptom pages. Ask about chest pain  37 and leg pain  65.
Depression At diagnosis and if control poor In the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either  143.
Alcohol/drug use At diagnosis and if control poor In the past year, has patient: 1) drunk ≥ 4 drinks4/session, 2) used drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.
BP Every visit If known hypertension  133. If not, check BP: if ≥ 140/90  132.
BMI and waist • Weight: at every visit • BMI = weight (kg) ÷ height (m) ÷ height (m).
circumference • BMI, waist circumference: at diagnosis • Aim for BMI ≤ 25 and waist circumference < 80cm (woman) or < 94cm (man). If trying to lose weight: check BMI/waist circumference 3 monthly.
Eyes At diagnosis, yearly and if visual problems Check visual acuity and fundoscopy. If visual problems, cataracts or retinopathy, refer.
Feet At diagnosis, yearly and more often if problems Check for pain, pulses, sensation, deformity, skin problems. For foot screen and foot care education  66.
Family planning Every visit Assess patient’s contraceptive needs  154. If pregnant or planning pregnancy, refer for specialist care.
Glucose Every visit If fasting glucose > 8 or non-fasting glucose taken 2 hours after eating > 10, step up treatment  131.
HbA1c (glucose control • Yearly if HbA1c ≤ 8% • If HbA1c ≤ 8%: diabetes controlled, continue same treatment for diabetes.
over past 3 months) • 3 months after treatment change • If HbA1c > 8%: diabetes uncontrolled, if adherent, step up treatment  131. If not adherent, give support and repeat HbA1c after 3 months.
Urine dipstick At diagnosis and yearly • If protein, start enalapril if not already on it  131.
• If no protein and not on enalapril, send urine to lab for albumin/creatinine ratio. If ratio > 3, start enalapril  131.
Creatinine (eGFR) • At diagnosis, then yearly • Give age and sex on form. If eGFR < 60, discuss with doctor. If eGFR < 30, refer.
• If on enalapril: at baseline and 4 weeks5 • If creatinine increases by > 20%, stop enalapril and refer to doctor.
• If eGFR < 60: 3-6 monthly
Potassium If on enalapril: at baseline, 4 weeks5, then yearly If potassium > 5.0, avoid/stop enalapril and refer to doctor.
Lipids At diagnosis Check fasting total cholesterol, triglycerides, HDL/LDL. Assess CVD risk  127. If total cholesterol > 7.5 or triglycerides > 10, refer/discuss.
1
Three teaspoons sugar (15g) in 1 cup (200mL) water. 2If dextrose 10% unavailable: mix 1 part dextrose 50% to 4 parts water to make a dextrose 10% solution. 3Avoid IV insulin as it may cause low potassium and heart dysrhythmia. Avoid using an insulin
needle to give IM insulin. 4One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer. 5If eGFR < 60, repeat instead at 2 weeks.
130
  86
Advise the patient with diabetes
• Help the patient to manage his/her CVD risk  129. Educate on foot care to prevent ulcers and amputation  66.
• Discuss diet: avoid white/brown sugar and honey, use artificial sweetener instead. Cut down on starch (rice, noodles, bread, potato, sweet potato, butternut, mielies, pap, samp).
• Explain importance of adherence and to eat regular meals. If difficulty with adherence, give adherence support  173 and refer to a community health worker, if available.
• Ensure patient can recognise and manage hypoglycaemia (shaking, sweating, palpitations, weakness, hunger):
- Drink milk with sugar or eat a sweet. Always carry something sweet. If not in clinic and fits, confusion or coma, rub sugar inside mouth and call ambulance. Go to clinic if illness (like diarrhoea).
- Identify and manage the cause: increased exercise, missed meals, inappropriate dosing of glucose-lowering medications, alcohol, infections.
• Advise patient that s/he is at risk of severe COVID-19 disease and should adhere strictly to physical distancing, good hand/respiratory hygiene and keep up to date with his/her COVID-19 vaccinations.
• If on/starting insulin: discuss injection technique/sites (abdomen, thighs, arms), store insulin in fridge/cool dark place, meal frequency, symptoms of hypoglycaemia/hyperglycaemia, disposal of sharps.
Injection technique and sites (abdomen, thighs, arms), store insulin in fridge/cool dark place, meal frequency, recognising hypoglycaemia/hyperglycaemia, sharps disposal at clinic.
- Advise that if unwell and vomiting/not eating as usual: to increase fluid intake, check glucose 3 times a day if possible and adjust insulin dose if necessary (avoid stopping insulin).

Treat the patient with diabetes

• Check that patient is up to date with COVID-19 vaccine. If age > 65 years , or known HIV or heart or lung disease, give influenza vaccine 0.5mL IM yearly.
• If known CVD1: give simvastatin2 40mg3 at night and aspirin daily. Avoid simvastatin if pregnant and avoid aspirin if peptic ulcer, dyspepsia, kidney disease. Avoid both if liver disease.
• If no known CVD1 but CVD risk > 20%, eGFR < 60, known with diabetes > 10 years or age > 40 years, give simvastatin2 10mg at night. Avoid if pregnant or liver disease.
• If albuminuria/proteinuria, give enalapril4 5mg 12 hourly, regardless of BP. If proteinuria persists and systolic BP > 100, increase up to 10mg 12 hourly, if tolerated.
• Give glucose-lowering medication using stepwise approach as in table below. Ensure patient is adherent before increasing treatment.
Step Medication Breakfast Supper Bedtime (before 22h00) Note
1 Metformin 500mg • Avoid if eGFR < 30, liver disease, uncontrolled heart failure, alcoholism.
500mg 500mg • If on dolutegravir or eGFR 30-45, halve dose, up to maximum of metformin 500mg 12 hourly.
850mg 850mg • Take with meals. May cause self-limiting nausea, abdominal cramps or diarrhoea. Advise not to stop treatment.
1g 1g • Increase monthly if fasting glucose > 8 (or postprandial5 glucose > 10) or HbA1c > 8%, and patient is adherent.
• If up to 2g needed daily, metformin may be given as 850mg 8 hourly instead of 1g twice daily.
• If after 3 months on maximum dose HbA1c > 8%, move to step 2.
2 Add glimepiride 1mg • Continue metformin.
(Preferred in elderly 2mg • Glimepiride: take glimepiride with breakfast.
patients: > 65 years) 3mg - Increase glimepiride by 1mg, at weekly intervals, up to 8mg daily if fasting glucose > 8 (or postprandial5 glucose
4mg (up to 8mg) > 10) or HbA1c > 8%, and patient is adherent.
or
2.5mg • Glibenclamide: avoid glibenclamide if > 65 years.
glibenclamide
5mg - Take glibenclamide 30 minutes before breakfast. Avoid missing meals.
5mg 2.5mg - Increase every 2 weeks if fasting glucose > 8 (or postprandial5 glucose > 10) or HbA1c > 8%, and patient is adherent.
5mg 5mg • Avoid both in pregnancy, severe kidney (eGFR < 60) and liver disease, co-trimoxazole allergy.
7.5mg 5mg • If after 3 months on maximum dose HbA1c > 8%, move to step 3.
10mg 5mg
3 Add basal insulin Start at 10IU. If glucose • Stop glimepiride/glibenclamide but continue metformin when starting insulin. Educate about insulin as above.
(intermediate or remains raised, increase by • Advise patient to check glucose daily after a meal and on waking 3 times a week. Keep a record of readings.
long acting) 2-4units each week. • If fasting glucose frequently > 8 (or postprandial5 glucose > 10), increase by 2-4units each week.
• If > 20IU needed or if patient having episodes of hypoglycaemia, discuss/refer to doctor.
4 Substitute with 0.2IU/kg 0.1IU/kg • Continue with metformin. Stop glimepiride/glibenclamide and basal insulin. Educate about insulin as above.
biphasic insulin 0.2IU/kg + 4IU 0.1IU/kg • Start with 0.3units/kg/day. Patient to give two-thirds of total daily insulin dose 30 minutes before breakfast and
0.2IU/kg + 4IU 0.1IU/kg + 4IU one-third of total daily insulin dose 30 minutes before supper.
0.2IU/kg + 8IU 0.1IU/kg + 4IU • Advise patient to check glucose daily after a meal and on waking 3 times a week. Keep a record of readings.
0.2IU/kg + 8IU 0.1IU/kg + 8IU • If fasting glucose frequently > 8 (or postprandial5 glucose > 10), increase dose by 4 units each week.
0.2IU/kg + 12IU 0.1IU/kg + 8IU etc • If HbA1c > 8% after 3 months, discuss with specialist.
Review the patient with diabetes 6 monthly once stable.
1
Cardiovascular disease (CVD) includes ischaemic heart disease, peripheral vascular disease and stroke/TIA. 2If HIV positive on lopinavir/ritonavir or atazanavir/ritonavir, avoid simvastatin, give instead atorvastatin 10mg at night. 3If on amlodipine, reduce
simvastatin dose to 20mg at night. No dose adjustment needed for rosuvastatin, pravastatin, atorvastatin. 4Avoid in pregnancy, previous angioedema or renal artery stenosis. If persistent cough, refer to doctor to consider alternative. 5Two hours after eating.
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 HYPERTENSION: DIAGNOSIS
Check blood pressure (BP)
• Position patient: ask patient to remove tight clothing covering upper arm. Seat with back against chair, both feet flat on floor and arm supported at heart level. Patient to avoid talking during reading.
• Position cuff correctly and ensure appropriate size: if obese (mid-upper arm circumference is ≥ 33cm), use a large BP cuff.
• Measure and record systolic BP (SBP) and diastolic BP (DBP). Take at least two readings 1-2 minutes apart.
- If first time BP measurement, or readings differ by > 5mmHg, or if BP ≥ 180/110, take a third reading. If able, use average of last 2 readings to interpret BP measurement, otherwise use lowest BP reading.
• If taking BP manually, SBP is the first appearance of sound. DBP is the disappearance of sound.
• If patient is pregnant, interpret reading 159.

Give urgent attention to the patient with BP ≥ 180/110 (SBP ≥ 180 and/or DBP ≥ 110) and any of:
• Visual disturbances
• Dizziness
• Confusion
• Severe headache
• Chest pain 37.
• Difficulty breathing worse on lying flat or with leg swelling 135.
• Sudden weakness on 1 or both sides, vision problems, dizziness, difficulty speaking or swallowing 136.
Manage and refer:
• If BP ≥ 180/130 (SBP > 180 and/or a DBP > 130) with symptoms listed above, treat as hypertensive emergency: give single dose amlodipine 10mg orally. Avoid short-acting nifedipine as it may drop
the BP too quickly, causing a stroke. Refer urgently.
• If dizzy or faint after treatment, lie patient down. If BP < 160/100, raise legs.

Approach to interpreting a BP in a patient not needing urgent attention

If systolic BP and diastolic BP fall into 2 different categories, use the higher blood pressure reading to classify further.

BP < 140/90 BP 140/90 – 179/109 BP ≥ 180/110

• Repeat BP on 2 further occasions at least 2 days apart (within 2 weeks if systolic BP ≥ 160). • If overweight, check that correct size cuff is being used.
• Avoid diagnosing hypertension on one reading alone. • Repeat BP readings after patient has rested for 1 hour.
• Take at least 3 BP readings.
BP < 140/90 BP 140/90 - 159/99 BP 160/100 - 179/109
BP confirmed ≥ 180/110
• Assess CVD risk  127. Diagnose mild Diagnose moderate
• Decide on frequency of follow-up: hypertension hypertension Diagnose severe hypertension
Check to see if patient needs urgent attention above.
• BP < 120/80 and • BP 120/80 – 139/89 or
• CVD risk < 10% and • CVD risk ≥ 10% or • Give routine hypertension care  133.
• No CVD risk factors1 • Any CVD risk factors1 • If < 30 years, refer to exclude secondary cause of hypertension.

Check BP after 5 years. Check BP after 1 year.

1
CVD risk factors include smoking, diabetes, BMI > 25, waist circumference > 80cm (woman) or 94cm (man), cholesterol > 5.2, parent/sibling with early onset CVD (man < 55 years or woman < 65 years).
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 HYPERTENSION: ROUTINE CARE
Assess the patient with hypertension
Assess When to assess Note
Symptoms Every visit Manage symptoms as on symptom pages. Ask about symptoms of heart failure  135, ischaemic heart disease  137 or stroke/TIA  136.
Pregnancy Women of child bearing age: every visit • If pregnancy diagnosed, stop ACE-inhibitors (like enalapril), give instead methyldopa 250mg 8 hourly and refer to high-risk antenatal clinic.
• If planning pregnancy, refer to doctor.
• Assess patient's contraceptive needs  154.
Alcohol/drug use At diagnosis In the past year, has patient: 1) drunk ≥ 4 drinks1/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If
yes to any  142.
Adherence Every visit If BP is not controlled, assess and support adherence  173.
BP control • Every visit (check 2 readings) • If BP < 140/90, BP is controlled: continue current treatment and review 6 monthly.
• For correct method  132. • If BP ≥ 140/90, BP is not controlled: if adherent, step up treatment  134. If not adherent, give support  173 and review in 1 month.
- If ≥ 180/110: also check if needs urgent attention  132.
• If SBP consistently ≤ 110, consider decreasing dose or medications.
Weight, BMI, waist • Weight: at every visit • BMI = weight (kg) ÷ height (m) ÷ height (m).
circumference • BMI, waist circumference: at diagnosis • Aim for BMI < 25 and waist circumference < 80cm (woman) or < 94cm (man).
CVD risk At diagnosis, then depending on risk Assess CVD risk  127.
Urine dipstick At diagnosis, then yearly If 1+ proteinuria on dipstick, check creatinine and eGFR. If glucose on dipstick, screen for diabetes  17.
Diabetes risk Yearly and if glucose on urine dipstick If known diabetes  130. If not known with diabetes, check glucose  17.
Creatinine (eGFR) • If 1+ proteinuria on dipstick • If eGFR < 30, refer.
• Yearly if: CVD2, hypertension for ≥ 10 years, • If eGFR < 60, send urine to lab for albumin/creatinine ratio and refer to doctor: if ratio > 3, discuss/refer.
uncontrolled hypertension , eGFR < 60 • If creatinine increases by > 20%, stop enalapril and refer to doctor.
Potassium • If on enalapril or eGFR < 30: at diagnosis If potassium > 5.0, stop enalapril and spironolactone and refer to doctor.
• If on spironolactone or eGFR < 30: 6 monthly

 82
Advise the patient with hypertension
• Educate the patient that blood pressure changes slightly during the day and night: hypertension is when it stays high, above a certain level. S/he may not have any symptoms.
• Emphasise salt restriction ≤ 1 teaspoon/day, regular physical exercise (150 minutes/week), weight reduction and smoking cessation. If patient smokes, encourage to stop  141.
• Advise to avoid NSAIDs (e.g. ibuprofen) and combined oral contraceptive.
• Explain importance of adherence and that patient will need lifelong hypertension care to prevent stroke, heart disease, eye disease and kidney disease.
• If newly diagnosed, refer for community health worker support.
• Advise patient on hydrochlorothiazide to limit exposure to sunlight and use sunscreen when exposed to sunlight.

1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer. 2Cardiovascular disease (CVD) includes ischaemic heart disease, peripheral vascular disease and stroke/TIA.
133
 Treat the patient with hypertension
• Give influenza vaccine 0.5mL IM yearly. Check that patient is up to date with his/her COVID-19 vaccine.
• If known CVD1:
- Give simvastatin2 40mg at night. If on amlodipine, give instead simvastatin2 20mg at night. No dose adjustment needed for rosuvastatin, pravastatin, atorvastatin. If patient develops muscle pain/
cramps, reduce dose to 10mg at night. Avoid if pregnant or liver disease.
- Give aspirin 150mg daily. Avoid if peptic ulcer, dyspepsia, kidney or liver disease.
• If no known CVD1: if CVD risk > 20%, give simvastatin2 10mg at night. Avoid if pregnant or liver disease.
• If BP is controlled, continue current treatment step and review 6 monthly.
• If BP is not controlled, decide treatment for hypertension using algorithm and table below. If already on step 7, refer instead.
Not yet on hypertension medication Already on hypertension medication

Mild hypertension Moderate Severe hypertension Adherent Not adherent

BP 140/90 - 159/99 hypertension BP ≥ 180/110
BP 160/100 - 179/109 Add next treatment step. • Check patient is using
Does patient have CVD1 or ≥1 CVD risk factor3? Start treatment with medication correctly.
steps 1, 2 and 3 and • Discuss side effects.
No Yes review patient in 1 week. • Refer for community health
worker support.
Start treatment with step 1. Start treatment with steps 1 and 2. • Review in 1 month.

Step Medication Note

1 Address modifiable CVD risk factors. Manage CVD risk  129. If BP not controlled after 3 months, add step 2.
2 Add hydrochlorothiazide (HCTZ) 12.5mg daily. • Avoid if pregnant, personal/family history of skin cancer, gout, severe liver disease or eGFR < 30.
• If diabetes or heart failure, start enalapril 10mg daily instead of HCTZ. Then if needed, add HCTZ as next step once on maximum
dose of enalapril.
3 Add enalapril 10mg at night. • Avoid if pregnant, eGFR < 30 or potassium ≥ 5.0.
• Advise patient to stop enalapril immediately if swelling of tongue/lips/face develops, angioedema likely  32.
4 Increase enalapril to 20mg at night.
5 Add amlodipine 5mg at night. Avoid if untreated heart failure. If on simvastatin, reduce simvastatin dose to 20mg at night. No dose adjustment needed for
rosuvastatin, pravastatin, atorvastatin.
6 Increase amlodipine to 10mg at night.
7 Add spironolactone 25mg daily and increase HCTZ to 25mg daily. Only use spironolactone if potassium can be monitored. Avoid spironolactone if pregnant or eGFR < 30.

• Review the patient monthly until BP controlled. Once controlled, review 6 monthly.
• If BP not controlled after 1 month on step 7, refer.

1
Cardiovascular disease (CVD) includes ischaemic heart disease, peripheral vascular disease and stroke/TIA. 2If on lopinavir/ritonavir or atazanavir/ritonavir, avoid simvastatin, give instead atorvastatin 10mg at night. 3CVD risk factors include age > 55
(man) or > 65 (woman), diabetes, smoker, waist circumference > 80cm (woman) or > 94cm (man).
134
 HEART FAILURE: ROUTINE CARE
The patient with heart failure has leg swelling and difficulty breathing which worsens on lying down/with effort. A doctor must confirm the diagnosis and refer the patient for specialist assessment.

Give urgent attention to the patient with heart failure and any of:
• Chest pain 37. • Rapid worsening of symptoms • Respiratory rate ≥ 30 or difficulty breathing • BP < 90/60 • New wheeze
Manage and refer urgently:
• Sit patient up and if oxygen saturation < 94%, give 40% face mask oxygen (6-8L/min).
• If systolic BP > 90: give furosemide 40mg slow IV. If no response after 30 minutes, give another 80mg IV. If good response, give 40mg IV after 2-4 hours.
• If systolic BP > 90: give sublingual isosorbide dinitrate 5mg even if there is no chest pain. Repeat once if pain relief needed. Repeat after 4 hours.
• If BP ≥ 180/130: give single dose enalapril 10mg orally.

Assess the patient with heart failure

Assess When to assess Note
Symptoms Every visit Manage symptoms as on symptom pages. If fainting/blackouts, refer same day.
Family planning Every visit Assess patient's contraceptive needs  154. If pregnant or planning pregnancy, refer for specialist care.
Alcohol/drug use Every visit In the past year, has patient: 1) drunk ≥ 4 drinks1/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.
Weight Every visit Assess changes in fluid balance by comparing with weight when patient least symptomatic.
BP and pulse Every visit If known hypertension  133. If not, check BP: if ≥ 140/90  132. If new irregular pulse, refer same day.
Palliative care At diagnosis, if deteriorating If disabling shortness of breath at rest on maximum treatment or ≥ 5 admissions in the past 6 months, also give palliative care  170.
Creatinine (eGFR) and At diagnosis, 6 monthly • If starting/increasing dose of enalapril/spironolactone: also check at 2 weeks (if eGFR < 60) or 4 weeks (if eGFR ≥ 60).
potassium • If creatinine increases by > 20%, eGFR < 30 or potassium > 5.0, stop enalapril/spironolactone and discuss with specialist.
Other blood tests At diagnosis Check Hb, TSH and if not known diabetes, check glucose  17. If abnormal, discuss with specialist. Test for HIV  110.

Advise the patient with heart failure

• Advise to adhere to treatment even if asymptomatic. Advise regular exercise within limits of symptoms. Help the patient to manage his/her CVD risk  129.
• Advise to restrict salt to < half a teaspoon/day and fluids to 1.5L/day (6 cups). If possible, advise to monitor weight daily. If s/he gains ≥ 2kg in 2 days, advise to return to clinic.

Treat the patient with heart failure

• Give influenza vaccine 0.5mL IM yearly. Check that patient is up to date with his/her COVID-19 vaccine.
• Aim to have patient on steps 1 and 2. Add step 3 if patient has ongoing symptoms on steps 1 and 2. If uncontrolled on steps 1-3, refer to specialist for digoxin.
Step Medication Dose Note
1 Give hydrochlorothiazide 25-50mg daily Use if mild heart failure and eGFR ≥ 60. Avoid in liver disease. Use with caution in gout, previous skin cancer.
or furosemide Start 40mg daily. If needed, increase every 2-3 days until • Use if significant heart failure symptoms or eGFR < 60. Once improved, consider switch to hydrochlorothiazide if eGFR ≥ 60.
and symptoms improve, up to 250mg/day. • If > 80mg needed, give half dose 12 hourly.
enalapril Start 2.5mg 12 hourly. If needed, increase up to 10mg 12 hourly. Avoid if pregnant, previous angioedema, aortic stenosis, hypertrophic obstructive cardiomyopathy, renal artery stenosis.
2 Add carvedilol Start 3.125mg 12 hourly. If tolerated, double dose every 2 weeks • Start once on optimal dose of enalapril. Avoid atenolol in heart failure.
until symptoms improve, up to 25mg 12 hourly. • Avoid if severe fluid overload, BP < 90/60, asthma. Avoid or decrease dose if pulse < 60.
3 Add spironolactone 25mg daily Monitor potassium and kidney function. Avoid if eGFR < 30 or potassium > 5. Stop potassium supplements.
1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer.
135
 STROKE: ROUTINE CARE
Sudden onset of one or more of the following suggests a stroke (or a transient ischaemic attack (TIA) if symptoms lasted < 24 hours and resolved completely):
• Weakness or numbness of the face, arm or leg, especially on one side of the body • Difficulty speaking or understanding
• Blurred or decreased vision in one/both eyes or double vision • Difficulty walking, dizziness, loss of balance or co-ordination

Give urgent attention to the patient with a new stroke/TIA:

• If oxygen saturation < 94% or respiratory rate ≥ 30, give face mask oxygen.
• Keep patient nil by mouth until swallowing is formally assessed.
• Check glucose: if < 3 (< 4 if diabetes)  17.
• Avoid treating BP ≥ 140/90 as this may worsen stroke. If BP ≥ 220/120, discuss with specialist about need for pre-referral treatment.
• Decide where to refer the patient depending on when symptoms started:
- If patient can reach hospital within 3 hours of onset of symptoms, refer urgently for thrombolysis (to specialist stroke unit if available).
- If patient cannot reach hospital within 3 hours of onset of symptoms, refer same day and give single dose aspirin 300mg (avoid if on long-term anticoagulant or headache/neck stiffness) if
fully conscious and can swallow.

Assess the patient with stroke/TIA

Assess When to assess Note
Symptoms Every visit Ask about symptoms of another stroke/TIA. Also ask about chest pain  37 or leg pain  65.
Depression Every visit In the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either  143.
Rehabilitation needs Every visit Refer to appropriate therapist: physiotherapy for mobility, physiotherapy/occupational therapy for self care, speech therapist for swallowing,
coughing after eating, speaking and drooling.
Palliative care Every visit If any of: severely disabled, worsening problems with speech or swallowing or breathing problem, also give palliative care  170.
BP Every visit If known hypertension  133. If not, check BP: if ≥ 140/90  132. If new hypertension, start treatment only 48 hours after a stroke  133.
Diabetes risk At diagnosis and yearly If known diabetes  130. If not known with diabetes, check glucose  17.
Fasting cholesterol and triglycerides At diagnosis if not already done If cholesterol > 7.5 or triglycerides > 10, check TSH and refer to doctor.
HIV At diagnosis, especially if age < 50 years Test for HIV  110. If HIV, give routine care  111.
ECG At diagnosis if not already done If abnormal, discuss/refer.

Advise the patient with stroke/TIA

• Educate the patient that stroke/TIA is a brain attack. Quick treatment of a minor stroke or TIA can reduce the risk of a major stroke. Refer to available helpline/s  178.
• Help patient to manage CVD risk  129. If < 55 years (man) or < 65 years (woman), advise the first degree relatives (parents, siblings, children) to have CVD risk assessment  127.
• Avoid oral contraceptives containing oestrogen. Advise other method such as copper IUD, injectable, progestogen-only pill  154.

Treat the patient with stroke/TIA

• Give aspirin 150mg daily for life. Avoid if < 30 years, haemorrhagic stroke, previous peptic ulcer, dyspepsia or on anticoagulant. If prosthetic heart valve, valvular heart disease or atrial fibrillation, refer for
warfarin instead.
• Give simvastatin1 40mg2 at night for life, regardless of cholesterol if patient had an ischaemic stroke. If patient develops muscle pain/cramps, reduce dose to 10mg at night. Avoid if pregnant or liver disease.
• Check that patient is up to date with COVID-19 vaccine. If age > 65 years, or known HIV or heart or lung disease, give influenza vaccine 0.5mL IM yearly.
1
If HIV positive on lopinavir/ritonavir or atazanavir/ritonavir, avoid simvastatin, give instead atorvastatin 10mg at night. 2If on amlodipine, reduce simvastatin dose to 20mg at night. No dose adjustment needed for rosuvastatin, pravastatin, atorvastatin.
136
 ISCHAEMIC HEART DISEASE (IHD): INITIAL ASSESSMENT
Is patient known with ischaemic heart disease (or angina1)?

No Yes

Is current or previous chest pain/discomfort any of: Is chest pain/discomfort any of:
• Feels like pressure, heaviness or tightness in centre or left side of chest • Occurs at rest or with minimal effort or
• Spreads to jaw, neck, arm/s • Not relieved by rest or sublingual nitrates or
• May be associated with nausea, vomiting, pallor or sweating • Lasts ≥ 10 minutes or
• Worse/lasts longer than usual or
• Occurs more often than usual
No Yes
Chest pain Is chest pain/discomfort:
different to • Brought on by exercise, effort or anxiety and Yes No
above • Relieved by rest and
• Lasts < 10 minutes
Patient has
Assess stable angina.
for other Yes No Give routine ischaemic
causes of heart disease care
chest pain 138.
Stable angina likely Acute coronary syndrome (heart attack or unstable angina) likely
37.
• A doctor must confirm the Do ECG2 within first 10 minutes. While doing ECG, start management and discuss with doctor:
diagnosis. • If oxygen saturation < 94% or oxygen saturation machine not available, or respiratory rate ≥ 30, give 40%
• Give routine ischaemic heart face mask oxygen.
disease care 138. • Give single dose aspirin 150mg chewed.
• Establish IV access.
• Doctor to review ECG and assess for streptokinase as soon as possible:
- Give streptokinase only if ECG shows ST elevation3 or left bundle branch block and if ≤ 6 hours since
onset of chest pain or ongoing chest pain. If > 6hrs since onset of chest pain, discuss streptokinase with
specialist or referral hospital.
- Avoid if streptokinase given in past year4 or known allergy to it, stroke in past 3 months, recent major
trauma, surgery or head injury, bleeding within past month, active bleeding, known bleeding disorder,
aneurysm or aortic dissection.
- Give streptokinase 1.5 million IU diluted in 100mL sodium chloride 0.9% IV over 30-60 minutes.
- Monitor BP: if < 90/60, slow rate of infusion (avoid stopping it).
• If current chest pain and BP > 90/60:
- Give isosorbide dinitrate sublingual 5mg every 5 minutes until pain relieved to a maximum of 4 doses of
5mg. Avoid if sildenafil (Viagra®) or vardenafil used within past 24 hours.
- Only if ongoing severe pain: give morphine 2-4mg slow IV5.
• If BP < 90/60 or > 180/130, discuss further management with specialist or referral hospital.
• Refer urgently.

1
Chest pain caused by ischaemic heart disease. 2ECG may show ST segment depression or elevation, but a normal ECG does not exclude diagnosis of unstable angina or heart attack. 3ST elevation > 1mm in two or more contiguous limb leads or ST
elevation > 2mm in two or more contiguous chest leads. 4Discuss use of alteplase with specialist/referral hospital. 5Dilute 10mg morphine with 9mL of sodium chloride 0.9%. Give diluted morphine 5mL IV over 5 minutes (1mL/minute). If needed, give
another 1mL/min until pain improved, up to 10mL. Stop if BP drops < 90/60.
137
 ISCHAEMIC HEART DISEASE: ROUTINE CARE
Assess the patient with ischaemic heart disease
Assess When to assess Note
Symptoms Every visit • If recent episodes of chest pain/discomfort, assess ischaemic heart disease symptoms if not already done  137.
• Ask about leg pain  65 and symptoms of stroke/TIA  136.
Depression Every visit In the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either  143.
BP Every visit If known hypertension  133. If not, check BP: if ≥ 140/90  132.
Diabetes risk At diagnosis and yearly If known diabetes  130. If not known with diabetes, check glucose  17.

Advise the patient with ischaemic heart disease

• If patient has had a heart attack, s/he can resume normal daily and sexual activity 1 month after heart attack if symptom free.
• Emphasize the importance of lifelong adherence to medication. If difficulty with adherence, give adherence support  173.
• Ensure patient knows how and when to use sublingual nitrates. Explain that they are not addictive and can also be used before activities which may provoke chest pain.
• Patient should avoid non-steroidal anti-inflammatories (like ibuprofen), as they may precipitate chest pain.
• If < 55 years (man) or < 65 years (woman), advise the first degree relatives (parents, siblings, children) to have CVD risk assessment.

Treat the patient with ischaemic heart disease

• Give influenza vaccine 0.5mL IM yearly. Check that patient is up to date with COVID-19 vaccine.
• Help the patient to manage his/her CVD risk  129.
• Give aspirin 150mg daily for life. Avoid if peptic ulcer, dyspepsia, kidney or liver disease.
• Give simvastatin1 40mg at night. If on amlodipine, give instead simvastatin1 20mg at night (no dose adjustment needed for rosuvastatin, pravastatin, atorvastatin). Avoid if pregnant or liver disease.
• Give atenolol 50mg daily, even if no chest pain/discomfort. Avoid in asthma, COPD, heart failure, peripheral vascular disease.
• If unstable angina or following heart attack: if signs of heart failure, give enalapril 2.5mg 12 hourly and increase slowly to 10mg 12 hourly. Avoid if pregnant, angioedema or renal artery stenosis.
• If patient has stable angina, treat using stepwise approach as in table below:
- If chest pain/discomfort controlled, continue same medication and dose.
- If still gets episodes of chest pain/discomfort, increase to maximum dose. If symptoms continue after this, add next step. Ensure patient is adherent before increasing medication.
Step Medication Dose Maximum dose Note
1 Isosorbide dinitrate with chest 5mg sublingual with angina 3 doses of 5mg with each If chest pain on exertion, rest and take 1st dose. If chest pain persists, take a further 2 doses 5 minutes apart. If no better
pain and before exertion episode of chest pain 5 minutes after 3rd dose, patient must seek medical attention urgently.
and
Atenolol 50mg daily 100mg daily Titrate to resting pulse rate of 60 beats/minute. Avoid if asthma, COPD, uncontrolled heart failure, peripheral vascular disease
or if side effects (headache, cold hands/feet, impotence, tight chest, fatigue) are intolerable. Use amlodipine instead.
2 Add amlodipine 5mg in the morning 10mg daily Avoid if heart failure, discuss with specialist. Reduce simvastatin dose to 20mg at night.
3 Add: isosorbide mononitrate 10mg at 8am and 2pm 20mg at 8am and 2pm -
or
isosorbide dinitrate 20mg at 8am and 2pm 30mg at 8am and 2pm -

• If atenolol and amlodipine contra-indicated/not tolerated or chest pain/discomfort persists on full treatment, refer to specialist.
• Review monthly until symptoms controlled. Then review 3-6 monthly.
1
If on lopinavir/ritonavir or atazanavir/ritonavir, avoid simvastatin, give instead atorvastatin 10mg at night.
138
 PERIPHERAL VASCULAR DISEASE (PVD)
• Peripheral vascular disease is characterised by claudication: muscle pain in legs or buttocks on exercise that is relieved by rest. Leg pulses are reduced and skin may be cool, shiny and hairless.
• Refer the patient newly diagnosed with peripheral vascular disease for specialist assessment.

Give urgent attention to the patient with peripheral vascular disease and any of:
• Sudden severe leg pain at rest with any of the following in the leg: numbness, weakness, pallor, no pulse: acute limb ischaemia likely
• Leg pain occurring at rest, ulcer or gangrene on leg: critical limb ischaemia likely
• Pulsatile mass in abdomen with abdominal/back pain or BP < 90/60: ruptured abdominal aortic aneurysm likely
Management:
• Acute limb ischaemia likely: refer urgently.
• Critical limb ischaemia likely: discuss same day urgency of referral with specialist.
• Ruptured abdominal aortic aneurysm likely: avoid giving IV fluids even if BP < 90/60 (raising blood pressure may worsen the rupture) and refer urgently.

Assess the patient with peripheral vascular disease

Assess When to assess Note
Symptoms Every visit • Manage symptoms as on symptom pages. Ask about chest pain  137 and symptoms of stroke/TIA  136.
• Document the walking distance before onset of claudication.
Depression Every visit In the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either  143.
BP Every visit If known hypertension  133. If not, check BP: if ≥ 140/90  132.
Legs and feet Every visit Check for pain, pulses, sensation, deformity, skin problems. For foot screen and foot care education  66.
Abdomen Every visit If a pulsatile mass felt, refer for assessment for possible abdominal aortic aneurysm. Refer urgently if abdominal/back pain or BP < 90/60.
Diabetes risk At diagnosis, then yearly If known diabetes  130. If not known with diabetes, check glucose  17.

Advise the patient with peripheral vascular disease

• Advise the patient to keep legs warm and below heart level (especially at night), and to avoid decongestant medications that may constrict blood vessels.
• If patient smokes, encourage to stop  141. Support the patient to make a change  177.
• Advise patient that physical activity is an important part of treatment. It increases the blood supply to the legs and may significantly improve symptoms.
• If < 55 years (man) or < 65 years (woman), advise the first degree relatives (parents, siblings, children) to have CVD risk assessment  127.

Treat the patient with peripheral vascular disease

• Help the patient to manage his/her CVD risk  129.Advise brisk exercise for 30 minutes at least 3 times a week (preferably daily). Advise patient to pause and rest whenever claudication develops.
• Give simvastatin1 40mg2 at night regardless of cholesterol level. If patient develops muscle pain/cramps, reduce dose to 10mg daily. Avoid if pregnant or liver disease.
• Give aspirin 150mg daily for life. Avoid if peptic ulcer, dyspepsia, kidney or liver disease.

• Refer to specialist at diagnosis (start medications and exercise while waiting for appointment) and if pain interferes with activities of daily living after 3 months of medication and exercise.
• Review 3 monthly until stable (coping with activities of daily living and able to work), then yearly.

1
If on lopinavir/ritonavir or atazanavir/ritonavir, avoid simvastatin, give instead atorvastatin 10mg at night. 2If on amlodipine, reduce simvastatin dose to 20mg at night. No dose adjustment needed for rosuvastatin, pravastatin, atorvastatin.
139
 THE MENTALLY ILL PATIENT NEEDING TREATMENT OR ADMISSION
Give urgent attention if a delay in referral may lead to the patient’s mental illness causing any of:
• Death • Irreversible health problem/s • Patient inflicting serious harm to self or others • Patient causing serious damage to or loss of property
Manage as an emergency and refer urgently with or without patient consent:
• If aggressive/disruptive  84. If restraints used, complete MHCA 48 form.
• If patient is not alert, fully conscious or physically stable, check for underlying causes  85.
• Complete a MHCA 01 form, Emergency care, treatment and rehabilitation or admission without consent, to admit for 24 hour assessment.
• If too dangerous for transfer in a staffed vehicle or likely to abscond, request police assistance. Police officer to complete MHCA 22 form.

Approach to the mentally ill patient in need of hospital admission/treatment not needing emergency referral

Patient able to give informed consent1. Patient incapable of giving informed consent1.

Patient does not refuse Patient refuses treatment/admission. Patient refuses treatment/admission Patient does not refuse treatment/admission
treatment/admission.
Does patient require treatment/admission for a mental illness that may result in: Admit or treat as an Assisted user under the
Admit or treat as • Patient seriously harming self or others or Mental Health Care Act (MHCA).
Voluntary user. • Serious damage to his/her financial interests or reputation

• Record clearly in No Yes: admit or treat as an Involuntary user under the Mental Health Care Act (MHCA).
patient notes and
referral letter.
Manage as an • Escort2 must complete MHCA 04 form. If escort unavailable, unwilling or incapable, then a health care provider3 can complete this form.
• If needing admission:
outpatient. • MHCP4 to assess patient and complete one MHCA 05 form. Doctor to separately assess patient and complete a second MHCA 05 form.
escort2 or staff
- If MHCP4/doctor not available, record clearly in patient notes/referral letter. Refer with MHCA 04 form, to nearest staffed facility.
member must
accompany the
patient to hospital. The two MHCA 05 forms agree to The two MHCA 05 forms do not agree: a third MHCP must complete a third MHCA 05 form independently.
admit or treat the patient under
the Mental Health Care Act.
Third MHCA 05 form agrees to treat or admit the patient under MHCA. Third MHCA 05 form does
not agree to treat or admit as
Assisted or Involuntary user
• Head of Health Establishment (HHE) to complete MHCA 07 form. under the MHCA.
• If admission (72 hour assessment) needed, send all forms with patient.
• If too dangerous for transfer in a staffed vehicle or likely to abscond, request police assistance. Police officer to
complete MHCA 22 form. If restraints used, also complete MHCA 48 form. Manage as an outpatient.
• If outpatient treatment, send all forms to Mental Health Review Board.

The patient may present to primary care with authorisation/order by a Court or Mental Health Review Board to receive mental health care, treatment and rehabilitation on an outpatient basis: review
patient and provide prescribed health intervention, regardless of patient consent. Record clearly in patient file. Report to Mental Health Review board as requested.
1
Informed consent means that patient understands that s/he is ill, needs treatment and can communicate his/her choice to receive treatment. 2Escort: if patient < 18 years old, this needs to be a parent or guardian; if patient ≥ 18 years old, escort can be
spouse, next of kin, partner or associate. 3This can be any health care provider but needs to have observed patient’s behaviour and must not be one of the mental health care practitioners who complete either of the MHCA 05 forms. 4Mental Health Care
Practitioner.
140
 TOBACCO SMOKING
Assess the patient who smokes tobacco currently or recently stopped
Assess When to assess Note
Symptoms Every visit • Ask about symptoms that might suggest cancer: cough/difficulty breathing  38, urinary symptoms  59 or weight loss  23.
• Ask about symptoms of CVD1: chest pain  37, leg pain  65, new sudden onset of any of: asymmetric weakness of face, arm or leg; numbness, difficulty speaking or visual
disturbance  136.
• Manage other symptoms as on symptom pages.
Tobacco use Every visit • Ask about number of cigarettes per day and what activities patient does while smoking.
• If recently stopped, praise patient and encourage to avoid re-starting: reinforce advice about risks, benefits, distraction techniques and support helpline/groups available  178.
• Ask about previous attempt at stopping: review what helped and why attempt failed, address reason for relapse before another quit attempt.
Stressors Every visit Help identify the domestic, social and work factors contributing to smoking tobacco. If low mood, stress or anxiety  86.
COPD At diagnosis If difficulty breathing when walking fast/up a hill, consider COPD  123. If known COPD  126.
CVD risk At diagnosis Assess CVD risk  127.

Advise the patient who smokes tobacco

• Ask if patient is willing to discuss tobacco smoking. For tips on how to communicate effectively  176. Support the patient to make a change  177.
• Advise patient that stopping tobacco smoking is the most important action s/he can take to improve health, quality of life and increase life expectancy.
• Explain that nicotine is very addictive and stopping can cause withdrawal symptoms: increased appetite, mood changes, difficulty sleeping/concentrating, irritability, anxiety, restlessness. These should
improve after 2-4 weeks.
• Advise that most smokers make several attempts to stop before they are successful.
• If patient is pregnant or breastfeeding, stress the importance of stopping for baby’s health.
• Ask if patient is willing/ready to stop smoking tobacco and give the advice below:

If patient is not ready to stop in the next month If patient is ready to stop in the next month
• Discuss risks to patient (worsening asthma, infertility, heart attack, stroke, • Help patient plan: set date to stop within 2 weeks, seek support from family and friends, support group or helpline
COPD, cancer) to spouse (lung cancer, heart disease) and to children (low  178, avoid/manage situations associated with smoking and remove cigarettes, matches, and ashtrays. Help
birth weight, asthma, respiratory infections). manage cravings using a stepwise approach, starting with step 1. If urge does not subside, move on to next step.
• Help identify benefits of stopping tobacco smoking like saving money, - Step 1: delay as long as you can.
improved health, taste, sense of smell and appearance and being a - Step 2: take a deep breath and blow out slowly (repeat 10 times).
positive role model for children. - Step 3: drink water as an alternative to tobacco smoking.
• Help identify barriers to stopping tobacco smoking and possible solutions. - Step 4: distract yourself with reading a book, going for a walk, listening to music, watching TV or other hobby.
• Ask if patient is ready to stop smoking tobacco in the next month. If • Offer referral for counselling especially if failed previous attempt at stopping, previous depression or alcohol misuse.
not ready to stop, encourage patient to return, use helpline  178 or
support group when ready to stop.

Review patient within the first week of stopping tobacco smoking and then as needed.

1
Cardiovascular disease (CVD) includes ischaemic heart disease, peripheral vascular disease and stroke/TIA.
141
MENTAL HEALTH
 ALCOHOL AND/OR DRUG USE
Unhealthy alcohol use refers to a pattern of use that puts the patient at risk of dependence and physical, mental and social harm. Any drug use is unhealthy. If patient smokes, encourage to stop  141.

Assess the patient with unhealthy alcohol use or any drug use
Assess Note
Symptoms • If recently reduced/stopped use and restless, agitated, difficulty sleeping, confused, anxious, hallucinating, sweating, tremors, headache or nausea/vomiting, treat for likely withdrawal  85.
• If aggressive/violent or disruptive behaviour  84.
• If patient has suicidal thoughts or plans, refer same day  83.
Harmful use • Assess quantity and frequency of alcohol use: if drinking > 14 drinks1/week or ≥ 4 drinks1/session, explain that this increases risks of harm and dependence.
• Look for harm: physical harm (like injuries, liver disease, stomach ulcer), mental harm (like depression), social harm (relationship, legal or financial) or risky behaviour.
Dependence Patient is dependent if ≥ 3 of: strong need to use substance; difficulty controlling use; withdrawal on stopping/reducing; tolerance (needing more); neglecting other interests; continued use despite harm.
Stressors Help identify domestic, social and work factors contributing to alcohol/drug use. Ask about reasons for his/her substance use. If patient is being abused  88.
Mental health In the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either  143. If stress or anxiety  86.

Advise the patient with unhealthy alcohol use or any drug use  37 and  41
• If pregnant/planning pregnancy or breastfeeding, advise to avoid alcohol/drugs completely. Alcohol/drugs can harm the developing baby.
• Suggest patient seeks support from close relatives/friends who do not use alcohol/drugs, a support group or a helpline  178. Refer patient to social worker, psychologist or counsellor.
• Discuss risks/harms that using alcohol/drugs may cause. Allow patient to decide for him/herself to stop or cut down. Support the patient to make a change  177.
Unhealthy alcohol use without dependence Any drug use without dependence Alcohol/drug dependence
• If pregnant, harmful drinking, previous dependence problem or • Advise to stop using illegal or misusing Advise that alcohol/drugs need to
contraindication (like liver damage, mental illness), advise to stop alcohol prescription drugs completely. be stopped slowly. If alcohol/drugs
completely. Avoid drinking places and keeping alcohol at home. • If patient chooses to continue, advise to reduce stopped suddenly, withdrawal effects
• If none of above and patient chooses to continue alcohol, advise to at harm: avoid injections or use sterile injection can be harmful. Detoxification (below)
least cut down to low-risk alcohol use: ≤ 2 drinks1/day and avoid alcohol technique, test regularly for HIV and hepatitis. will safely wean the body from alcohol
on at least 2 days of the week. • Consider the need for PrEP  106. or drug/s.

If alcohol/drug dependence, doctor to treat the patient with the help of the carer
• Arrange inpatient detoxification if previous withdrawal delirium/fits or failed detoxification, pregnant, chronic medical or mental illness, homeless/no social support, dependent on opioid or > 1 drug.
• Doctor can do outpatient detoxification if none of the above. Ensure patient has a close relative/friend to act as supervisor during programme.
Substance Detoxification programme - Write out programme for patient and chosen supervisor
Alcohol • Give thiamine 300mg daily for 14 days.
• Give diazepam 10mg with withdrawal symptoms then 5mg 6 hourly for 3 days. Then 5mg 12 hourly for 2 days. Then 5mg daily for 2 days. Then stop. If withdrawal symptoms persist despite this, refer/discuss.
Cannabis/Tik/ • Medication is not always needed.
Cocaine/Mandrax • Treat anxiety or sleep problems with diazepam 5mg daily or 12 hourly, tapering over 5-7 days. Monitor for depression and psychosis.
Benzodiazepines • Avoid suddenly stopping benzodiazepines. Withdrawal may take months.
• Replace benzodiazepine patient is taking with diazepam. If taking lorazepam 0.5mg-1mg, replace with diazepam 5mg. For other benzodiazepines, refer to SAMF, MIC hotline or substance helpline  178.
• Decrease diazepam every 2 weeks by 2-2.5mg. If symptoms occur, continue or increase dose for 2 more weeks. Once at 20% of initial dose, decrease by 0.5-2mg every week.

Review the patient on a detoxification programme daily until stable. Advise to return immediately if any problems. Stop programme if patient resumes alcohol/drug use.
1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer.
142
 DEPRESSION: DIAGNOSIS
Has patient had 1 or more of the following core features of depression for at least 2 weeks?
• Depressed mood most of the day, nearly every day
• Loss of interest or pleasure in activities that are usually pleasurable

Yes No
Has patient had 5 or more of the following features of depression for at least 2 weeks?
• Depressed mood most of the day, nearly every day • Disturbed sleep or sleeping too much • Reduced concentration or indecisiveness
• Loss of interest or pleasure in activities that are usually pleasurable • Change in appetite or weight • Visible agitation or restlessness or talking or moving more slowly than usual
• Fatigue or loss of energy • Feeling guilty or worthless • Ideas or acts of self-harm or suicide

Yes: does the patient have difficulty carrying out ordinary work, domestic or social activities? No

Yes No
Check for anaemia Check for thyroid disease Screen for substance misuse Check for medication side effects
If pallor, check Hb. If weight gain, dry skin, In the past year, has patient: 1) drunk Review medication: prednisone, Continue to assess and manage the
If < 12 (woman) or constipation or cold ≥ 4 drinks1/session, 2) used illegal drugs or efavirenz, metoclopramide, theophylline patient with low mood, stress or
< 13 (man), anaemia intolerance, check TSH. If 3) misused prescription or over-the-counter and contraceptives can cause anxiety 86.
likely  27. abnormal, refer to doctor. medications? If yes to any  142. depression. Discuss with specialist.

If none of above or depressive symptoms persist despite treatment: does the patient have any psychotic symptoms2?

Yes No
Check if known bipolar disorder or symptoms of mania (now or in the past): 3 or more of the following for ≥ 1 week
Refer same day. and interfered with ordinary work, domestic or social activities?
• Elevated mood and/or irritability • Increased activity, feeling of increased energy, talkative, rapid speech
• Decreased need for sleep • Impulsive/reckless behaviour like excess spending, thoughtless decisions,
• Inappropriate social behaviour sexual indiscretion
• Easily distracted • Inflated self esteem

No: has there been a major loss or bereavement within last 6 months? Yes

Yes: does patient have ideas of suicide or self-harm, feelings of worthlessness or No Bipolar disorder
is s/he talking or moving unusually slowly? likely.

No: has patient had depression in the past? Yes Discuss/refer.

No: symptoms likely due to loss/bereavement. Provide Yes

support  86. If persists ≥ 6 months, discuss/refer.
Depression likely 144.

1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer. 2Psychotic symptoms include any of: hallucinations (hearing voices/seeing things that are not there); delusions: (unusual/bizarre beliefs not shared by society;
beliefs that thoughts are being inserted or broadcast); disorganised speech (incoherent or irrelevant speech); behaviour that is disorganised or catatonic (inability to talk, move or respond).
143
 DEPRESSION AND/OR ANXIETY: ROUTINE CARE
Assess the patient with depression and/or generalised anxiety
Assess When to assess Note
Symptoms Every visit • Assess symptoms of depression and anxiety. If no better after 8 weeks of treatment or worse on treatment, discuss/refer.
• Manage other symptoms as on symptom pages.
Self-harm Every visit Asking a patient about thoughts of self-harm/suicide does not increase the chance of this. If patient has suicidal thoughts or plans, assess and manage risk before continuing
 83. Discuss with specialist before starting antidepressant.
Mania Every visit If abnormally happy, energetic, talkative, irritable or reckless, discuss/refer.
Anxiety At diagnosis • If excessive worry causes impaired function/distress for at least 6 months with ≥ 3 of: muscle tension, restlessness, irritability, difficulty sleeping, poor concentration, tiredness:
generalised anxiety disorder likely.
• If anxiety is induced by a particular situation/object, phobia likely, refer/discuss.
• If repeated sudden fear with physical symptoms and no obvious cause, panic disorder likely, refer/discuss.
• If previous bad experience causing nightmares, flashbacks, avoidance of people/situations, jumpiness or a feeling of detachment, post-traumatic stress disorder likely  88.
Dementia At diagnosis If for at least 6 months ≥ 1 of: memory problems, disorientation, language difficulty, less able to cope with daily activities and work/social function: consider dementia  148.
Alcohol/drug use Every visit In the past year, has patient: 1) drunk ≥ 4 drinks1/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.
Side effects Every visit Ask about side effects of antidepressant medication  145.
Stressors Every visit Help identify domestic, social and work factors contributing to depression or anxiety. If patient is being abused  88. If recently bereaved  86.
Family planning Every visit • Assess patient's contraceptive needs  154
• If patient pregnant or breastfeeding, doctor to discuss risks: the risk to baby from untreated depression may outweigh any risk from antidepressants. If possible, avoid
antidepressants in first trimester of pregnancy. Ensure counselling/support and follow-up 2 weekly until stable. If possible, discuss with specialist.
Chronic conditions Every visit Ensure that other chronic conditions are adequately treated. If on oral steroids, efavirenz or atenolol, discuss with specialist.

Depression  96 Anxiety  100

Advise the patient with depression and/or generalised anxiety
• Explain that depression is a very common illness that can happen to anybody. It does not mean that a person is lazy or weak. A person with depression cannot control his/her symptoms.
• Explain that thoughts of self-harm and suicide are common. Advise patient that if s/he has these thoughts, s/he should not act, but tell a trusted person and return for help immediately.
• Educate the patient that anti-depressants can take 4-6 weeks to start working. Explain that there may be some side effects, but these usually resolve in the first few days.
• Emphasise importance of adherence even if feeling well. Advise patient that s/he will likely be on treatment for at least 9 months and it is not addictive. If difficulty with adherence, give support  173.
• Advise to avoid stopping treatment abruptly as patient may have withdrawal symptoms. If stopping, treatment needs to be tapered.
• Help the patient to choose strategies to get help and cope:
Get enough sleep Encourage patient to take time to relax: Get active
If difficulty sleeping  87. Regular exercise might help.
Find a Do a relaxing
creative or breathing
fun activity exercise Access
to do. each day. support
Link patient
with helpline
or support
group  178.
Spend time with supportive friends or family.

1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer.
144
 Treat the patient with depression and/or generalised anxiety
• Refer patient for counselling (ideally cognitive behavioural therapy or interpersonal therapy if available) and to social worker and/or helpline/support group  178.
- If occupational therapist (OT) available, refer for mood, self-esteem, motivation, coping skills and constructive use of leisure time.
• Discuss benefits of antidepressants for depression and generalised anxiety disorder. Respect the patient’s decision if s/he declines antidepressants.
• If generalised anxiety disorder or severe anxiety1 on starting antidepressant, consider diazepam 2.5-5mg daily as needed, for up to 10 days. Avoid if patient is known to use substances.
• Start fluoxetine. If fluoxetine poorly tolerated, give instead citalopram. If difficulty sleeping and sedating antidepressant desired and no suicidal thoughts, start instead amitriptyline.

Medication Dose Note Side effects

Fluoxetine Start 20mg on alternate days for 2 weeks, then increase to • Explain that anxiety may increase initially and to return if severe. Changes in appetite and weight, headache,
20mg daily in the morning. If patient has increased anxiety, • Discuss with specialist if patient has epilepsy, liver or kidney disease. restlessness, difficulty sleeping, nausea,
delay increase in dose for another 2 weeks. • Monitor glucose more often in diabetes. diarrhoea, sexual problems.
• Advise family to monitor and return if condition worsens (suicidal thoughts/ unusual
changes in behaviour).
• If patient unable to tolerate fluoxetine, stop fluoxetine and start citalopram 10mg next day.
Citalopram Start 10mg daily for 1 week, then increase to 20mg daily. Avoid if heart failure, arrhythmias, kidney failure. Drowsiness, difficulty sleeping, headache,
dry mouth, nausea, sweating, changes in
appetite and weight.
Amitriptyline Start 25mg at night. Increase by 25mg every 5 days. Use if fluoxetine and citalopram contraindicated or poorly tolerated. Avoid if on bedaquiline, Dry mouth, constipation, difficulty urinating,
Review at 2 weeks: if good response, continue at this dose suicidal thoughts (can be fatal in overdose), heart disease, urinary retention, glaucoma, blurred vision, sedation
(75mg). If partial or no response, continue to increase by epilepsy and elderly patients.
25mg every 5 days as needed, up to 150mg/day.

Decide duration of antidepressant

Has patient had previous episode/s of depression and/or anxiety?

No Yes

Does patient have any of: severe depression/anxiety2, previous suicide attempt/s, sudden onset of symptoms, family history of bipolar disorder?

No Yes

Does patient have generalised anxiety disorder (with or without depression)? Consider long term
treatment for at least
No Yes 3 years. If ≥ 3 episodes,
advise lifelong treatment.
Consider stopping antidepressant when patient has had no/minimal symptoms Consider stopping antidepressant when patient has had no/minimal symptoms
and has been able to carry out routine daily activities for > 9 months. and has been able to carry out routine daily activities for > 12 months.

Reduce dose gradually over at least 4 weeks. If withdrawal occurs (irritability, dizziness, difficulty sleeping, headache, nausea, fatigue) reduce even more slowly.

• Review 2 weekly, even if not on antidepressants, until symptoms get better, then monthly. Once stable, review 3-6 monthly.
• If no better after 8 weeks either on antidepressant or not, refer.

1
Patient has felt nervous, anxious or panicky or been unable to stop worrying or thinking too much. 2Patient has multiple depressive/anxiety symptoms, occurring nearly every day, that severely impairs daily functioning.
145
 SCHIZOPHRENIA
• Ensure a specialist confirms the diagnosis of schizophrenia.
• Consider schizophrenia in the patient who (if no mental health or alcohol/drug disorder) has for at least 6 months had difficulty carrying out ordinary work, domestic or social activities and
for at least 1 month has had ≥ 2 of the following symptoms of psychosis:
- Delusions: unusual/bizarre beliefs not shared by society; beliefs that thoughts are being inserted or broadcast.
- Hallucinations: usually hearing voices or seeing things that are not there.
- Disorganised speech: incoherent or irrelevant speech
- Behaviour that is disorganised or catatonic (inability to talk, move or respond) or negative symptoms: lack of emotion or facial expression, no motivation, not moving or talking much, social withdrawal.

Assess the patient with schizophrenia

Assess When to assess Note
Symptoms Every visit • Assess symptoms of psychosis above. If symptoms of psychosis and:
- Aggressive/violent  84.
- Varying levels of consciousness over hours/days and/or temperature ≥ 38°C, delirium likely  85.
- Patient has interrupted treatment: restart intramuscular treatment  147 and explore reasons for poor adherence (like side effects, substance misuse)  173.
- Good adherence to optimal doses of treatment, discuss/refer.
• Manage other symptoms as on symptom pages.
Self-harm Every visit If patient has suicidal thoughts or plans, refer same day  83. If intent to harm others, alert intended victim/s if possible.
Stressors Every visit Help identify stressors that may worsen or cause symptoms to recur. If patient is being abused  88.
Alcohol/drug use Every visit In the past year, has patient: 1) drunk ≥ 4 drinks1/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.
Family planning Every visit Assess patient's contraceptive needs  154. If patient is pregnant, planning pregnancy or breastfeeding, refer to specialist.
Medication Every visit • Ask about treatment side effects  147.
• Ask about adherence. If non-adherent, restart medication at same dose, explore reasons for stopping treatment and refer for community health worker support.
• Discuss with specialist if patient is on medication that might cause acute psychosis, like prednisone, efavirenz, moxifloxacin and terizidone.
Weight (BMI ) Every visit • BMI = weight (kg) ÷ height (m) ÷ height (m).
• If gaining weight, refer to dietician if available and discuss with specialist about possible alternative schizophrenia treatment.
Glucose At diagnosis, then yearly If known diabetes  130. If not known with diabetes, check glucose  17.
Random total At diagnosis, then 2 yearly • Assess and manage CVD risk  127.
cholesterol • If cholesterol increasing, discuss with specialist about possible alternative schizophrenia treatment.
HIV At diagnosis or if status unknown Test for HIV  110. If HIV positive, avoid efavirenz, discuss treatment with specialist.
Syphilis At diagnosis If positive, treat  53 and refer.

1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer.
146
  108
Advise the patient with schizophrenia and the patient’s carer
• Educate carer/family and patient: the patient often lacks insight into the illness and may be hostile towards carers. S/he may have difficulty functioning, especially in high stress environments.
• Encourage carer to be supportive and avoid trying to convince patient that beliefs or experiences are false or not real. Avoid hostility and criticism towards the patient.
• Advise patient to avoid alcohol/drug use and encourage regular sleep routine. Emphasise importance of treatment adherence.
• Advise the patient to continue social/educational/occupational activities if possible. Refer to social worker to help find educational or employment opportunities.
• Consider housing/assisted living support and try to avoid long-term hospitalisation.
• Refer patient and carer to support group and cognitive behavioural therapy if available. Arrange support for carer and refer for therapy if available. Refer to community health worker.

Treat the patient with schizophrenia

• Give medication as in table below. Use lowest effective dose. Give one medication at a time. Allow 6 weeks on typical effective dose before considering medication ineffective.
• If repeated adherence problems, consider changing from oral to long-acting intramuscular medication (for health care workers with advanced psychiatric training). If possible, stabilise patient on oral
antipsychotic agent before changing to IM depot preparation. Once stable on long-term depot, reduce oral formulation.
• If unsure or more than typical effective dose needed, discuss with specialist.
Medication Starting dose Maintenance dose Note
Haloperidol Start 1mg orally daily. If poor response, increase gradually to 5mg daily. Usually 5mg daily. Minimal anticholinergic side effects1. Monitor for extrapyramidal side effects
If > 65 years start 0.75mg 12 hourly and increase more gradually. (EPSE)2: if present, switch to risperidone.
Risperidone Start 2mg orally daily. If poor response after 4 weeks, increase to 4mg daily. Usually 2-4mg daily. • Use in patients with extrapyramidal side effects (EPSE)2.
• Use short term for breakthrough episodes. Discuss, if possible.
Flupenthixol Start single dose 20mg IM. If poor response, give further 20mg IM after Usually 20–80mg IM every 4 weeks. • Full response can take 2 months.
decanoate 1-2 weeks. If > 65 years: avoid use of IM antipsychotics, discuss with specialist. • Fewer anticholinergic side effects1 than chlorpromazine.
Zuclopenthixol Start single dose 100mg IM. If poor response, give further 200mg IM after Usually 200-600mg IM every 4 weeks. • Monitor for extrapyramidal side effects2 (EPSE): if any EPSE develop, start
decanoate 1-2 weeks. If > 65 years, avoid use of IM antipsychotics, discuss with specialist. orphenadrine 50mg 8 hourly and refer for specialist review.
Chlorpromazine Start 25mg orally 12 hourly. If poor response increase at 25mg intervals. Usually 75-300mg daily but 800mg may • One of the most sedating antipsychotics. Avoid starting unless no other option.
be needed. Once symptoms controlled, • Continue chlorpromazine only if patient stable on it and coping with any side
give as once daily bedtime dose. effects.

Look for and manage schizophrenia treatment side effects

Urinary retention Stop treatment, insert urinary catheter and refer same day.
Blurred vision Stop treatment and refer same day.
Painful muscle spasms: acute dystonic reaction likely Usually within 2 days of starting medication. Give biperiden 2.5mg IM. If needed, repeat after 30 minutes, up to 3 doses in 24 hours. Refer same
day. If biperiden unavailable, give instead promethazine 50mg IM.
Abnormal involuntary movements Stop treatment and discuss/refer same day. Doctor to consider switch to risperidone (above).
Muscle restlessness Stop treatment and discuss/refer same day. Doctor to consider switch to risperidone (above).
Slow movements, tremor or rigidity Discuss switch to risperidone (above) and arrange specialist review. Give orphenadrine 50mg 8 hourly whilst awaiting review.
Breast enlargement, nipple discharge, amenorrhoea Discuss with specialist whether to change medication.
Dizziness/fainting on standing Usually when starting/increasing dose. Usually self-limiting over hours to days. Advise to stand up slowly.
Dry mouth/eyes Usually self-limiting.
Constipation Usually self-limiting. Advise high fibre diet and adequate fluid intake.

Once stable, review 3 monthly. Advise to return immediately if symptoms of psychosis. If restarting treatment after interruption, review after 2 weeks, sooner if symptoms worsen.
1
Anticholinergic side effects include: urinary retention, blurred vision, dry mouth/eyes, constipation. 2Extrapyramidal side effects (EPSE) include: acute dystonic reaction (acute painful muscle spasm), abnormal involuntary movements, muscle restlessness,
slow movements, tremor or rigidity.
147
 DEMENTIA
• Ensure a doctor confirms the diagnosis of dementia. Consider dementia in the patient who for at least 6 months has the following, which are getting worse:
- Problems with memory: test this by asking patient to repeat 3 common words immediately and then again after 5 minutes.
- Disorientated to time (unsure what day/season it is) and place (unsure of shop closest to home or where the consultation is taking place).
- Difficulty with speech and language (unable to name parts of the body).
- Struggles with simple tasks, decision making and carrying out daily activities.
- Is less able to cope with social and work function.
- If patient has HIV, has difficulty with coordination.

Assess the patient with dementia with the help of the carer
Assess When to assess Note
Symptoms Every visit • If recent change in mood, energy/interest levels, sleep or appetite, consider depression and discuss/refer.
• If suicidal thoughts or plans  83.
• If sudden deterioration in behaviour  85.
• If hallucinations (seeing or hearing things), delusions (unusual/bizarre beliefs), agitation or wandering, discuss/refer to mental health practitioner.
• Manage other symptoms as on symptom pages.
Side effects If on treatment If abnormal movements or muscle restlessness, stop treatment and discuss/refer same day.
Vision/hearing problems Every visit Refer to optometry/audiology services for testing and proper devices.
Nutritional status Every visit Ask about food and fluid intake. If BMI < 18.5 arrange nutritional support. BMI = weight (kg) ÷ height (m) ÷ height (m).
Palliative care Every visit If any of: bed-bound, unable to walk and dress alone, incontinence, unable to talk meaningfully or do activities of daily living, also give palliative care  170.
BP At diagnosis If known hypertension  133. If not, check BP: if BP ≥ 140/90  132.
CVD risk At diagnosis,then depending on risk Assess CVD risk  127.
HIV At diagnosis or if status unknown Test for HIV  110. If HIV positive, give routine care  111. If new HIV diagnosis with dementia, discuss with specialist.
Syphilis At diagnosis If positive, treat  53 and refer.
Thyroid function At diagnosis Check TSH. If abnormal, refer.  112

Glucose At diagnosis If known diabetes  130. If not known with diabetes, check glucose  17.

Advise the patient with dementia and his/her carer

• Discuss what can be done to support the patient, carer/s and family. Identify local resources, social worker, counsellor, NGO  178. Refer to occupational therapy if available.
• Discuss with carer if respite or institutional care is needed. Advise the carer/s to:
- Give regular orientation information (day, date, weather, time, names) - Use simple short sentences. - Remove clutter and potential hazards at home.
- Stimulate memories and give current information with newspaper, radio, TV, photos. - Maintain a routine. - Maintain physical activity and plan recreational activities.

Treat the patient with dementia

• If HIV positive, ensure patient on ART  111, as HIV-associated dementia often responds well to ART.
• If aggression, wandering, night-time disturbance or psychotic symptoms or anxiety, discuss/refer. Avoid benzodiazepines (lorazepam, diazepam, midazolam) if > 65 years.

Review the patient with dementia every 6 months.

148
 EPILEPSY: ROUTINE CARE
• If fitting now 19. If not known with epilepsy and has had a recent fit 19 to assess further.
• A doctor must confirm the diagnosis of epilepsy and start long term anticonvulsant medication.

Assess the patient with epilepsy

Assess When to assess Note
Symptoms Every visit Ask about fit frequency and review fit diary. Manage other symptoms as on symptom pages.
Adherence Every visit Ask if takes treatment every day. If not, explore reasons, support adherence and refer to community health worker.
Side effects Every visit Ask about side effects of treatment  150. If side effects intolerable, switch anticonvulsant.
Other medication Every visit If patient on any other medication (especially TB treatment, ART or contraceptive), consider possible interactions: check SAMF or discuss with MIC hotline  178.
Family planning Every visit • Assess patient’s contraceptive needs  154.
• If woman of child-bearing potential on sodium valproate, discuss the risk of birth abnormalities2 and advise to switch anticonvulsant. If patient agrees, switch to lamotrigine
 150. If patient wishes to continue valproate, ensure patient on reliable contraception3 and have patient sign risk acknowledgment form4 yearly.
• If pregnant or planning pregnancy: discuss/refer to specialist. Give routine antenatal care  159 and give folic acid 5mg daily. Refer to high risk antenatal clinic within 2 weeks.
Depression Every visit In the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either  143.
Alcohol/drug use Every visit In the past year, has patient: 1) drunk ≥ 4 drinks1/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.

Advise the patient with epilepsy  124

• If newly diagnosed, refer to community health worker and Epilepsy South Africa for support  178. Help to get a MedicAlert® bracelet  178.
• Advise to keep a fit diary to record frequency and duration of fits, triggers and changes in medication. Educate about the need for adherence and to continue treatment even if no fits.
• Help identify and avoid triggers like lack of sleep, alcohol/drug use, dehydration, flashing lights and video games.
• Help reduce chance of injury: advise to avoid dangers like heights, fires, swimming alone, walking/cycling on busy roads, operating machinery. Advise to avoid driving until fit free for 1 year.
• Advise patient there are many medications that may interact with anticonvulsants (see table  150) and to discuss with doctor before starting any new medication.

Treat the patient with epilepsy

• If not on treatment:
- Choose an anticonvulsant based on if patient is a man or woman, child-bearing potential and other medication  150.
- Start a single anticonvulsant at low dose and increase until fits stop or side effects intolerable.
• If already on treatment:
- If woman of child-bearing potential on sodium valproate, discuss risks2 and explain the need to switch anticonvulsant.
- If no further fits, continue same dose.
- If still having fits:
• If poor adherence: support adherence, continue same dose and review patient in 2 weeks.
• If medication interactions: adjust medications as needed and review patient in 2 weeks.
• If none of above: increase anticonvulsant dose  150. If already on maximum dose for 4 weeks, switch anticonvulsant once  150. If already on second anticonvulsant, avoid switching and refer instead.
• If switching medication: add new anticonvulsant and increase as needed. Continue old anticonvulsant for first 2 weeks, then slowly reduce dose over 6-8 weeks, until old anticonvulsant stopped.

Continue to treat the patient with epilepsy 150.

1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer. 2If woman on sodium valproate becomes pregnant, risks to baby include problems with development of spine, brain and other learning problems. 3Reliable
contraception includes intrauterine device (IUD), subdermal implant, injectable or sterilisation. 4Form available from: www.sahpra.org.za/wp-content/uploads/2022/08/GLF-CEM-PV-S01_v1-Valproate-Annual-Risk-Acknowledgement-Form.pdf
149
EPILEPSY
Medication Dose Notes Side effects
Lamotrigine • Starting dose: • Preferred anticonvulsant if on ART. • Urgent: rash  73
- Week 1 and 2: 25mg daily • No significant interactions with dolutegravir. • Self-limiting: nausea, vomiting, blurred
- Week 3 and 4: 25mg 12 hourly • If on lopinavir/ritonavir: doctor to double the dose of or double vision, dizziness, drowsiness,
- Week 5: 25mg in the morning and 50mg at night lamotrigine. insomnia, fatigue
- Week 6: 50mg 12 hourly • May also interact with paracetamol, rifampicin, other
- Week 7 onwards: increase by 50mg every 2 weeks until controlled anticonvulsants, oral contraceptive: check SAMF or discuss with
MIC  178.
• Usual maintenance dose: 50-100mg 12 hourly (or 100-200mg daily) • If known liver or kidney disease, discuss with specialist.
• Maximum dose: 250mg 12 hourly • If lamotrigine not suitable or not tolerated, refer.
• If treatment is interrupted for > 1 week, titrate up again using
If switching from sodium valproate: starting dose.
• Continue sodium valproate while starting lamotrigine.
• Titrate lamotrigine up slowly:
- Week 1 and 2: 25mg on alternate days
- Week 3 and 4: 25mg daily
- Week 5: 25mg 12 hourly
- Week 6: 25mg in the morning and 50mg at night
- Week 7: 50mg 12 hourly
• Once on full dose of lamotrigine, slowly reduce sodium valproate dose over 4-6
weeks until stopped.
Carbamazepine • Starting dose: 100mg 12 hourly for 1 week, then 200mg 12 hourly for 1 week. • Avoid if on/needing ART. • Urgent: rash  73
If needed, increase every week by 100-200mg/day. • May interact with dolutegravir, isoniazid, rifampicin, warfarin, • Self-limiting: drowsiness, dry mouth,
• Usual maintenance dose: 300-600mg 12 hourly fluoxetine, amitriptyline, theophylline, other anticonvulsants, dizziness, nausea
• Maximum dose: 600mg 12 hourly oral/subdermal contraceptive: check SAMF or discuss with MIC
hotline  178.
Phenytoin • Starting dose: 200mg at night (this is equivalent to 4.5–5mg/kg lean body • Only use if already well controlled on phenytoin. • Urgent:
mass daily). If needed, increase up to 300mg daily (or 150mg 12 hourly). • Avoid if a woman or on/needing ART. - Rash  73
• Maximum dose: 300mg daily • May interact with isoniazid, rifampicin, warfarin, fluoxetine, - If unsteady on feet, blurred/double vision
fluconazole, theophylline, folate, other anticonvulsants, oral/ or slurring, doctor to check phenytoin level
subdermal contraceptive: check SAMF or discuss with MIC for toxicity. If doctor not available, refer
hotline  178. same day.
• If on > 300mg daily, monitor drug levels regularly. Take trough • Self-limiting: drowsiness
level 2-3 days after initial dose adjustment (timing of trough • Other: large gums; facial hair/course
levels is not critical if on extended release formulation). If features in women: switch medication.
needed, adjust dosing according to result. Repeat level after
5-8 days since initial dose change. Repeat weekly until stable.
Once stable, monitor levels at 3-12 month intervals.

Review the patient with epilepsy

• If no further fits, review 6 monthly.
• If still fitting, doctor to review monthly until fits stop.
• Refer if any of:
- Newly diagnosed for CT scan
- Seizures other than generalised tonic-clonic seizures (e.g. absence and focal seizures)
- Fits increasing in frequency or changing in type
- No fits for ≥ 2 years, for possible treatment withdrawal
- Patient has switched anticonvulsant once and is adherent but still fitting after 4 weeks on maximum dose of second anticonvulsant.

150
 CHRONIC ARTHRITIS
• If patient has discrete episodes of joint pain and swelling that completely resolve in between, consider gout 152.
• The patient with chronic arthritis has had continuous joint pain for at least 6 weeks. Distinguish mechanical osteoarthritis from inflammatory rheumatoid arthritis as follows:
Osteoarthritis likely if: Rheumatoid (inflammatory) arthritis likely if:
• Affects joints only. • May be systemic: weight loss, fatigue, poor appetite, muscle wasting
• Weight-bearing joints and possibly hands and feet • Hands and feet are mainly involved.
• Joints may be swollen but not warm. • Joints are swollen and warm.
• Stiffness on waking lasts less than 30 minutes. • Stiffness on waking lasts more than 30 minutes.
• Pain is worse with activity and gets better with rest. • Pain and stiffness get better with activity.
If rheumatoid arthritis likely or uncertain of diagnosis, refer for specialist assessment.

Assess the patient with chronic arthritis

Assess When to assess Note
Symptoms Every visit Manage symptoms as on symptom pages. Assess and advise on chronic pain  61. If difficulty sleeping  87.
Activities of daily living Every visit Ask if patient can walk as well as before, can cope with buttons and use knife and fork properly.
Depression Every visit In the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either  143.
Joints Every visit Look for warmth, tenderness and limitation in range of movement of joints.
BMI At diagnosis BMI = weight (kg) ÷ height (m) ÷ height (m). BMI > 25 puts stress on weight-bearing joints. If BMI > 25, assess CVD risk  127.
HIV At diagnosis Test for HIV  110.

Advise the patient with chronic arthritis

• If BMI > 25, advise to reduce weight to decrease stress on weight-bearing joints like knees and feet.  128
• Encourage the patient to be as active as possible, but to rest with acute flare-ups. If patient smokes, encourage to stop  141. Refer to support group/helpline  178.
• Ensure the patient using disease modifying medication knows to have regular blood monitoring depending on the prescribed medications from the specialist clinic.

Treat the patient with chronic arthritis

• Give methyl salicylate ointment to apply to affected joints.
• If osteoarthritis: give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) as needed. If better, reduce dose to 500mg 6-8 hourly as needed.
- If no response to paracetamol and inflammation present, give ibuprofen1 400mg 8 hourly with food as needed for 7 days. If > 65 years, previous peptic ulcer, on aspirin, warfarin or prednisone, also
give lansoprazole 30mg daily for 7 days.
- Refer to doctor if available to consider steroid injection/s.
• If rheumatoid (inflammatory) arthritis: refer to specialist to confirm diagnosis. Rheumatoid arthritis must be treated early with disease modifying anti-rheumatic medication to control symptoms,
preserve function, and minimise further damage.
- While awaiting appointment, give ibuprofen1 400mg 8 hourly with food for up to 3 months. If > 65 years, previous peptic ulcer, on aspirin or prednisone, also give lansoprazole 30mg daily to take
while on ibuprofen.
- If confirmed diagnosis and acute flare (symptoms much worse): refer. While waiting for appointment, give ibuprofen2 400mg 8 hourly with food for up to 2 weeks. Avoid ibuprofen if peptic ulcer,
asthma, hypertension, heart failure, kidney disease or on warfarin: give instead prednisone 7.5mg daily for up to 2 weeks.
• If rheumatoid arthritis, or if osteoarthritis with difficulty with activities of daily living, refer to physiotherapist or occupational therapist.

Review monthly until symptoms controlled, then 3-6 monthly. If poor response to treatment, refer to specialist.
1
Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease or on warfarin, discuss instead. If patient also taking aspirin, advise to wait at least 30 minutes after taking aspirin before taking ibuprofen. 2If > 65 years, previous peptic ulcer, on
aspirin or prednisone, also give lansoprazole 30mg daily to take while on ibuprofen.
151
MUSCULOSKELETAL
DISORDERS
 GOUT
• An acute gout attack tends to affect a single joint, most commonly the big toe or knee. There is a sudden onset of severe pain, redness and swelling. It resolves completely, usually within days.
• Chronic tophaceous gout tends to asymmetrically affect > 1 joint and may not be very painful. Deposits can be seen or felt at the joints and there is incomplete recovery.

Assess the patient with gout

Assess When to assess Note
Symptoms Every visit Manage symptoms as per symptom pages.
Alcohol/drug use Every visit In the past year, has patient: 1) drunk ≥ 4 drinks1/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.
Medication Every visit Hydrochlorothiazide, furosemide, ethambutol, pyrazinamide and aspirin may induce a gout attack. Discuss with doctor. Avoid stopping aspirin given for CVD risk.
Joints Every visit • Recognise the acute gout attack: Sudden onset of 1-3 hot, extremely painful, swollen joints with red, shiny overlying skin (often big toe, knee or ankle).
• Recognise chronic tophaceous gout: deposits appear as painless yellow hard irregular lumps around the joints (picture).
CVD risk At diagnosis, then depending • Assess CVD risk  127.
on risk
Creatinine (eGFR) At diagnosis, then 6 monthly If eGFR < 60, refer.
Urate • At diagnosis • Wait at least 2 weeks after an acute gout attack before checking urate level. If urate > 0.5, start allopurinol (see below).
• On allopurinol • If starting/on allopurinol: repeat urate monthly and increase allopurinol dose if needed until urate < 0.35, then repeat urate yearly.

Advise the patient with gout

• Help the patient to manage his/her CVD risk  129. If BMI2 > 25 advise to reduce weight.  129
• Give dietary advice:
- Reduce alcohol (especially beer), sweetened fizzy drinks, seafood, offal and meat intake.
- Increase low-fat dairy intake.
- Avoid fasting and dehydration as they may increase the risk of an acute gout attack.
• Advise patient to avoid medication above that may induce an acute gout attack. Discuss with doctor before starting any new medication.

Treat the patient with gout

Treat the patient with an acute gout attack © Stellenbosch University
• Give ibuprofen3 400mg with food 8 hourly until pain and swelling are better.
• If peptic ulcer, asthma, hypertension, heart failure or kidney disease, avoid ibuprofen and give instead prednisone 40mg daily for 5 days.
• If patient is already using allopurinol, avoid stopping it during the acute attack.
Treat the patient with chronic gout
• Patient needs allopurinol if any of: ≥ 2 attacks per year, chronic tophaceous gout (picture), kidney stones, kidney disease, serum urate > 0.5.
• Wait at least 3 weeks after an acute gout attack before starting allopurinol.
• Start allopurinol 100mg (or 50mg if ≥ 65 years) daily. Use lowest dose to keep urate < 0.35: if needed, increase monthly by 100mg daily, up to 400mg daily in divided doses. Usual maintenance dose
300mg daily. For doses > 300mg, divide dose.

• If no response to treatment or unsure about diagnosis, doctor to discuss/refer patient to specialist.

• If patient < 40 years or has BMI2 < 18.5, refer within 1 month to exclude possible cancer cause for gout.

1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer. 2BMI = weight (kg) ÷ height (m) ÷ height (m). 3If patient also taking aspirin, advise to wait at least 30 minutes after taking aspirin before taking ibuprofen.
152
 FIBROMYALGIA
• Consider fibromyalgia if the patient has had general body pain above and below the waist, affecting both sides of the body for
more than 3 months associated with at least 11 of 18 tender points (see picture) on palpation.
• Fibromyalgia diagnosis more likely if any of: woman, family history, fatigue, reduced ability to think and remember clearly, mood or
sleep disturbances.
• Check for other causes of general body pain:
- If weight loss  23.
- Screen for a joint problem: patient to place hands behind head; then behind back. Bury nails in palm and open hand.
Press palms together with elbows lifted. Walk. Sit and stand up with arms folded. If unable to do screen comfortably 62. Press tender points
- Check CRP, Hb, TSH and test for HIV  110. with the pressure
• A doctor must make or confirm the diagnosis of fibromyalgia. If joint problem, HIV positive, blood results abnormal or that would blanch a
uncertain, consider another diagnosis and refer. fingernail. Compare
with a control site
Assess the patient with fibromyalgia on forehead.

Assess When to assess Note

Symptoms Every visit • Manage symptoms as on symptom pages. Ask patient to identify the 3 symptoms that bother her/him most and focus on these.
• Do not dismiss all symptoms as fibromyalgia: exclude treatable and serious illness. If unsure, refer.
Chronic pain At diagnosis Further assess and advise on chronic pain  61.
Sleep Every visit If patient has difficulty sleeping  87.
Stressors Every visit Help identify psychosocial stressors that may exacerbate symptoms. If stress or anxiety  86.
Depression Every visit In the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either  143.
Chronic arthritis Every visit If patient also has chronic arthritis, give routine care 151.

Advise the patient with fibromyalgia

• The cause is unknown but may be a result of generalised hypersensitivity of the nervous system, so patient feels more pain than others, despite normal muscles and joints.
• The patient may also have irritable bowel syndrome, tension-headache, chronic fatigue syndrome, interstitial cystitis, sleep disturbances or depression.
• Explain that s/he will have good days and bad days, but that fibromyalgia does not get worse over time. It is not life-threatening, but there is no cure.
- Advise the patient against overuse of painkillers (e.g. paracetamol and ibuprofen) as they are often not helpful for fibromyalgia and may have unwanted side effects.
- Advise patient to keep as active as possible: start with 5 minutes of gentle walking every day and build up by 1 minute a day until able to walk or run for 30 minutes at least 3 times per week.
- Encourage good sleep habits  87.
- Refer to available support group and helpline  178.
- If no better with a combination of education, exercise and medication, refer for cognitive behavioural therapy if available.

Treat the patient with fibromyalgia

• Give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) as needed.
• If no better with education and exercise, give amitriptyline1 10mg at bedtime. Increase by 5mg every 2 weeks until improvement (maximum dose 75mg).
• If still symptomatic after 3 months on maximum dose, refer/discuss.

A supportive relationship with the same health practitioner can contain frequent visits for multiple problems. Review patient 6 monthly once stable.
1
Avoid if on bedaquiline.
153
 CONTRACEPTION
Give emergency contraception if patient had unprotected sex in past 5 days and does not want pregnancy:
• Give as soon as possible single dose levonorgestrel 1.5mg orally or if patient wanting long-term contraception, check pregnancy test and if negative, insert Copper IUD1 instead.
- If patient > 80kg, BMI2 ≥ 30, or on efavirenz, rifampicin, phenytoin or carbamazepine, increase dose of levonorgestrel to 3mg.
- Give metoclopramide 10mg 8 hourly as needed for nausea/vomiting. If patient vomits < 2 hours after taking levonorgestrel, repeat dose.
- Offer to start long-term contraceptive at same visit (if IUD not chosen). If injectable or implant given, check pregnancy test in 2 weeks.
• Advise patient to return for pregnancy test if next period is more than 1 week late.
• Consider need for HIV and hepatitis B post-exposure prophylaxis  108.

Assess the patient starting and using contraception

Assess When to assess Note
Symptoms Every visit Check for symptoms of STIs: vaginal discharge, ulcers, lower abdominal pain. If present  49. Manage other symptoms as on symptom pages.
Chronic First visit Check suitability of method if any of: cancer (especially breast, cervical, uterine), blood clots, hypertension, CVD, stroke, ischaemic heart disease, diabetes, liver disease, migraines, or
conditions unexplained vaginal bleeding  156.
Medication Every visit If on ART, TB or epilepsy treatment, check method is suitable  156.
Periods Every visit Ask about periods: interval between periods, blood loss, number of days period lasts, dysmenorrhoea (pain/cramps associated with periods).
Menopause If > 40 years: yearly Ask about menopausal symptoms: hot flushes, night sweats, vaginal dryness, mood changes, difficulty sleeping. If menopausal  169.
Sexual health Every visit If risky sexual behaviour: new or multiple partner/s, uses condoms unreliably, has sex under influence of alcohol/drugs, give safe sex advice.
Adherence Every visit • If already on contraceptive, ask about concerns and satisfaction with method. If unsatisfied, consider different contraceptive, rather than risking unwanted pregnancy.
• If patient has missed injections or pills, manage  155.
Side effects Every visit If already on contraceptive, ask about and manage side effects  155.
Weight (BMI ) 2
Every visit If BMI > 25, assess CVD risk  127.
BP First visit; every visit • Check BP: if ≥ 140/90  132.
if on pill or injectable • If hypertension or BP ≥ 140/90, avoid/change from combined oral contraceptive. If BP ≥ 160/100, also avoid/change from injectable.
Breast check First visit, then yearly3 Check for lumps in breasts  43 and axillae  25.
Pregnancy Every visit • Before starting contraception, exclude pregnancy  157.
• If pregnancy suspected (nausea/breast tenderness or missed period when using combined oral contraceptive), exclude pregnancy  157.
HIV Every visit Test for HIV  110. If positive, give routine HIV care  111. If negative, consider need for PrEP, if available  106.
Cervical screen When needed If HIV negative: do 3 cervical screens, each 10 years apart from age 30  55; if HIV positive: do cervical screen at HIV diagnosis (regardless of age), then 3-yearly  55.

 51
Advise the patient starting/on contraception
• Educate patient to use contraceptive reliably. Advise to discuss concerns/problems with method and find an alternative, rather than stopping it and risking unwanted pregnancy.
• Recommend dual contraception: one method of contraception plus condoms to protect from STIs and HIV. Demonstrate and give male/female condoms.
• Discuss risky sexual behaviour. Explain risks of pregnancy and infections. Encourage patient to have 1 partner at a time and if HIV negative to test for HIV between partners. Advise that partner/s test too.
• Educate about the availability of emergency contraception (see above) and termination of pregnancy  158 to prevent unwanted pregnancy. Also educate about PrEP, if available.
• Advise patient on pill or implant to tell clinician if starting ART, TB or epilepsy treatment as these may interfere with pill or implant effectiveness.
• If on pill: if vomits within 2 hours, or severe diarrhoea within 12 hours of taking pill, repeat dose as soon as possible. If persistent vomiting/diarrhoea > 24 hours, advise to use condoms or abstain during
illness and for 7 days after resolved.
1
The newly available levonorgestrel IUD 52mg (LNG-IUD) is not coded for emergency contraception as yet. 2BMI = weight (kg) ÷ height (m) ÷ height (m). 3If patient > 40 years old: check breasts 6 monthly.
154
 Treat the patient according to her current situation:
Starting or changing Already using contraceptive Recent delivery, miscarriage or termination of pregnancy (TOP) Menopausal
contraception • If patient satisfied with • Insert IUD within 48 hours of delivery/miscarriage or TOP if no • If < 50 years, give contraception for 2
Use steps 1-4 to help method, check method is reason to avoid  157, otherwise can be inserted ≥ 4 weeks or years after last period.
patient to choose best still suitable. • Insert subdermal implant, or start injectable or POP at any stage, or • If ≥ 50 years, change to progestogen-
option according to • If using IUD or subdermal • Offer sterilisation (tubal ligation), if appropriate, or only or non-hormonal contraceptive
her needs  156. implant, check when • Start COC or POP immediately after miscarriage/TOP. until 1 year after last period.
replacement needed. • Start POP immediately after delivery:
- Avoid COC for 6 weeks after delivery.
- Avoid COC for 6 months if breastfeeding.

Manage the patient who has missed an injection or pill:

Late injection Missed progestogen-only Missed combined oral contraceptive (> 24 hours late)
• If ≤ 4 weeks late: give the injection. pill (> 3 hours late) • If 1 active pill missed: take 1 pill immediately and take next pill at usual time.
• If > 4 weeks late: exclude pregnancy  157. • Take pill as soon as • If ≥ 2 active pills missed during:
• If not pregnant, give injection and remembered, continue pack. - First 7 active pills: offer emergency contraception  154, and restart active pills 12 hours later.
use condoms/abstain for 7 days. If • If unprotected sex in past 5 - Middle 7 active pills: take the most recent missed pill immediately (discard others). Continue remaining pills
unprotected sex in past 5 days, offer days, also offer emergency as usual. No emergency contraception required.
emergency contraception  154. contraception  154. - Last 7 active pills: finish active pills of current pack. Omit inactive pills. Immediately start active pills of next pack.

Manage contraception side effects

Side effect Management
Menstrual abnormalities Reassure that menstrual abnormalities usually resolve within 3-6 months. If no periods or periods irregular, heavy or painful: assess and manage  57.
Headaches • Reassure that headaches usually resolve within 3 months. If headaches persist, consider switch to non-hormonal method like copper IUD.
• If using LNG-IUD and first time migraines/severe headaches: refer.
Sexual problems • If using IUD: if irritation of partner’s penis during sex: cut IUD strings shorter.
• Reassure that contraceptives unlikely to affect sexual function. If sexual problems persists, consider alternative method: consider IUDs, or subdermal implant or sterilisation if appropriate.
Acne Reassure that acne usually resolve within 3 months. If problem, consider switch to COC.
Weight gain Reassure this is often a temporary side effect due to fluid retention, and resolves within 3 months. If BMI > 25, assess CVD risk  127. Advise healthy lifestyle.
Breast tenderness Reassure that this usually resolves within 3 months. Advise to wear supportive bra.
Moodiness Reassure this should resolve. If persists, assess for low mood, stress or anxiety  86 or consider switch to non-hormonal method like copper IUD.
Red, swollen, painful wound • Refer to doctor, if available: clean with saline or antiseptic solution (diluted povidone iodine or chlorhexidine solution), remove slough– leave on for 5-15 minutes. Apply an antiseptic ointment
after implant insertion or (silver or povidone iodine or chlorhexidine or honey) and moisture absorbent dressing. Change dressing daily.
sterilisation • If surrounding tissue involved, give flucloxacillin 500mg 6 hourly or cefalexin 500mg 6 hourly for 5 days. If unwell with fever or pulse > 100, refer.

Review the patient on contraception

• If IUD or subdermal implant inserted this visit, review in 3-6 weeks. Thereafter, review yearly as needed.
• If oral or injectable contraceptive started this visit, review in 3 months. Thereafter, review as needed.

155
WOMEN'S HEALTH
 Start or change contraception
STEP 1. Help the patient decide which method is the best option according to her needs.
• If wanting long term protection, consider IUD (5 years), subdermal implant (3-5 years), injectable (3 months), sterilisation (permanent).
• If needing quick return to fertility, consider IUD or subdermal implant.
• If worried about adherence issues, consider IUD, subdermal implant or injectable.
• If problems with heavy/painful/irregular periods, acne or premenstrual syndrome, consider COC.
• If the patient prefers to avoid hormones, consider copper IUD and/or reliable condom use (both hormone free), sterilisation or LNG-IUD (low dose hormone released locally into uterus).
STEP 2. Check if reasons to avoid chosen method (use table). If there is a reason, consider another method (or sterilisation, if appropriate) that will be acceptable to patient:
Heavy or ≥ 35 years old Medications Chronic conditions
painful periods and smoker • If on rifampicin: use injectable, IUDs. • If breast cancer (avoid pregnancy for 5 years after diagnosis): use copper IUD.
Use LNG-IUD Use IUD, • If on phenytoin, carbamazepine: use injectable, IUD. • If cancer of uterus/cervix/ovary: use implant, injectable, COC, POP.
or COC. implant, • If on lamotrigine: use IUD, implant, injectable, POP. • If severe liver disease: use copper IUD.
injectable or • If on EFV: use IUD or injectable. • If history of blood clots: if stable on blood thinner, use implant, LNG-IUD, POP, injectable.
POP. • If on NVP, LPVr, ATVr: use IUD, implant or injectable. • If history stroke/TIA, heart attack, ischaemic heart disease: use IUD, implant, POP.
• If on DTG: use IUD, implant, injectable, COC, POP. • If hypertension or BP ≥ 140/90, use: IUD, implant, POP. Only use injectable if BP < 160/100.
• If diabetes complications (eye, nerve, kidney damage): use IUD, implant, POP.
STEP 3. Explain possible side effects. If unacceptable to patient, consider another method.
STEP 4. Explain instructions for use (use table) and check understanding.
Method Reasons to avoid Side effects Instructions for use
Intrauterine devices (IUDs) • Avoid both IUDs if: current STI/PID, unexplained vaginal • Discomfort or cramping during/ • Trained staff to insert/remove. Insert any time during cycle.
(Small device fitted inside the uterus) bleeding, abnormality or cancer of cervix/uterus, or if following insertion. • If pain, give ibuprofen1 400mg 8 hourly with food for 3 days.
1. Levonorgestrel IUD 52mg (LNG-IUD) unwell with advanced stage 3 or 4 HIV disease. • Menstrual abnormalities. • Gives long-term protection: 5 years.
2. Copper IUD eg. Cu T380A • Also avoid LNG-IUD if: severe liver disease, breast cancer. LNG-IUD usually results in no/ • No significant drug interactions expected.
• Also avoid copper IUD if: heavy/prolonged periods. lighter periods, but may cause • Advise to return if excessive bleeding/pain, fever, foul-smelling discharge: refer.
• Postpartum (≤ 48 hours): avoid if chorioamnionitis, rupture irregular bleeding. • If after delivery/miscarriage/TOP: insert ≤ 48 hours (if no reason to avoid) or
of membranes for > 18 hours or postpartum haemorrhage. • Rarely, headaches with LNG-IUD. ≥ 4 weeks.
Subdermal implant (Small plastic rod/s just • Unexplained vaginal bleeding, previous breast cancer, • Pain/bruising. • Trained staff to insert/remove.
under skin of upper arm) liver disease. • Irregular bleeding, breast • If inserted after day 7 of cycle, use condoms/ abstain for 7 days.
1. Etonorgestrel 68mg (1x rod: 3 years) • Patient on rifampicin, efavirenz, phenytoin, carbamazepine. tenderness, weight gain, acne, • If pain: give ibuprofen1 400mg 8 hourly with food for 3 days.
2. Levonorgestrel 2x 75mg (2x rods: 5 years) headaches, moodiness, nausea. • Gives long-term protection: 3-5 years depending on device used.
Injectable Unexplained vaginal bleeding, breast cancer, ischaemic heart Irregular, heavy, prolonged bleeding • If started after day 7 of cycle, use condoms/ abstain for 7 days.
(Long-lasting injection into upper arm) disease, stroke, severe liver disease, diabetes complications or no periods, hot flushes, breast • Protection lasts 3 months.
eg. Medroxyprogesterone (DMPA) IM (eye, nerve, kidney damage). tenderness, appetite changes, • No need to adjust dosing interval for ART, TB or epilepsy treatment.
150mg 12 weekly weight gain, acne, nausea/bloating. • May be a delay in return of fertility (± 9 months).
Oral pill (tablet to be swallowed every day) • Avoid both POP and COC if: breast cancer, severe liver Menstrual abnormalities, breast • If POP started after day 5 of cycle, use condoms/abstain for 2 days. If COC
1. Combined oral contraceptive (COC): disease or on rifampicin, phenytoin, carbamazepine, EFV, tenderness, headaches, moodiness, started after day 5, use condoms/abstain for 7 days.
1 tablet daily NVP, LPVr, ATVr. weight gain. • Strict adherence needed: take every day at same time. POP less effective if
• Monophasic: eg. ethinylestradiol/ • Also avoid COC if: on lamotrigine, blood clots or stroke, taken ≥ 3 hours late.
levonorgestrel 30mcg/150mcg smoker ≥ 35 years, migraines and ≥ 35 years or visual • If vomits < 2 hours or severe diarrhoea < 12 hours of taking pill, repeat dose.
• Triphasic: eg. ethinylestradiol/ disturbances, BP ≥ 140/90, hypertension, CVD risk > 10%, If > 24 hours diarrhoea/vomiting, use condoms or abstain. Continue for 7
levonorgestrel (varying doses) ischaemic heart disease, diabetes complications (eye, days after better.
2. Progestogen-only pill (POP): 1 tablet nerve, kidney damage), for 6 weeks after delivery and for 6 • May be a delay in return of fertility (± 3 months).
daily eg. levonorgestrel 30mcg months if breastfeeding. • Give 3 month supply.
Sterilisation (Tubal ligation/Vasectomy) Ensure patient understand that this is permanent and cannot • No return to fertility. • Permanent.
Reproductive tubes closed. be reversed: avoid if patient unsure. • Surgical complication risks • Refer for procedure. Consent needed
1
Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease.
156
 PREGNANCY
Approach to diagnosing pregnancy in a sexually active woman of child-bearing potential
Decide if a pregnancy test is needed:

Did woman’s last period start within the past 7 days1?

Yes No
Has woman had sexual intercourse since her last period (or since a delivery, miscarriage or TOP)?

No Yes
Has woman used reliable contraceptive method consistently and correctly since her last period (or since a delivery, miscarriage or TOP)?

Yes No
Has woman had a baby in the last 4 weeks?

Yes No
Did woman deliver baby less than 6 months ago?

Yes No

Is woman fully or nearly-fully2 breastfeeding?

Yes No

Has woman had a period since delivery? Has woman had a miscarriage or TOP in the last 7 days1?

No Yes No Yes

Pregnancy unlikely. The patient might be pregnant. Do a urine pregnancy test: Pregnancy unlikely.
No need for further pregnancy test at this time. No need for further
If starting contraception, provide method  156. Positive Negative pregnancy test at this time.
If starting contraception,
provide method  156.
Patient is pregnant. Pregnancy unlikely.
Discuss if the patient A negative test result may be unreliable if done very early in a
wants the pregnancy pregnancy. If starting contraception:
and if so, where • If IUD chosen method, delay insertion by 4 weeks. Advise to abstain
she should receive or use pill, injectable or condoms in meantime and repeat pregnancy
antenatal care test in 4 weeks. If 2nd pregnancy test negative, insert IUD.
 158. • If chosen method is implant, injectable or pill, provide method now
 156. Arrange to repeat pregnancy test in 4 weeks.

Or 12 days if excluding pregnancy as part of work up to insert IUD. 2Fully breastfeeding means baby gets all his/her food from suckling at the breast. Nearly-fully breastfeeding means baby gets some liquid or food in addition to breastfeeding but no
1

more than 1 or 2 mouthfuls a day.

157
 Approach to the newly diagnosed pregnant patient

Does the patient want the pregnancy?

No or patient unsure Yes

• Discuss the options around continuing with pregnancy, choosing adoption or termination of pregnancy (TOP). If the patient chooses adoption, refer to social worker.
• Discuss future contraceptive needs  154.
• Determine gestational age by dates and on examination. If unable to determine gestational age, refer for ultrasound.

Patient requests a TOP. Patient decides to continue with pregnancy.

Gestation < 20 weeks Gestation ≥ 20 weeks

• Check the following (avoid delaying TOP referral): • TOP is not an option.
- Screen for STI: if vaginal discharge, rash, itch, lumps, • Discuss possibility of adoption.
ulcers  49.
- Do a cervical screen if needed  55.
Decide if patient eligible for basic antenatal care:
- Test for HIV  110.
Ask about previous pregnancies and operations. Has patient had any of:
• Arrange booking as soon as possible (within 2 weeks)
at designated facility according to gestation: • Stillborn or newborn that died within first 28 days of life • Hospital admission for gestational hypertension or pre-eclampsia
• ≥ 3 consecutive miscarriages • Surgery to uterus or cervix (caesarean section, fibroid removal, cone
• Birth weight of previous baby < 2500g or > 4500g biopsy, cervical stitch for cervical incompetence)
Gestation is Gestation is
≤ 12 weeks and 0 days ≥ 12 weeks and 1 day
No Yes

Book an on-demand TOP: Book assessment for

• If < 9 weeks, refer to nearest TOP as soon as possible Ask about current pregnancy. Does patient have any of:
facility offering medical (before 20 weeks) at • Diagnosed/suspected multiple pregnancy • Rhesus negative with antibodies • Pelvic mass
outpatient TOP. facility offering 2nd • Age ≤ 16 or ≥ 37 years • Vaginal bleeding • Diastolic BP ≥ 90 at booking
• If 9 - 12 weeks, refer for trimester TOP
facility-based TOP. No Yes

Arrange appointment for patient to return after TOP Ask about general medical problems. Does patient have any of:
for counselling and contraception. • Diabetes • Kidney disease • Epilepsy • Alcohol/drug use disorder
• Heart disease • Asthma • TB • Hypertension

No Yes

Patient is eligible for basic antenatal care. Patient is not eligible for basic antenatal care.
• Continue with routine first antenatal visit  159. • Complete booking/first antenatal visit at this visit, then
• If ≥ 5 pregnancies or previous postpartum haemorrhage, arrange hospital refer to next level of care  159.
delivery. • If known hypertension: stop ACE-inhibitors (like enalapril),
give instead methyldopa 250mg 8 hourly and refer.

158
 ROUTINE ANTENATAL CARE
Give urgent attention to the pregnant patient with any of:
• Fitting or just had a fit • Vaginal bleeding
• BP ≥ 140/90 and persistent headache/blurred vision/abdominal pain: treat as severe pre-eclampsia • Temperature ≥ 38°C and severe back or abdominal pain
• BP ≥ 160/110 and ≥ 1+ proteinuria: treat as severe pre-eclampsia • Difficulty breathing
• BP ≥ 160/110 without proteinuria: treat as severe hypertension • Swollen painful calf
• Painful contractions < 37 weeks: preterm labour likely • Decreased/no fetal movements  161.
• Sudden gush of clear or pale fluid from vagina with no contractions: prelabour rupture of membranes (PROM) likely
Manage urgently:
• If difficulty breathing, give face mask oxygen and refer urgently.
• If BP < 90/60, give sodium chloride 0.9% 500mL IV over 30 minutes, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. Refer urgently.
• If temperature ≥ 38°C and difficulty breathing/back pain/abdominal pain, give ceftriaxone 1g IV1/IM unless PROM (see below). Refer urgently.
Fitting or just had a fit Severe pre- Severe Vaginal bleeding Preterm labour Prelabour rupture of
eclampsia hypertension membranes (PROM)
• If < 20 weeks 19. Early pregnancy < 22 weeks3 Late pregnancy • If < 26 weeks: refer
• If between 20 weeks and ≥ 22 weeks3 to hospital. • Confirm amniotic fluid
1 week postpartum, treat Cervical os open/dilated or products of • If 26-33+ weeks: with sterile speculum:
for eclampsia: conception in cervical os/vagina? • Avoid digital - Give 2 doses of litmus turns/stays blue.
- Lie patient in left lateral vaginal betamethasone • Avoid digital vaginal
position. No Yes examination. 12mg IM 12 hours examination.
- Avoid placing anything in • Give IV fluids apart. Record • If chorioamnionitis4: give
mouth. Threatened Incomplete or inevitable as above. time given in ampicillin5 1g IV and
- Give 100% face mask or complete miscarriage likely referral letter. metronidazole 400mg
oxygen. miscarriage - Give sodium orally. Refer urgently.
- Give magnesium sulphate: likely • Remove products of chloride 0.9% • If no chorioamnionitis4:
conception digitally if possible. 200mL IV, then - If ≥ 37 weeks: if not in
• Give magnesium sulphate 4g in 200mL Refer to • If bleeding heavy (pad soaked nifedipine 20mg active labour 12 hours
sodium chloride 0.9% IV over 20 minutes and exclude in < 5 minutes): orally. If still after PROM, give
5g IM in each buttock. Repeat 5g IM 4 hourly ectopic - Give IV fluids as above. contractions after ampicillin5 1g IV and
in alternate buttocks. pregnancy - Give oxytocin 20units IV 30 minutes, give metronidazole 400mg
• Insert catheter and record urine output every and confirm diluted in 1L sodium chloride another 10mg. orally. Refer urgently.
hour. diagnosis. 0.9% at 125mL/hour. Then give 10mg - If < 37 weeks: give
• Stop magnesium if urine output < 100mL • If pain, give paracetamol 4 hourly until amoxicillin5 500mg and
in 4 hours or respiratory rate < 162 or knee 1g 4-6 hourly (up to 4g in transferred. metronidazole 400mg
reflexes disappear. 24 hours) - Refer urgently. both 8 hourly.
• If fit persists or recurs, give further • If ≥ 34 weeks: • If 26- 33+ weeks,
magnesium sulphate 2g IV over 10 minutes. If temperature ≥ 38°C , pulse > 100, or allow labour to also give 2 doses
If no response, discuss. foul-smelling products of conception, betamethasone 12mg
continue at MOU.
give ceftriaxone 1g IV1/IM and IM 12 hours apart.
• If BP ≥ 160/110 and patient alert: give nifedipine 10mg metronidazole 400mg orally. Record time given in
to swallow, not chew. Repeat BP after 30 minutes: if still referral letter.
≥ 160/110, give second dose of nifedipine 10mg. • If rhesus negative, give anti-D immunoglobulin 50mcg IM. • Refer urgently.
• Refer urgently. • Refer urgently.

1
Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. 2If respiratory rate < 16, give calcium gluconate 10% 10mL IV slowly over 2 minutes. 3If gestation not known, manage as late
pregnancy if uterus palpable above umbilicus. 4Temperature ≥ 38˚C, painful abdomen or foul-smelling amniotic fluid. 5If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give instead azithromycin 500mg daily.
159
 The booking/first antenatal visit
Assess the pregnant patient at the booking visit, ideally before 14 weeks. If already booked 161. If not done, check patient wants pregnancy and is eligible for Basic Antenatal Care  158.
Assess Note
Symptoms Manage symptoms as per symptom page. Check if patient needs urgent attention  159.
Estimated Delivery • Use first day of the patient's last period and SFH1 to determine EDD and current gestation.
Date (EDD) • If unsure of dates and SFH1 < 24cm, refer for ultrasound to confirm EDD. TB tests changing from
Fetal movements 'Xpert Ultra' to 'TB NAAT'
If > 20 weeks, ask about fetal movements: if reduced  161. (NAAT = nucleic acid
TB • If cough, weight loss, night sweats or fever, check for TB  92. If patient has TB, refer to next level of antenatal care clinic. amplification test and includes
• If HIV positive, send 1 sputum sample for TB NAAT, even if no TB symptoms. Xpert as well as newer TB tests).

Mental health • In the past 2 weeks, has patient: 1) been unable to stop worrying or thinking too much 2) felt down, depressed, hopeless? If yes to any  143.
• In the past 2 weeks, has patient had thoughts or plans to harm herself? If yes  83.
Alcohol/drug use Any alcohol/drug use is risky for baby. In the past year, has patient: 1) drunk ≥ 4 drinks2/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any, discuss/refer.
MUAC and BMI
3 4
• If MUAC < 23cm or BMI < 18.5 (or BMI < 23 if HIV positive): exclude TB  92 and HIV  110 and refer for nutritional support or to dietician, if available. Arrange advanced midwife/doctor review.
• If MUAC ≥ 33cm or BMI ≥ 32, check diabetes risk below.
Abdomen • Use tape measure to measure size of uterus from symphysis pubis to top point of uterus. This is the symphysis-fundal height (SFH).
• Plot SFH according to gestation on SFH growth chart. Assess growth by looking where measurement falls in relation to percentile lines:
- If SFH < 24 cm at booking, refer for ultrasound (ideally at 18-20 weeks), if facilities available.
- If < 28 weeks and measurement above 90th percentile or multiple pregnancy likely, refer.
- If SF below 10th percentile, check SF at next visit: if still below 10th percentile, refer/discuss for likely poor fetal growth.
• If ≥ 34 weeks: palpate presenting part: if breech or transverse lie suspected, reassess at ≥ 38 weeks. If breech or transverse lie still suspected, refer.
• If mass other than uterus in abdomen or pelvis, refer for assessment.
Vaginal discharge If abnormal discharge, treat  49. If watery discharge and no contractions, suspect prelabour rupture of membranes  159.
BP • If BP ≥ 160/110, manage and refer urgently 159.
• If ≥ 140/90, lie patient on left side for at least 1 hour, then repeat BP:
- If repeat BP ≥ 150/100, refer same day  159.
- If repeat BP < 150/100, check urine dipstick for protein:
• If ≥ 1+ proteinuria, refer same day.
• If no proteinuria but headache, blurred vision or severe abdominal pain, treat for severe pre-eclampsia  159.
• If no proteinuria, educate about warning signs (persistent headache, blurred vision or abdominal pain), advise to rest/reduce workload and review in 1 week:
- If BP at review ≥ 140/90, arrange same day doctor/advanced midwife review: treat for gestational hypertension  163 and review weekly. If proteinuria/symptoms develop, refer urgently  159.
- Refer all at 38 weeks for hospital delivery.
Urine dipstick: • If leucocytes and nitrites in urine treat for likely complicated urinary tract infection  59.
test clean, • If proteinuria:
midstream urine - If trace or 1+ proteinuria with normal BP, reassess at next antenatal visit. If BP raised, manage above.
- If ≥ 2+ proteinuria, repeat dipstick on a new urine specimen: if still ≥ 2+ proteinuria, discuss/refer.
• If glucose in urine, check diabetes risk.
Diabetes risk • Screen for diabetes only if risk factor5.
• To screen for diabetes: give unfasted patient oral glucose 75g in 250mL water upon arrival at clinic. Check glucose after 1 hour: if ≥ 7.8, arrange further fasting test at next level of care clinic.
Continue to assess the pregnant patient 161.

1
Symphysis-fundal height. 2One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer. 3Mid Upper Arm Circumference. 4Body Mass Index (BMI) = weight (kg) ÷ height (m) ÷ height (m). 5Glucose in urine, BMI ≥ 32, age
≥ 40 years, previous diabetes in pregnancy, family history of diabetes, previous unexplained stillbirth, previous baby ≥ 4000g, polyhydramnios, SFH large for gestational age, Indian ethnicity.
160
 Booking/first antenatal visit continued:
Assess Note
Haemoglobin (Hb) Give iron according to Hb  163. Refer if:
• If Hb < 6, or Hb 6-7.9 with symptoms (dizzy, pulse > 100, difficulty breathing at rest): refer same day to regional hospital.
• If Hb 6-7.9 without symptoms: refer within 1 week to next level of care clinic.
• If booking late and Hb < 10 at ≥ 36 weeks: refer to next level of care clinic and arrange delivery at hospital.
Rapid rhesus (Rh) If rhesus negative, send Coombs test to check for antibodies: if Coombs positive, refer. If Coombs negative, patient will need anti-D immunoglobulin IM after delivery.
Syphilis • Ideally, use rapid fingerprick test, as result immediately available. If HIV negative or unknown, use a dual HIV syphilis rapid test, if available. If syphilis positive  53. If HIV positive  110.
• If rapid tests unavailable: send blood for syphilis serology (RPR). On request form, write: "If RPR titre 1:4 or less, do specific syphilis test on same specimen." If syphilis positive  53.
HIV • If HIV negative or status unknown, test for HIV  110. If test negative, consider need for PrEP  106.
• If HIV positive, start ART same day if not on ART yet  111. If on ART, switch to DTG-based regimen if not on already  117. Offer couple/partner testing.
Viral load (VL) if • If on ART for ≥ 3 months: do VL at this visit, regardless of previous tests. Follow up result at next visit (ideally within 1 week)  163.
HIV positive • If on ART for < 3 months: do VL at 3 months on ART or at delivery if this is sooner.
Note: fill in the code 'C#PMTCT'
Hepatitis B (HBsAg) Manage according to result  120. on the blood request form for
viral load to be identified as that
Cervical screen • If ≥ 20 weeks: delay cervical smear. Plan to do it at 6-week postnatal visit. of pregnant woman
• If < 20 weeks:
- If HIV negative: if patient ≥ 30 years and no screen in past 10 years, do cervical screen  55.
- If HIV positive: do cervical screen at HIV diagnosis (regardless of age), then 3-yearly  55.
Continue to advise and treat the pregnant patient 163.

Follow-up antenatal visits

Assess the pregnant patient at booking/first visit  160 and 7 follow-up visits around 20, 26, 30, 34, 36, 38, 40 weeks. Review at 41 weeks if undelivered.
Assess When to assess Note
Symptoms Every visit Manage symptoms as per symptom page. Check if patient needs urgent attention  159.
Gestation1 Every visit If ≥ 40 weeks, advanced midwife/doctor to review: if sure of dates, to go to hospital at exactly 41 weeks for induction (give referral letter). If unsure of dates, refer.
Fetal movements Every visit from 20 weeks • If reduced or absent fetal movements, listen for fetal heartbeat: if fetal heart beat not heard, refer.
• If fetal heart beat heard, arrange for cardiotocograph (CTG). Refer if not available at facility. Ideally, advanced midwife to perform and interpret CTG:
TB Every visit • Check for TB symptoms at every visit: if cough, weight loss/poor weight gain or fever, exclude TB  92. If patient has TB, refer to next level of antenatal care clinic.
• If HIV positive, check TB NAAT result sent at first visit (if not done, do at this visit, even if no symptoms):
- If TB NAAT positive, start TB treatment and refer to next level of care antenatal clinic.
- If TB NAAT negative (or unable to produce sputum) and:
• TB symptoms: if CD4 ≤ 200 or WHO stage 3 or 4 disease, do a urine LAM2. If LAM positive, start TB treatment and refer. If CD4 > 200 or LAM negative, refer/discuss.
• No TB symptoms: start ART, if not already done  113 and TB preventive treatment (TPT)  113.
Mental health Every visit • In the past 2 weeks, has patient: 1) been unable to stop worrying or thinking too much 2) felt down, depressed, hopeless? If yes to any  143.
• In the past 2 weeks, has patient had thoughts or plans to harm herself? If yes  83.
Alcohol/drug use Every visit • Any alcohol/drug use is risky for the baby.
• In past year, has patient: 1) drunk ≥ 4 drinks3/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any, discuss/refer.
Continue to assess the pregnant patient 162.
1
Use obstetric wheel to determine gestation, based on estimated date of delivery (EDD). 2Urine LAM (lipoarabinomannan): urine test used to detect active TB in patients with low CD4s. 3One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of
beer. 4Symphysis-fundal height. 5Glucose in urine, BMI ≥ 32, age ≥ 40 years, previous diabetes in pregnancy, family history of diabetes, previous unexplained stillbirth, previous baby ≥ 4000g, polyhydramnios, SFH large for gestational age, Indian ethnicity.
161
 Follow-up antenatal visit continued:
Assess When to assess Note
Abdomen Every visit • Measure and plot SFH1 according to gestation on SFH growth chart.
• Assess growth by looking at pattern of growth over time and where measurement falls in relation to percentile lines:
- If < 28 weeks and measurement > 90th centile or multiple pregnancy likely, refer.
- Refer/discuss for likely poor fetal growth if:
• Two consecutive SF measurements below 10th percentile (or three separate SF measurements below 10th percentile)
• Three consecutive SF measurements remain the same (or two consecutive SF measurements, taken at least 6 weeks apart, remain the same).
• SF measurement less than measurement recorded 2 visits previously.
• If ≥ 34 weeks: palpate presenting part. If breech or transverse lie suspected, reassess at ≥ 38 weeks. If still suspected, refer.
Vaginal discharge Every visit • If abnormal discharge, treat  49.
• If watery discharge with history of a sudden gush of clear or pale fluid from vagina, and no contractions, suspect prelabour rupture of membranes  159.
BP Every visit • If BP ≥ 160/110, manage and refer urgently 159.
• If ≥ 140/90, lie patient on left side for at least 1 hour, then repeat BP:
- If repeat BP ≥ 150/100, refer same day  159.
- If repeat BP < 150/100, check urine dipstick for protein:
• If ≥ 1+ proteinuria, refer same day.
• If no proteinuria but headache, blurred vision or severe abdominal pain, treat for severe pre-eclampsia  159.
• If no proteinuria, educate about warning signs (persistent headache, blurred vision or abdominal pain), advise to rest/reduce workload and review in 1 week:
- If BP at review ≥ 140/90, arrange same day doctor/advanced midwife review: treat for gestational hypertension  163 and review weekly. If proteinuria/
symptoms develop, refer urgently  159.
- Refer all at 38 weeks for hospital delivery.
Urine dipstick: test Every visit • If leucocytes and nitrites in urine treat for likely complicated urinary tract infection  59.
clean, midstream • If proteinuria:
urine - If trace or 1+ proteinuria with normal BP, reassess at next antenatal visit. If BP raised, manage above.
- If ≥ 2+ proteinuria, repeat dipstick on a new urine specimen: if still ≥ 2+ proteinuria, discuss/refer.
• If glucose in urine, check diabetes risk.
Diabetes risk If risk factor2: 26 weeks Give unfasted patient oral glucose 75g in 250mL water upon arrival at clinic. Check glucose after 1 hour: if ≥ 7.8, arrange further fasting test at high risk clinic.
Haemoglobin (Hb) • Between 28 and 32 weeks Give iron according to Hb  163. Refer if:
• At 36 weeks • If Hb < 6, or Hb 6-7.9 with symptoms (dizzy, pulse > 100, difficulty breathing at rest): refer same day to regional hospital.
• If patient pale • If Hb 6-7.9 without symptoms: refer within 1 week to next level of care clinic.
• If Hb < 10: 1 month after • If Hb 8-9.9 and Hb is not improving after 1 month of treatment: refer within 1 week to next level of care clinic.
treatment started • If Hb < 10 at ≥ 36 weeks: refer to next level of care clinic and arrange delivery at hospital.
If Rh negative: anti-D Send Coombs test to check for • If Coombs positive, refer.
antibodies antibodies at 26, 34 and 38 weeks • If Coombs negative, give anti-D immunoglobulin 100mcg IM after delivery/miscarriage preferably within 72 hours, up to 7 days later.
Syphilis 20, 26, 30, 34, 38 weeks and at • Use fingerprick test, as result immediately available. If HIV negative/unknown, use dual HIV syphilis rapid test. If HIV positive  111. If syphilis positive  53.
delivery • If rapid tests unavailable: send syphilis serology (RPR). On request form, write: "If RPR titre 1:4 or less, do specific syphilis test on same specimen." If positive  53.
• Follow positive syphilis results up: check mother has received all 3 treatment doses  53.
HIV 20, 26, 30, 34, 38 weeks and at • If HIV negative or status unknown, test for HIV  110. If patient refuses, offer at each visit, even in early labour. If test negative, consider need for PrEP  106.
delivery • If HIV positive, give routine HIV care and check that mother on ART. If not on ART, start ART same day  111.
Viral load (VL) if HIV • 3 months on ART • If VL < 50, continue ART and repeat VL at delivery. Note: fill 'C#PMTCT' or 'C#DELIVERY' in code field on request form so VL not rejected.
positive • At delivery • If VL ≥ 50, manage unsuppressed viral load  166.
Continue to advise and treat the pregnant patient 163.

Symphysis-fundal height. 2Glucose in urine, BMI ≥ 32, age ≥ 40 years, previous diabetes in pregnancy, family history of diabetes, previous unexplained stillbirth, previous baby ≥ 4000g, polyhydramnios, SFH large for gestational age, Indian ethnicity.
1

162
 Advise the pregnant patient
• Complete Maternity Case Record and give to patient, remind patient to bring it to every visit and when in labour.
• Encourage patient to register on MomConnect (dial *134*550#) to receive messages to support her and her baby during pregnancy, childbirth and baby’s first year.  55
• Advise patient to only take medications prescribed by nurse/doctor who knows she is pregnant. If she is unsure, advise her to check with nurse/doctor.
• Alert patient to the risks of smoking and drinking alcohol and urge to stop. Support patient to change  177 and refer patient to available helpline  178.
• Discuss safe sex. Advise patient to use condoms throughout pregnancy and have only 1 partnership at a time.
• Discuss contraception choice for after delivery  154.
• Educate about signs of early labour and pregnancy emergency: persistent headache, blurred vision, abdominal pain (not discomfort), drainage of liquor, vaginal bleeding, reduced fetal movements.
• From 30 weeks, ensure patient knows where she is going to give birth and check if transport arrangements have been made should she go into labour.
• Discuss infant feeding:
- Encourage exclusive breastfeeding for 6 months, regardless of HIV status: this means that baby gets only breast milk (no formula, water, cereal) and if HIV-exposed, infant prophylaxis.
- From 6 months, introduce food while continuing with feeding choice. Continue breastfeeding until 2 years for all, ensuring that HIV positive mother is adherent on ART and virally suppressed.
- If mother chooses to exclusively formula feed, check that mother will be able to afford it long-term, has access to clean boiled water, and that it will be acceptable (i.e. no disclosure issues).

Treat the pregnant patient

• Give folic acid 5mg daily up to 13 weeks gestation. If on anticonvulsants, family history or previous baby with neural tube defect, continue folic acid throughout pregnancy.
• Give iron1 according to Hb:
- If Hb ≥ 10, give ferrous sulphate compound BPC 170mg daily or ferrous fumarate 200mg daily throughout pregnancy. If daily iron not tolerated2, give instead ferrous sulphate compound BPC
340mg once weekly with food or ferrous fumarate 400mg once weekly with food throughout pregnancy.
- If Hb < 10, give ferrous sulphate compound BPC 170mg 12 hourly with food or ferrous fumarate 200mg 12 hourly with food.
• Continue for 3 months once Hb ≥ 10, then once daily throughout pregnancy.
• Give elemental calcium 1g daily (given as 3 tablets of calcium carbonate (420mg tablets), 12 hourly) to reduce the risk of pre-eclampsia.
- If previous pre-eclampsia, discuss giving low-dose aspirin from 6 weeks' gestation (preferably before 16 weeks) with specialist.
• If first pregnancy, give tetanus toxoid (TT) 0.5mL IM into arm (when available, give instead Tdap). If < 5 previous tetanus vaccinations4 in lifetime documented, catch up vaccinations.
• Give influenza vaccine 0.5mL IM if at time of annual campaign.
• Check that patient is up to date with COVID-19 vaccination.
• If gestational hypertension:
- Start methyldopa 250mg 8 hourly and titrate up to 750mg 8 hourly if needed.
- Review weekly, check for new symptoms, BP, urine, weight, SFH and fetal heart/movements  161.
- Refer at 38 weeks for delivery at hospital.
• If HIV positive: start or continue ART and check if prophylaxis (e.g. co-trimoxazole preventive therapy or TB preventive treatment) needed  113.
• If in malaria area, discuss need and choice of malaria prophylaxis with specialist.

Review the pregnant patient at 20, 26, 30, 34, 36, 38, 40 weeks. If undelivered, also review at 41 weeks.

Treat the HIV positive patient in labour

• If on ART, continue ART throughout delivery. Check viral load, regardless of when last done, and review results at 3-6 day postnatal visit.
Note: fill 'C#DELIVERY' in the code field on
• If not on ART, give together single dose NVP 200mg as early as possible in labour and single dose (TLD) TDF/3TC/DTG 300/300/50mg. blood request form so VL not rejected.
• Give ideally during early labour, and urgently if delivery is imminent.
• Start mother on ART next day  114. Give mother 2 months ART supply.
• Decide HIV transmission risk of HIV-exposed baby and give infant prophylaxis according to risk  168.
DTG - dolutegravir; FTC – emtricitabine; NVP - nevirapine; TDF – tenofovir; 3TC – lamivudine, TLD - TDF/3TC/DTG or tenofovir/lamivudine/dolutegravir

Give routine postnatal care to mother and baby 164.

1
If possible, avoid taking iron within 4 hours of taking calcium or methlydopa and within 2 hours of milk and tea. If on dolutegravir and taking at same time as iron, take with food. 2Abdominal pain, nausea, vomiting, constipation. 3If on dolutegravir and
taking at same time as calcium, take with food. 4Tetanus vaccinations include DTP, DTP-Hib, DTaP-IPV/Hib, TD or TT.
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 ROUTINE POSTNATAL CARE
Give urgent attention to the postnatal patient (within 6 weeks of delivery) with any of:
• Heavy bleeding (soaks pad in < 5 minutes): postpartum haemorrhage likely • Perineal tear extending to anus or rectum • Hb < 6
• Fitting or just had a fit up to 1 week postpartum: treat as eclampsia 159. • BP < 90/60 • Pallor with respiratory rate ≥ 30,
• Unwell and temperature ≥ 38˚C • Pulse ≥ 100 dizzy, faint or chest pain
Manage and refer urgently:
• If BP < 90/60, give sodium chloride 0.9% 1L IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens.
• If postpartum haemorrhage likely: call for help, this is a life-threatening condition and requires immediate referral. Manage urgently:
- Massage uterus, remove clots from vagina and empty bladder (with catheter if needed).
- Whilst setting up IV, give oxytocin 10units IM if not already given after baby delivered. Give oxytocin 20units in 1L sodium chloride 0.9% at 250mL/hour IV in a 2nd IV line.
- Ensure placenta is delivered. If controlled cord traction fails, try manual delivery.
- If uterus still soft after this:
• Give ergometrine 0.5mg IM or oxytocin/ergometrine 5units/0.5mg (1mL) IM and continuously massage uterus. Avoid if eclampsia, pre-eclampsia, known hypertension or heart disease unless
bleeding is life-threatening. Repeat after 10–15 minutes if no response to 1st dose, while arranging referral.
• Only if oxytocin and oxytocin/ergometrine unavailable, give misoprostol 600mcg rectally or sublingually.
- Repair any bleeding tears.
- If still bleeding heavily, insert balloon catheter1 into uterus, inflate with 400-500mL of saline, clamp catheter and pack vagina with swabs to prevent expulsion.
- Apply bimanual compression2 during transfer.
• If unwell and temperature ≥ 38°C: give ceftriaxone 1g IV3/IM. If painful abdomen or foul-smelling vaginal discharge, also give metronidazole 400mg orally.

Assess the mother and her baby 6 hours, 6 days, and 6 weeks after delivery.
Assess When to assess Note
Symptoms Every visit Manage mother’s symptoms as on symptom page. Manage baby’s symptoms with IMCI guide.
Mental health Every visit • In the past 2 weeks, has patient: 1) been unable to stop worrying or thinking too much 2) felt down, depressed, hopeless? If yes to any  143.
• In the past 2 weeks, has patient had thoughts or plans to harm herself? If yes  83.
Alcohol/drug use Every visit In the past year, has patient: 1) drunk ≥ 4 drinks4/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.
Family planning Every visit Assess patient’s contraceptive needs  154. Ideally, insert IUD within 48 hours of delivery if no contraindications5 or, insert subdermal implant or start injectable or POP at any stage
after delivery, or offer tubal ligation if appropriate. Avoid COC pill for 6 weeks after delivery and for 6 months if breastfeeding.
Infant feeding Every visit If breastfeeding: check for breast problems  43. Check that baby latches well. If formula feeding: ensure correct mixing of formula and water.
Baby Every visit • Assess and manage the baby according to the IMCI guide.
• Ensure baby gets immunisations at birth and 6 weeks. If mother known to have TB, hepatitis B or syphilis, prevent infections in the newborn  167.
Psychosocial risk Every visit Help access support especially if at risk of mental health problem: patient not interacting with baby, difficult life event in last year, unhappy about pregnancy, absent/unsupportive
partner, violence at home, abused as a child, no social/family support, previous depression/anxiety, < 20 years, no money for food, patient is a refugee or has HIV.
Abdomen and Every visit • If painful abdomen or foul-smelling vaginal discharge, refer/discuss same day.
perineum • If perineal or abdominal wound: check healing. Advise salt baths twice daily in warm water for perineal wounds. If red/warm/painful/swollen/foul-smell/oozing pus, discuss/refer.
BP Every visit Check BP. If BP ≥ 140/90, recheck after 1 hour rest. If BP still ≥ 140/90  132, unless ≤ 1 week postpartum: discuss same day.
BMI Every visit Mother’s BMI = weight (kg) ÷ height (m) ÷ height (m). If < 18.5, arrange nutritional support.
Continue to assess the postnatal patient and baby 165.
1
If balloon catheter unavailable, make condom catheter: slip open condom over large Foley's catheter and tie with string at the base. 2Bimanual compression: insert clenched fist into vagina, with back of hand posteriorly. Place other hand on abdomen
behind uterus and squeeze uterus firmly between two hands. 3Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. 4One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/
bottle (330mL) of beer. 5Avoid IUD if: chorioamnionitis, rupture of membranes for > 18 hours or postpartum haemorrhage.
164
 Assess When to assess Note
Syphilis If not done or not repeated later in pregnancy Ideally, use rapid fingerprick test, as result immediately available. If HIV negative or unknown, use a dual HIV syphilis rapid test, if available.
HIV test in • At delivery (if not done/repeated) • Test for HIV  110. If test negative, consider need for PrEP  106.
mother • If breastfeeding: at 10 weeks, 6 months, then • If HIV positive, give routine HIV care and start ART same day  113. Test baby for HIV same day and if breastfeeding, give infant prophylaxis  166.
3 monthly
Viral load (VL) • At delivery • Follow up results of VL done at delivery at the 3-6 days postnatal visit. If VL not done at delivery, do at this visit.
if HIV positive • 6 months after delivery • If VL < 50, continue ART and give routine HIV care  111.
• If breastfeeding: 6 monthly • If VL ≥ 50: manage unsuppressed VL  166.
HIV test in • HIV-exposed: birth, 10 weeks, 6 months, • If mother diagnosed with HIV while breastfeeding or baby unwell, do HIV test same day.
baby 18 months, 6 weeks after breastfeeding stopped • If baby < 18 months old: use HIV PCR as initial test. If positive, start ART and confirm result with second HIV PCR (or HIV viral load).
• HIV-unexposed: 18 months • If baby 18-24 months old: use rapid HIV test as initial test. If positive, confirm with HIV PCR test before starting ART.
• At any time if baby unwell • If baby ≥ 24 months old: as for adult testing  110.
Haemoglobin 6 weeks Give iron according to Hb (see below). If Hb < 10: repeat monthly until Hb reaches 10. If no improvement 1 month after starting treatment, discuss/refer.
Cervical From 6 weeks • HIV negative: do cervical screen if ≥ 30 years and no screen in past 10 years  55.
screen • HIV positive: do cervical screen at HIV diagnosis (regardless of age), then 3-yearly  55.
Rhesus (Rh) If mother rhesus negative: 6 hour and 6 day visit If baby rhesus positive/unknown, give mother single dose anti-D immunoglobulin 100mcg IM, preferably within 72 hours, up to 7 days after delivery.

 59
Advise the mother
• Encourage mother to become active soon after delivery, rest frequently and eat well. Advise mother to keep perineum clean and to change pads 4-6 hourly.
• Advise to return urgently if heavy bleeding, foul-smelling vaginal discharge, red/oozing wound, fever, dizziness, severe headache or abdominal pain, blurred vision, calf pain or baby unwell.
• Refer to an infant feeding support group. Give feeding advice:
- Regardless of HIV status, encourage exclusive breastfeeding for 6 months: baby gets only breast milk (no formula, water, cereal) and if HIV-exposed, infant prophylaxis.
- Advise to only introduce food from 6 months of age while continuing with feeding choice. Advise the working mother to consider expressing breast milk for baby while away.
- Regardless of HIV status, continue to breastfeed until 2 years of age. If HIV positive, ensure viral suppression on ART. If HIV negative, advise 3-monthly HIV tests.
- If mother chooses to formula feed: check that she is able mix it correctly, afford it long-term, has access to clean boiled water, and that it will be acceptable (i.e. no disclosure issues).
• Discuss family planning and importance of spacing children. Advise to use reliable contraception and condoms as soon after delivery as possible.
• Explain that the first 1000 days of a child's life are vital to his/her development: encourage mother and father to respond when baby cries and to hold, talk/sing and make eye contact with baby to help
with bonding and development. If mother finds this difficult, encourage her to return more frequently and refer to support group, if available.

Treat the mother

• Give iron1 according to Hb:
- If Hb ≥ 10, give ferrous sulphate compound BPC 170mg daily or ferrous fumarate 200mg daily for 6 weeks after delivery.
• If daily iron not tolerated2, give instead ferrous sulphate compound BPC 340mg once weekly with food or ferrous fumarate 400mg once weekly with food for 6 weeks.
- If Hb < 10, give ferrous sulphate compound BPC 170mg 12 hourly with food or ferrous fumarate 200mg 12 hourly with food. Continue for 3 months after Hb reaches 10.
• If pain after delivery: give paracetamol 1g 4-6 hourly (up to 4g in 24 hours) and ibuprofen3 400mg 8 hourly with food for up to 5 days.
• If HIV positive mother not on ART, start ART same day  113, especially if breastfeeding.

• Treat the HIV-exposed baby 166.

• Routinely review mother and baby 6 hours, 6 days, and 6 weeks after delivery.

1
If possible, avoid taking iron within 4 hours of taking methlydopa and within 2 hours of milk and tea. If on dolutegravir and taking at same time as iron, take with food 2Abdominal pain, nausea, vomiting, constipation. 3Avoid ibuprofen if pre-eclampsia,
peptic ulcer, asthma, hypertension, heart failure, kidney disease.
165
 MANAGE THE PREGNANT/BREASTFEEDING PATIENT WITH
AN UNSUPPRESSED VIRAL LOAD (VL ≥ 50)
Assess and manage possible causes of unsuppressed viral load (VL ≥ 50):
• Check adherence and dosing and give enhanced adherence support  173. Check if pregnant mother has been vomiting up medications. Encourage disclosure.
• Consider medication interactions: ask about other medications, especially TB and epilepsy treatment and common over-the-counter medications like: calcium, iron, antacids. If using any of these,
manage possible medication interactions  118 or discuss with experienced ART doctor or HIV hotline  178.

Switch to the DTG-based regimen

• If not on TLD (or ALD), check if same day ART switch is appropriate  117.
• If on DTG-based regimen, continue below.

If breastfeeding, assess and manage baby:

• Do HIV test on baby same day.
• If baby not on prophylaxis currently, start/restart AZT 12 hourly for 6 weeks and NVP daily for at least 12 weeks  168 (only stop NVP once mother’s VL < 50 or 4 weeks after final breastfeed).

Repeat mother’s VL after 4 weeks (if VL done at delivery, VL can be repeated at the 6-week postnatal visit):

Second viral load result < 50 Second viral load result ≥ 50

Repeat VL as per routine VL • Increase efforts to resolve adherence1 issues and address possible drug-drug interactions  173.
monitoring: • Manage further according to duration of DTG-based ART:
• If pregnant: repeat VL at
delivery. On DTG for less On DTG for 2 years or more
• If breast-feeding: repeat VL than 2 years • Assess adherence in last 6-12 months by checking script for pharmacy refills and notes for clinic appointment attendance1.
6 monthly. • Have refills been collected > 80%2 of time or has patient attended > 80%3 clinic visits?

No Yes

Adherence Adherence considered good.

considered poor. Has woman had 2 or more consecutive viral load results ≥ 1000 after starting DTG-based regimen?

No Yes

Continue to support adherence and repeat VL in 3 months or at delivery if this is sooner: Virological failure confirmed.
if ≥ 2 viral loads ≥ 1000 after starting DTG-based regimen (with adherence > 80%):

• Discuss with HIV expert, specialist, third line ART committee or HIV hotline  178.
• If VL ≥ 1000, monitor CD4 6 monthly.
• If CD4 ≤ 200, restart co-trimoxazole  113.

1
If available, also do drug level on urine or blood specimen: adherence is considered good if medications are detected in patient's urine/blood. 2Calculate adherence % for pharmacy refills: ‘number of actual refills done during period assessed’ ÷ ‘number of
months in period assessed’. Then x by 100. 3Calculate adherence % for clinic attendance: ‘number of scheduled visits actually attended by patient during period assessed’ ÷ ‘number of scheduled visits during period assessed’. Then x by 100.
166
 PREVENT COMMUNICABLE INFECTIONS IN THE NEWBORN
Assess and manage the newborn exposed to HIV, TB, hepatitis B or syphilis. If exposed to HIV, assess and manage further  168.

Assess the newborn exposed to TB, or the newborn who tests positive for HIV, for TB preventive treatment (TPT)
Was baby born to mother or household contact with TB and any of: 1) diagnosed with TB ≤ 2 months before delivery, 2) poor clinical response to TB treatment,
3) TB smear or TB culture positive or unknown at delivery, 4) diagnosed with TB soon after delivery?

Yes No

Baby HIV positive Baby HIV negative

• If x-ray available, do anterior-posterior (AP) and lateral chest x-ray on baby and arrange doctor review. No need for TPT.
• Does baby have any of: 1) respiratory rate > 60, 2) breathing problem, 3) feeding problem, 4) birth weight < 2500g/premature, Give routine care.
5) abdominal distension/enlarged liver/spleen, 6) jaundice, 7) weight loss > 10% , 8) appears unwell/lethargic?

Yes No
• Congenital TB likely. Treat further according to TB exposure history and HIV status:
Refer urgently and
notify1. TB exposed HIV positive, not TB exposed
• Avoid giving BCG • Avoid giving BCG vaccine soon after birth. Give BCG vaccine after TPT completed. • Give BCG vaccine if not yet given.
vaccine if not yet • If exposed to drug-resistant TB, discuss with TB expert/hotline  178. • Start 6H and pyridoxine at 14 weeks
given. routine care visit.
HIV unexposed HIV positive or HIV exposed on nevirapine • If not yet done, give HIV routine care.
Give 3RH and pyridoxine and Give 6H and pyridoxine and review after
review after 1 month  90. 1 month  90.

Manage the baby born to mother with hepatitis B infection

• Arrange delivery at a facility that stocks immunoglobulin (HBIG) and the monovalent hepatitis B vaccine:
- Give hepatitis B immunoglobulin (HBIG) 200IU IM and hepatitis B vaccine 0.5mL (10mcg/0.5mL) IM, as soon after delivery as possible, within 12-24 hours.
• Continue routine hepatitis B immunisations at 6, 10, 14 weeks and 18 months.
Arrange follow up when baby is 9 months old: take blood from baby for HBsAg and hepatitis B surface antibodies (HBsAbs):

HBsAg positive HBsAg negative and HBsAbs positive (HBsAb titre ≥ 10) HBsAg negative and HBsAbs negative (HBsAb titre <10)
Baby has hepatitis B infection, Baby has immunity against hepatitis B. Repeat hepatitis B vaccine 0.5mL (10mcg/0.5mL) IM at this visit and again in 1 month.
refer and notify1. Reassure parent/carer, no further testing needed. Then repeat HBsAbs test 1 month later: if HBsAbs still negative, refer.

Manage the baby born to mother with syphilis

• If rash (peeling rash, red/blue spots or bruising especially on soles and palms), jaundice, pallor (pale conjunctiva/palms of hands), distended abdomen, swelling, birth weight < 2500g, runny nose,
respiratory distress, hypoglycaemia, congenital syphilis likely. Refer urgently and notify1.
• If no signs/symptoms of congenital syphilis and any of the following, give baby single dose benzathine benzylpenicillin 50 000 units/kg IM into outer thigh, and discuss/refer:
1) Mother received < 3 doses of benzathine benzylpenicillin injections 3) Delay (> 14 days) between maternal doses of benzathine benzylpenicillin
2) Mother received antibiotic other than benzathine benzylpenicillin to treat syphilis 4) Baby delivered within 30 days of mother receiving last dose of benzathine benzylpenicillin
1
Complete notifiable medical conditions (NMC) case notification form and send to [email protected] or notify electronically: https://www.nicd.ac.za/nmc-overview/notification-process.
167
 PREVENT VERTICAL TRANSMISSION OF HIV
Assess and manage the newborn exposed to HIV
• Do HIV positive mother's viral load at delivery and HIV PCR test on her baby as soon after birth as possible (within 48 hours). Place barcodes on discharge form and RtHB.
• If abandoned baby, do rapid HIV test1 and HIV PCR test on baby. If < 72 hours since delivery, manage as high risk formula feeding baby below.

Start post-exposure prophylaxis (PEP) as soon as possible, ideally within 1 hour of birth
• Give baby zidovudine (AZT) 12 hourly (see dosing table below) and give nevirapine (NVP) once daily (see dosing table below). Give supply for 6 weeks and advise carer to bring all medication to next visit.
• Advise to return for baby's HIV PCR and mother’s viral load results in 3-6 days.

At 3-6 day postnatal visit, check results of baby’s HIV PCR and mother’s viral load and manage according to results:
If results not available, continue AZT and NVP and follow-up after 1 week. If no HIV PCR done, do at this visit and follow-up after 1 week.

Baby’s HIV PCR negative Baby’s HIV PCR Baby's HIV PCR
positive indeterminate
Mother’s VL < 50 Mother’s VL ≥ 50 or unknown at delivery
at delivery • Send 2nd HIV • Continue
PCR test and HIV PEP
Higher risk
refer to doctor according
Low risk • Manage mother’s unsuppressed VL  166.
to change to to mother's
• If mother's VL ≥ 1000, discuss need for HIV resistance test for mother and baby with HIV expert/hotline  178.
ART. delivery VL
• Stop AZT2. • Advise mother result (see
• Give NVP daily Breastfeeding3 Formula feeding to breastfeed adjacent).
for 6 weeks (see for at least • Do HIV PCR
table). 2 years. test and
• Give AZT 12 hourly for 6 weeks (see dosing table below)and Give AZT (12 hourly) • If formula HIV viral
• If breastfeeding:
• Give NVP daily for at least 12 weeks (see dosing table below) and NVP (daily) for feeding, load, review
repeat mother’s
• Stop NVP only once mother's VL < 50 or 4 weeks after final breastfeed. 6 weeks (see dosing consider child and
VL 6 monthly.
• If mother on TLD2 or 3rd line ART for ≥ 3 months and VL ≥ 1000, alert to risks of breastfeeding, discuss changing tables below). feasibility of check results
to formula feeding and refer to nutritional therapeutic programme (NTP). Discuss with HIV expert/hotline  178. re-establishing within
breastfeeding. 3 days.
• Repeat baby's HIV test at 10 weeks, 6 months, 18 months, 6 weeks after final breastfeed or nevirapine stopped (if given ≥ 12 weeks) or any time if baby unwell.
• If mother's VL ≥ 50 at any time during breastfeeding after NVP and/or AZT stopped or mother tests HIV positive for the first time during breastfeeding: repeat/do
child's HIV test at that visit, restart/start NVP and AZT (see above), and reassess once child's HIV test result available.
Nevirapine syrup (10mg/mL) Zidovudine syrup (10mg/mL)
Age Current Weight Once daily dose Age Current Weight 12 hourly dose
Birth to 6 weeks 2-2.49kg4 1mL (10mg) daily Birth to 6 weeks 2-2.49kg4 1mL (10mg) 12 hourly
≥ 2.5kg 1.5mL (15mg) daily ≥ 2.5kg 1.5mL (15mg) 12 hourly
6 weeks to 6 months 2mL (20mg) daily 6 weeks to 6 months 6mL (60mg) 12 hourly
6 to 9 months 3mL (30mg) daily ≥ 6 months Dose 12 hourly according to weight.
≥ 9 months 4mL (40mg) daily

1
An HIV rapid test shows whether baby was exposed to HIV, but cannot determine whether baby is infected with HIV. An HIV PCR test determines if baby is infected with HIV. 2Return unused AZT to pharmacy to be discarded. 3A breastfed baby has
breastfed in the past 7 days or is mixed feeding. 4If weight < 2kg, discuss medication options with HIV expert/hotline  178.
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 MENOPAUSE
• Exclude pregnancy before diagnosing menopause  157.
• Menopause is no menstruation for at least 12 months in a row. Most women have menopausal symptoms and irregular periods leading up to menopause.
• If menopausal and < 40 years, discuss with specialist.

Assess the menopausal patient

Assess When to assess Note
Symptoms Every visit • Ask about menopausal symptoms: hot flushes, night sweats, vaginal dryness, mood changes, difficulty sleeping  87 and sexual problems  58.
• If night sweats, ask about other TB symptoms : if cough, weight loss or fever, exclude TB  92.
• Manage other symptoms as on symptom pages.
Vaginal bleeding Every visit If bleeding between periods, after sex or after being period-free for 1 year, refer within 2 weeks.
Depression Every visit In the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either  143.
Osteoporosis risk At diagnosis Refer for possible treatment if high osteoporosis risk: < 60 years with loss of > 3cm in height or fractures of hip/wrist/spine, previous non-traumatic fractures, oral steroid
treatment for > 3 months, onset of menopause < 45 years, BMI < 18.5, heavy alcohol user, heavy smoker.
Family planning At diagnosis • If < 50 years, give contraception for 2 years after last period.
• If ≥ 50 years, change to progestogen-only or non-hormonal contraceptive until 1 year after last period  154.
BP 3 monthly on HT1 If known hypertension  133. If not, check BP: if ≥140/90  132.
CVD risk At diagnosis Assess CVD risk  127.
Breast check At diagnosis, 6 monthly If lump/s found in breasts or axillae, refer same week to breast clinic. If available, arrange mammogram at HT1 initiation.
Cervical screen When needed If HIV negative: do 3 cervical screens, each 10 years apart from age 30  55; if HIV positive: do cervical screen at HIV diagnosis (regardless of age), then 3-yearly  55.
Thyroid At diagnosis If weight change, pulse ≥ 100, tremor, weakness/tiredness, dry skin, constipation or intolerance to cold or heat, check TSH. If abnormal, refer to doctor.

Advise the menopausal patient

• To cope with the flushes, advise patient to dress in layers and to decrease alcohol, avoid spicy foods, hot drinks and warm environments.  62
• If patient is having mood changes or not coping as well as in the past, refer to counsellor, support group or helpline  178.
• Educate that long term use of hormone therapy (HT) can increase risk of breast cancer, deep vein thrombosis (DVT) and cardiovascular disease. It can be used to treat menopausal symptoms for up to 5 years.

Treat the menopausal patient

• If menopausal symptoms interfere with daily function, treat with hormone therapy (HT) if no contraindications2. If dose range given, start with lowest dose and increase until symptoms improve.
- If patient has had uterus removed (hysterectomy): give only estradiol 1-2mg daily or conjugated estrogens 0.3mg-1.25mg daily.
- If patient still has a uterus (no hysterectomy), choose HT according to menstruation pattern:

If ≥ 1 year since last period, give: If still menstruating/recently stopped, give:

• Conjugated estrogens 0.3-0.625mg and • Estradiol/cyproterone 1 tablet daily (estradiol valerate 2mg for 11 days, followed by estradiol valerate/cyproterone acetate 2mg/1mg for 10
medroxyprogesterone 2.5-5mg daily or days, then placebo tablet for 7 days).
• Estradiol/norethisterone 1mg/0.5mg daily or • Estradiol 1-2mg daily for 21 days with medroxyprogesterone 5-10mg daily from day 12-21, followed by no therapy from day 22-28 or
• Estradiol/norethisterone 2mg/1mg daily. • Conjugated estrogens 0.3-0.625mg daily for 21 days with medroxyprogesterone 5-10mg daily from day 12-21, followed by no therapy from day 22-28.
• Treat vaginal dryness and pain with sex with lubricants (avoid petroleum jelly with condoms). If no better with HT or if HT contraindicated, refer.
• Review 6 monthly once on HT. Decrease/stop if symptoms are controlled. If ≥ 5 years of HT or patient ≥ 60 years, stop treatment. If still symptomatic, refer to specialist.
1
Hormone therapy. 2Avoid if ≥ 60 years, abnormal vaginal bleeding, cancer of uterus or breast, previous deep vein thrombosis or pulmonary embolism, recent heart attack, liver disease , porphyria (rare hereditary disorder).
169
 ROUTINE PALLIATIVE CARE
A patient can be given curative and palliative care at the same time. A doctor should confirm the patient needs palliative care:
• Patient is in bed or chair for 50% or more of the day or dependent on others for most care or has had 2 or more unplanned hospital admissions in past 6 months and/or
• Patient with advanced disease chooses palliative care only and refuses curative care and/or
• Patient with advanced disease not responding to treatment: heart failure, COPD, kidney or liver failure, cancer, HIV, TB, dementia or other progressive neurological disease.

Assess the patient needing palliative care

Assess Note
Symptoms • If pain: assess and advise  61. Give medication/s to treat pain  171. If new or sudden pain, temperature ≥ 38°C, tender swelling, redness or pus, also treat on symptom page. If no better or
uncertain of cause, discuss.
• If constipation, diarrhoea, nausea/vomiting, abdominal cramps, itchiness, acute anxiety or cough/difficulty breathing, manage  171.
• If patient has difficulty sleeping  87.
• Manage other symptoms as on symptom pages.
Side effects • Ask about side effects from pain medication (see next page).
• If on morphine, advise that nausea, confusion and sleepiness usually resolve after a few days. Check that patient is using regular laxative.
Mental health • Ask if patient has persistent feelings of hopelessness or worthlessness? If yes  143.
• If patient has suicidal thoughts or plans  83.
• If low mood, stress or anxiety  86.
Chronic care • Assess how much patient and family understand about the condition and ask what further information the patient and carer need.
• Assess ongoing need for chronic care in discussion with patient and health care team. Consider which medication could be discontinued.
• If known kidney failure with eGFR < 15, discuss.
Psychosocial • Ask how patient is coping and what support and/or spiritual care is needed.
• Ask how the carer/family are coping and what support they need now and in the future.
• Ask about distressing social issues: problems with family relationships, finances, home care. If needed, refer patient's dependents and family members to social worker.
Dying If known with terminal disease and deteriorating with ≥ 2 of: bed bound, decreased consciousness, only able to sip fluid, unable to take tablets, address patient's needs  172.
Mouth Check oral hygiene and look for dry mouth, ulcers and thrush  35. If gum or tooth problem  36. If difficulty swallowing, discuss/refer.
Pressure sores If patient is bedridden or in a wheel chair, check common areas for damaged skin (change of colour) and pressure sores (see picture). If patient has pressure ulcer/sore  75.

Advise the patient needing palliative care and his/her carer

• In a caring manner, explain the condition and prognosis. Explaining what is happening relieves fear and anxiety. Support the patient to give as much self care as able.
• Emphasise the importance of taking pain medication regularly (not as needed) and if using tramadol/morphine to use a laxative daily to prevent constipation.
• Refer patient and carer to available community health worker, social worker, physiotherapist, counsellor, spiritual counsellor, support group  178 Deal with bereavement issues  86.
• Prevent mouth disease: brush teeth and tongue regularly using toothpaste or dilute bicarbonate of soda. Rinse mouth with ½ teaspoon of salt in 1 cup of water after eating and at night.
• If bedridden or in wheelchair, prevent pressure ulcers: wash and dry skin daily. Keep linen dry. Move (lift, avoid dragging) patient every 1-2 hours if unable to shift own weight. Look daily for skin colour
changes (see picture).
• If bedridden, prevent contractures: at least twice a day, gently bend and straighten joints as far as they go. Avoid causing pain. Massage muscles.
• The patient's appetite will get less as s/he gets sicker. Offer small meals frequently and allow the patient to choose what s/he wants to eat from what is available and encourage fluid intake.
• Discuss the plan for caring for the patient. Advise whom to contact when pain or other symptoms get severe. Discuss advance-care plans and preferences. Document decisions.
• Educate the carer to recognise signs of deterioration and impending death: s/he may be less responsive, become cold, sleep a lot, have irregular breathing, and will lose interest in eating.

170
 Treat the patient needing palliative care
• If pain, aim to have patient pain free at rest, able to sleep and manage daily tasks. Start pain medication based on type and severity of pain:
Non-cancer pain Cancer pain
• If mild (1-3) pain, start at step 1. • If mild (1-3) pain, start at step 1.
• If moderate (4-7) or severe (8-10) pain start at step 2. • If moderate (4-7) pain start at step 2. If severe (8-10) pain start at step 3.
• If nerve pain or central pain, also give amitriptyline at any step. • Also consider adding amitriptyline at any step.

If unsure, start at lower step and increase pain medication if needed.

• If pain controlled, continue same dose. Once controlled for 1 month, consider reducing dose/stepping down. If pain worsens, then increase dose/step up again.
• If pain persists > 2 days or worsens, increase dose to maximum. If still no better after 2 days, move to next step.
• If pain not responding well, assess and provide additional social, spiritual and emotional support  61.
• If non-cancer pain uncontrolled on step 2, refer. If cancer pain uncontrolled on step 3, discuss.
Step Pain medication Start dose Maximum dose Note
Step 1 Paracetamol 1g 4-6 hourly 4g daily If starting, give paracetamol 1g in clinic and reassess pain after 4 hours. If no better, add ibuprofen.
Start one or both of: Ibuprofen 400mg 8 hourly 1.2g daily • If starting step 1 with ibuprofen, reassess pain after 4 hours. If no better, add paracetamol.
• Give with/after food. Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease.
• If also taking aspirin, advise to take at least 30 minutes apart.
Step 2 Tramadol 50mg 4-6 hourly 400mg daily • If constipation or nausea/vomiting, manage as below.
Add to step 1: • Use with caution if patient on amitriptyline as may cause over-sedation.
Step 3 (only if Morphine 5-10mg 4 hourly • No maximum- • Start with morphine hydrochloride. Once dose stable, consider changing to long-acting morphine sulphate.
cancer pain) hydrochloride If ≥ 65 years: start titrate against pain. • Also give lactulose 10-20mL daily to prevent constipation. Avoid if diarrhoea.
Stop tramadol, (short-acting, 2.5-5mg • If sedated/ • If constipation, nausea/vomiting or itchiness, manage as below.
continue solution) confused or • If on morphine hydrochloride and breakthrough pain (pain that occurs before next scheduled dose):
paracetamol/ or respiratory rate<12, - Give one extra dose morphine, then continue regular dose at scheduled times for the rest of that day.
ibuprofen and add: Morphine sulphate 10-20mg 8-12 hourly skip 1 dose, then - Increase morphine doses the next day. Calculate new dose: add up total amount of extra morphine given in last 24 hours.
(long-acting, tablet) halve usual doses. Divide this amount by 6 and add this to each regular 4 hourly dose1.

Add adjuvant Amitriptyline • 25mg at night 75mg at night • Use at night. Advise it may cause dizziness, drowsiness and to avoid driving and using heavy machinery.
therapy to any step • If ≥ 65 years: 10mg • Avoid if on bedaquiline, refer/discuss if pain uncontrolled on above medication.

Treat side effects from pain medication or other symptoms

Constipation Diarrhoea Nausea/vomiting Abdominal Generalised Acute Cough or difficulty breathing
cramps itchiness anxiety
• Check for impaction (solid bulk of stool Give loperamide • Give metoclopramide • If thick sputum, give steam
in rectum). If impacted, gently remove 4mg initially, then 10mg 8 hourly as Give hyoscine Give Give inhalations. If more than 30mL/day,
stool from rectum using lubrication. If 2mg after each needed. butylbromide chlorphenamine diazepam try deep breathing with postural
unsuccessful, refer. loose stool up to • Allow patient to 10mg 6 hourly as 4mg 6-8 hourly 2.5-5mg drainage. Refer to physio if available.
• Give sennosides A and B 13.5mg at night 6 hourly, up to choose what to eat. needed for up to as needed. 12 hourly • If excess thin sputum or persistent
and/or lactulose 10-20mL orally daily. If 12mg daily. Avoid if Encourage frequent 3 days. as needed dry cough, discuss with palliative
needed, increase sennosides A and B to overflow diarrhoea small meals/sips of for up to care specialist.
27mg at night and/or increase lactulose or side effect of fluids like water, tea or 10 days. • If low oxygen saturation, refer for
to 12 hourly. If no response, refer. antibiotics. ginger drinks. home-based oxygen.

Review 2 days after starting or changing medication. If pain/symptoms persist despite treatment or side effects intolerable, discuss/refer.
1
Example: patient on morphine 10mg 4 hourly has 3 episodes of breakthrough pain: 10mg x 3 = 30mg (total extra morphine); 30mg ÷ 6 = 5mg. Add 5mg to each 10mg regular dose. Increase morphine to 15mg 4 hourly.
171
PALLIATIVE CARE
 ADDRESS THE DYING PATIENT'S NEEDS
The patient with a life-limiting illness is dying if s/he is deteriorating and ≥ 2 of: bed bound, decreased consciousness, only able to sip fluid or unable to take tablets. A doctor should confirm this.

Assess the dying patient's needs every 4 hours

Assess Note
Symptoms Assess for noisy/difficulty breathing, agitation, pain, constipation, diarrhoea, nausea/vomiting and abdominal cramps. If present, manage below.
Current care • Assess current medication and discontinue non-essential medications.
• Assess patient's ongoing need for tests in discussion with patient/carer and health care team.
• Consider switching medication route if unable to swallow orally to subcutaneous.
Intake Check with carer/family what patient's fluids/food intake needs are and whether fluids/food is needed or necessary.
Psychological well-being Ask how patient and carer are coping and what support and/or spiritual care is needed. If carer unable to cope at home, refer patient to hospital/hospice.
Mouth Check oral hygiene. Ensure patient's mouth is moist and clean. Consider using glycerine to keep lips/mouth moist.
Personal hygiene Check skin care, clean eyes and change of clothing according to patient's needs.

Advise the dying patient and carer

• Ensure patient and/or carer is aware that patient is dying and that carer/family have been referred to social worker and community health worker.
• Educate carer/family that food/fluids are for comfort only, will not prolong life and a reduced need for food/fluids is part of the normal dying process.
• Advise that investigations and curative treatments like antibiotics may no longer be indicated and will be kept to a minimum according to patient’s care plan.
• Discuss with patient and carer: preferred place of death (home, hospice or hospital), how family are to be informed of impending death, what to do in the event of death.
• Discuss patient's wishes, feelings, faith, beliefs and values. Discuss patient's needs now, at death and after death. Listen and respond to patient/carer’s worries/fears.
• Ensure patient and/or carer/family receive full explanation and express understanding of current plan of care. Identify and document any concerns about current plan of care.

Treat the dying patient

• If noisy breathing, excessive secretions likely: try changing position.
• If difficulty breathing, use fan or open window/s. Give morphine hydrochloride solution 2.5-5mg. Increase slowly as needed.
• If urinary retention, insert urethral catheter.
• If pain, constipation, diarrhoea, nausea/vomiting or abdominal cramps, manage  171.
• If agitated:
- First assess for and manage pain, urinary retention, constipation and dehydration.
- If none of above, consider changing position and give diazepam 5mg (or 2.5mg if liver failure). If no better, repeat dose.

Review the dying patient

• Doctor to review every 3 days or sooner if carer/family concerned about current plan of care or if patient's conscious level, functional ability, oral intake or mobility improves.
• If carer/family unable to cope at home or difficulty breathing relieved by oxygen, refer to hospital/hospice if available.
• If unsure, discuss with palliative care specialist.

Diagnose death if:

No carotid pulse in neck for 2 minutes and no heart sounds for 2 minutes and no breath sounds or chest movement for 2 minutes and pupils are fixed, dilated and do not respond to light.

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 SUPPORT THE PATIENT TAKING LONG-TERM MEDICATION
Assess the patient taking long-term medication
Assess Note
Adherence • Ask patient open ended questions like “What makes it difficult for you to take your treatment? Do you sometimes find it difficult to remember to take your medication? How many doses have
you missed this week?” Encourage patient to open up with statements like “We all miss doses now and then”.
• Ask about factors that may influence adherence:
- Is the cost of clinic visits a problem (like transport, loss if income for the day, paying another person to take on responsibilities at home).
- Is the time it takes to visit clinic a problem (like time away from work, home, responsibilities).
- Are medications causing any side effects? If patient stopped taking ART because of a side effect, refer to doctor to review to switch out responsible medications  116.
- Is there difficultly taking the medications (like do they taste terrible, are they difficult to swallow, is food available so meds aren’t taken on empty stomach).
- Is disclosure an issue? Is patient trying to keep treatment a secret at home?
- Is patient feeling well enough to take medications (like is there a problem with nausea, diarrhoea, constipation or heart burn). Manage on symptom pages.
- Is there a problem with understanding: check patient knows his/her diagnosis and understands his/her condition and what it means to be well controlled.
Recent illness Ask about and document recent infection/s or illness. Manage other symptoms as on symptoms pages. Test for TB if cough, weight loss, night sweats or fever  92.
Correct doses • Ask patient to show you his/her pills and tell you the dose and how often s/he should take it. Check patient knows how the medication works and why it is important to take it as advised.
• Check that dose is correct for weight.
Drug interactions • Review other medications that patient may be on and check for known interactions: especially ART, TB and epilepsy treatment, contraceptives and other common medications like: calcium, iron,
zinc, antacids, metformin. Consult the South African Medicines Formulary (SAMF), use web-based drug interaction checker2 (see QR code) or MIC helpline (021) 406 6829 if unsure.
• Ask if patient is taking herbal/traditional medications. Discuss with MIC helpline (021) 406 6829 if unsure.
Resistance to treatment If on TB or HIV treatment, consider drug resistance if other causes have been excluded and patient is adherent. Discuss with HIV hotline  178.
Daily routine Ask about patient's daily routine and if it causes difficulty with adherence. Identify opportunities that can be used as reminders to take medication.
Support Ask if patient receives support from family, friends or others in the community.
Mental health In the past month, has patient: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either  143. If stress or anxiety  86.
Alcohol/drug use In the past year, has patient: 1) drunk ≥ 4 drinks1/session, 2) used illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any  142.
Check for HIV
medication
interactions
Advise the patient taking long-term medication
• Be supportive and non-judgemental. If newly diagnosed or poor understanding, spend extra time educating and counseling the patient. Explain the condition and the benefits of medication.
• If difficulty with adherence, avoid blaming patient. Rather explore his/her reasons for poor adherence and come up with ideas together to improve.
• Discuss ways to help patient to remember to take medication, like diaries, alarms, pill boxes. Use reminders that form part of daily routine.
• Explain that good adherence is taking medication at the correct dose and time every day, and will improve control and reduce risk of long-term complications.
• Encourage patient to involve partner or family member in his/her treatment.

Treat the patient taking long-term medication

• Refer for extra support: if challenges taking/remembering to take treatment, refer to counsellor for enhanced adherence counselling (EAC). Consider linking with a support group, treatment buddy, or
community health worker.
• Try to keep medication regimen simple with as few tablets and doses as possible. Use fixed dose combination tablets if available. Avoid changing medications or doses without good reason.
• Involve patient in his/her treatment plan and adapt treatment schedule to daily routine as much as possible. Schedule appointments on days and times that suit the patient.
• If difficulty with adherence, see the patient more frequently (e.g. weekly instead of monthly).
1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer. 2www.hiv-druginteractions.org/checker
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 PROTECT YOURSELF FROM OCCUPATIONAL INFECTION
Give urgent attention to the health worker with a sharps injury or splash to eye, mouth, nose or broken skin with exposure to any of:
• Blood • Vaginal secretions
• Blood-stained fluid/tissue • Semen
• Wound secretions • Breast milk
• Pleural/pericardial/peritoneal/amniotic/synovial/cerebrospinal fluid
Management:
• If broken skin, clean area immediately with soap and water.
• If splash to eye, mouth or nose, immediately rinse mouth/nose or irrigate eye thoroughly with water.
• Assess need for HIV and hepatitis B post-exposure prophylaxis  106.

Adopt measures to diminish your risk of occupational infection

Protect yourself Protect your facility
Adopt standard precautions with every patient: Clean the facility:
• Wash hands with soap/water or use alcohol-based cleaner after contact with patients or body fluid. • Clean frequently touched surfaces (door handles, telephones, keyboards) daily with soap and water.
• Dispose of sharps correctly in sharps bins. • Disinfect surfaces contaminated with blood/secretions with 70% alcohol or chlorine-based
Wear protective gear: disinfectant.
• Wear gloves when handling blood, body fluids, secretions or non-intact skin. Ensure adequate ventilation:
• Wear surgical mask if in contact with patient with respiratory illness (N95 respirator if performing • Leave windows and doors open when possible and use fans to increase air exchange.
aerosol-generating procedure or patient has suspected or confirmed infectious TB.). Organise waiting areas:
• Wear surgical mask with a visor or glasses if at risk of splashes. • Prevent overcrowding in waiting areas.
Get vaccinated: • Fast track patients with suspected respiratory infections, TB or acute gastroenteritis.
• Get vaccinated against hepatitis B (if not yet done) and yearly against influenza. Manage sharps safely:
• Ensure COVID-19 and pertussis vaccinations are up to date. • Ensure sharps bins are easily accessible and regularly replaced.
Know your HIV status: Manage infection control in the facility:
• Test for HIV  110. ART and TPT can decrease the risk of TB. • Appoint an infection control officer for the facility to coordinate and monitor infection control policies.
• If HIV positive, you are entitled to work in an area of the facility where exposure to TB is limited.

Manage possible occupational exposure promptly

Reduce TB risk Reduce risk of respiratory infections (including pertussis, influenza and COVID-19)
Identify patients with possible TB promptly: • Before managing a patient with suspected or confirmed respiratory infection, wear
• The patient with cough ≥ 2 weeks is has possible TB. appropriate PPE.
• Separate patients with possible TB from others in the facility. • Wash hands with soap and water. Wear a surgical mask over mouth and nose during
• Educate about cough hygiene and give face mask/tissues to cover mouth/nose to protect others. procedures.
Diagnose TB rapidly: • Encourage patient to wear face mask, cover mouth/nose with a tissue when coughing/
• Fast track TB workup and start treatment as soon as diagnosed. sneezing, to dispose of used tissues correctly and to wash hands regularly with soap/water.
• Advise patient to avoid close contact with others.
Protect yourself from TB:
• Wear an N95 respirator (not a surgical mask) if in contact with a patient with infectous TB.
Screen and test yourself for TB every 6 - 12 months:
• Screen and test for TB according to your facility policy. If TB test negative and depending on your
risk profile, discuss TB preventive treatment (TPT) with your occupational health practitioner.
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 PROTECT YOURSELF FROM OCCUPATIONAL STRESS
Experiencing pressure and demands at work is normal. However if these demands exceed knowledge and skills and challenge your ability to cope, occupational stress can occur.

Arrange urgent assessment for to the health worker with occupational stress and any of:
• Alcohol or drug intoxication at work
• Aggressive or violent behaviour at work
• Inapproproate behaviour at work
• Suicidal thoughts or behaviour

Adopt measures to reduce your risk of occupational stress

Protect yourself Protect your team
Look after your health: Decide on an approved way of behaving at work:
• Get enough sleep. • Communicate effectively with your patients and colleagues  176.
• Exercise, eat sensibly, minimise alcohol and avoid smoking. • Treat colleagues and patients with respect.
• Address your general health and get screened for chronic conditions. • Support each other. Consider setting up a staff support group.
Look after your chronic condition if you have one: • Instead of complaining, rather focus on finding solutions to problems.
• Adhere to your treatment and your appointments. Cope with stressful events
• Avoid diagnosing and treating yourself. • Develop procedures to deal with events like complaints, harassment/bullying,
• If you can, confide in a trusted colleague/manager. accidents/mistakes, violence or death of patient or staff member.
Manage stress: Look at how to make the job less stressful:
• Delegate tasks as appropriate; develop coping strategies. • Examine the team’s workload to see if it can be better streamlined.
• Talk to someone (friend, psychologist, mentor), or access helpline  178. • Identify what needs to be changed to make the job easier and frustrations
• Take time to do a relaxing breathing exercise each day. fewer: equipment, drug supply, training, space, décor in work environment
• Find a fun or creative activity to do. • Discuss each team member’s role. Ensure each one has say in how s/he does
• Spend time with supportive family or friends. his/her work.
Have healthy work habits: • Support each other to develop skills to better perform your role.
• Manage your time sensibly. Celebrate:
• Take scheduled breaks. • Acknowledge the achievements of individuals and the team.
• Remind yourself of your purpose as a clinician. • Organise or participate in staff social events.
• Be sure you are clear about your role and responsibilities.

Identify occupational stress in yourself and your colleagues

Possible alcohol or drug problem Change in mood Recent distressing event Poor attendance at work Marked decline in
• In the past year, have you/colleague: • Indifferent, tense, irritable or angry • Diagnosis of chronic condition • Frequent absenteeism work performance
1) drunk ≥ 4 drinks1/session, 2) used illegal drugs or • In the past month, have you/colleague: • Bereavement • Frequent lateness • Reduced
3) misused prescription or over-the-counter medications? If 1) felt down, depressed, hopeless or • Needlestick injury • Often takes sick leave concentration
yes to any substance misuse likely. 2) felt little interest or pleasure in doing • Traumatic event • Fatigue
• Smells of alcohol things? If yes to either depression likely.

The health worker with any of the above may have substance misuse, stress, depression/anxiety or burnout and would benefit from referral for assessment and follow-up.

1
One drink is 1 tot of spirits, or 1 small glass (125mL) of wine or 1 can/bottle (330mL) of beer.
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 COMMUNICATING EFFECTIVELY
Communicating effectively with your patient during a consultation need not take much time or specialised skills.
Try to use straightforward language and take into account your patient’s culture and belief system.

Integrate these four communication principles into every consultation:

Listen
Listening effectively helps to build an open and trusting relationship with the patient.

Do The patient might feel: Don’t The patient might feel:

• Give all your attention • ‘I can trust this person’ • Talk too much • ‘I am not being listened to’
• Recognise non-verbal behaviour • ‘I feel respected and valued’ • Rush the consultation • ‘I feel disempowered’
• Be honest, open and warm • ‘I feel hopeful’ • Give personal advice • ‘I am not valued’
• Avoid distractions e.g. phones • ‘I feel heard’ • Interrupt • ‘I cannot trust this person’

Discuss
Discussing a problem and its solution can help the overwhelmed patient to develop a manageable plan.

Do The patient might feel: Don't The patient might feel:

• Use open ended questions • ‘I choose what I want to deal with’ • Force your ideas onto the patient • ‘I am not respected’
• Offer information • ‘I can help myself’ • Be a ’fix-it’ specialist • ‘I am unable to make my own decisions’
• Encourage patient to find solutions • ‘I feel supported in my choice’ • Let the patient take on too many problems • ‘I am expected to change too fast’
• Respect the patient’s right to choose • ‘I can cope with my problems’ at once

Empathise
Empathy is the ability to imagine and share the patient’s situation and feelings.

Do The patient might feel: Don't The patient might feel:

• Listen for, and identify his/her feelings • ‘I can get through this’ • Judge, criticise or blame the patient • ‘I am being judged’
e.g. ‘you sound very upset’ • ‘I can deal with my situation’ • Disagree or argue • ‘I am too much to deal with’
• Allow the patient to express emotion • ‘My health worker understands me’ • Be uncomfortable with high levels of • ‘I can’t cope’
• Be supportive • ‘I feel supported’ emotions and burden of the problems • ‘My health worker is unfeeling’

Summarise
Summarising what has been discussed helps to check the patient’s understanding and to agree on a plan for a solution.

Do The patient might feel: Don't The patient might feel:

• Get the patient to summarise • ‘I can make changes in my life’ • Direct the decisions • ‘My health worker disapproves of my
• Agree on a plan • ‘I have something to work on’ • Be abrupt decisions’
• Offer to write a list of his/her options • ‘I feel supported’ • Force a decision • ‘I feel resentful’
• Offer a follow-up appointment • ‘I can come back when I need to’ • ‘I feel misunderstood’

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 SUPPORT THE PATIENT TO MAKE A CHANGE
Use the five-A’s approach to help the patient make a change in behaviour to help avoid or lessen a health risk:

Ask the patient about the risks

• Identify with the patient the risk/s to his/her health.
• Ask what the patient already knows about these risks and how they will affect the patient’s health.

Alert the patient to the facts

• Request permission to share more information on this risk.
• Use a neutral, non-judgemental manner. Avoid prescribing what the patient must do.
• Build on what the patient already knows or wants to know.
• Discuss results of tests or examination that indicate a risk.
• Link the risk to the patient’s health problem.

Assess the patient’s readiness to change

• Assess the patient’s response about the information on his/her risk. ‘What do you think/feel about what we have discussed?’
• Use the scale to help patient assess the importance of this issue for him/her. Also rate how confident s/he feels about making a change.

Not at all important/not at all confident 1 2 3 4 5 6 7 8 9 10 Very important/very confident

• Ask the patient why s/he rated importance/confidence at this number. Ask what might help improve this rating.
• Summarise the patient’s view. Ask how ready s/he feels to make a change at this time.

Assist the patient with change

If the patient is ready to change: If the patient is not ready to change:
• Assist the patient to set a realistic change goal. • Respect the patient's decision.
• Explore the factors that may help the patient to change or may make it difficult. • Invite patient to identify the pros and cons of change.
• Help the patient plan how s/he will fit the change into the routine of the day. • Acknowledge patient’s concerns about change.
• Encourage patient to use strategies s/he used successfully in the past. • Explore ways of overcoming the difficulties preventing change.
• Offer more information or support if the patient would like to consider the issue further.

Arrange support and follow up

• Offer referral to counselor and available support services (social worker, health promoter, community care worker, helpline  178).
• Identify a friend, partner, or relative to support the patient and if possible attend clinic visits.
• Document decision and goals set by the patient.
• Schedule follow-up contact (clinic visit, email, phone) to review readiness and goals.

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 HELPLINE NUMBERS
Helpline Services provided Contact number/s
General counselling
Lifeline National Counselling Line Counselling for any life crisis and referral to relevant services 0861 322 322 (24 hour helpline)
Childline SA (ages 0 - 16 years) For children and young adolescents who are in crises, abuse or at risk of abuse and violence 0800 055 555 (24 hour helpline)
National Council Against Smoking Support for a patient to quit smoking. 011 720 3145 (08:00-17:00 Monday to Friday)
Abuse
Stop Gender Violence Support for children, women and men experiencing domestic violence 0800 150 150 (24 hour helpline)
Rape Crisis Counselling and court support for rape survivors > 13 years 021 447 9762 (24 hour helpline)
Chronic condition
Arthritis Foundation Education and monthly support groups for patient with arthritis and/or fibromyalgia 0861 30 30 30 (24 hour helpline)
Epilepsy South Africa Education, counselling and support groups for patient with epilepsy and his/her family 0860 37 45 37 (08:00-16:30 Monday to Thursday; 08:00-14:00 Friday)
Diabetes South Africa Education, dietary plans, support groups and workshops for patient with diabetes 086 111 3913 (08:30-16:00 Monday to Thursday; 08:30-14:00 Friday)
Heart & Stroke Foundation Education and support groups for patient with stroke, any heart condition or CVD risk. 021 422 1586 (08:00-16:00 Monday to Friday)
National AIDS helpline Counselling and information for patient who has HIV or thinking of testing 0800 012 322 (24 hour helpline)
People living with cancer Cancer related queries. Link to further resources for patient/family with cancer 0800 033 337 (9am-5pm, toll free)
Mental health
Suicide crisis line For any suicide related support 0800 567 567 (8am-8pm) or sms 31393 and a counsellor will call back.
Mental health helpline Counselling and support for patient with mental illness or substance misuse 0800 12 13 14 (24 hour helpline)
Alzheimer’s South Africa Information, training and support groups for carers 0860 102 681 (08:00-16:00 Monday to Thursday; 08:00-15:00 Friday)
Alcoholics Anonymous Counselling, education and support groups for patient with alcohol misuse 0861 435 722 (24 hour helpline)
Health worker
Poisons Information Helpline Advice on the management of exposure to or ingestion of poisonous substances 0861 555 777 (24 hour national helpline)
National HIV & TB Health Care Worker Hotline For HIV and TB related clinical queries 0800 212 506 (08:30-16:30 Monday to Friday)
Right to Care Adult HIV Helpline For adult HIV related clinical queries 082 957 6698 (adult helpline) 0823526642 (paediatric helpline)
Medicines Information Centre (MIC) Advice on medicine related query like drug interactions, side effects, dosage, treatment failure 021 406 6829 (08:30-16:30 Monday to Friday)
Nutrition Information Centre (NICUS) For all nutrition related queries for health workers and the public. 021 933 1408 (08:30-16:30 Monday to Friday)
Rabies hotline For any rabies related queries 082 883 9920 (24 hour)
Administration
Legal Aid Information and guidance on any legal matter. They will return messages left after hours. 0800 110 110 (07:00-19:00 Monday to Friday)
Women's Legal Centre Provides free legal advice to women who do not have access to legal services. 021 424 5660 | [email protected] | www.wlce.co.za
MedicAlert Assistance with application for Medic Alert disc or bracelet 086 111 2979 (09:00-16:00 Monday to Friday)

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