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ethiopian-health-clinical-guidelines.pdf

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The Ethiopian Primary Health Care Clinical Guidelines provide a standardized, algorithmic approach to the diagnosis and management of health conditions for children aged 5-14 and adults in primary health care settings. Developed by the Ministry of Health, the guidelines aim to enhance the quality of care and align with national health policies, focusing on prevalent diseases like cardiovascular conditions, diabetes, and mental health. Encouragement is given to health workers to utilize these guidelines effectively to improve health outcomes in Ethiopia.

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Addis Ababa 2010 (EC) | 2017 (GC) Care of Children 5-14 years and Adults 15 years or older in Health Centers Ethiopian primary health care clinical guidelines Federal Democratic Republic of Ethiopia Ministry of Health
Foreword The Ethiopian health care system has three tiers: primary health care, general hospital and specialized care centers. The primary health care level includes health posts, health centers and district hospitals. These health facilities are the first patient contact levels. Early case detection and appropriate treatment at the primary care level has pivotal role in better treatment outcome, disease control, and provision of quality of care. This is in line with global initiatives of achieving universal health coverage (UHC). And most importantly it can be a crucial input for the realization of Woreda transformation agenda of the HSTP (Health Sector Transformation Plan) by strengthening high performing PHCUs (Primary Health Care Units). Standardization of patient care at all health tier levels is important. To achieve this important goal, in the past years several guidelines have been developed. Some of these address specific diseases while others are general. This First Edition of the Ethiopian Primary Health Care Clinical Guidelines is a guide for the primary care of older children and adults. The adult content is a comprehensive guide to the adult presenting to primary health care facilities. The paediatric content addresses priority conditions in children aged 5-14 years presenting to primary care and is intended to complement the Integrated Management of Childhood Illness which addresses the child younger than 5 years old. The Ethiopian Primary Health Care Clinical Guidelines is an integrated symptom-based algorithmic approach to address the common presenting symptoms and priority chronic conditions in the country. The scope of what is covered in chronic conditions for adults, and long-term health conditions for older children includes: cardiovascular diseases; diabetes; chronic respiratory diseases; mental health, musculoskeletal disorders; and women’s health. The Guidelines provides basic management principles to deal with these diseases at a health center level in an integrated user-friendly way to support health workers to provide care that is evidence-informed, compliant with local guidelines, comprehensive, compassionate and respectful. The Ethiopian Primary Health Care Clinical Guidelines were developed by localizing the PACK Global Adult (2017) and PACK Western Cape Child (2017) guides developed by the Knowledge Translation Unit of the University of Cape Town Lung Institute, South Africa. Localising the Ethiopian Primary Health Care Clinical Guidelines to reflect Ethiopian policy and burden of disease required the establishment of a core technical team working full time and three intensive workshops with many clinicians. We thank the many clinicians who contributed to the development of the Ethiopian Primary Health Care Clinical Guidelines for their efforts (see Acknowledgements). The localisation process aligned the Ethiopian Primary Health Care Clinical Guidelines to Federal Ministry of Health policies, guidelines and clinical protocols. These include: Standard Treatment Guidelines for Health Center (2014), List of Medicine for Health Centers (2012), Guidelines on Clinical and Programmatic Management of Major Non Communicable Diseases (2016) , National guidelines for comprehensive HIV prevention, care and treatment (2014), Guidelines for clinical and programmatic management of TB/HIV and leprosy in Ethiopia (2016), Guidelines for the management of acute malnutrition (2016), National guidelines for the management of sexually transmitted infections using syndromic approach (2015), National malaria guidelines, National guidelines for family planning, Ethiopian paediatric hospital care (2016) and others. FMOH Ethiopia has a strong belief that the full implementation of this clinical guide in the health centers will standardize the care given at this level, will improve the quality of service and in effect will improve the health outcomes of the country. In this regards, I strongly encourage health workers in health centers to utilize this guide to the best of their capacity in the provision of health care, especially outpatient health service. And also in the same line, I encourage the health managers in the health system (especially in the Woreda Health Offices) to ensure the implementation and institutionalization of this guide and its practice in the health centers. Kebede Worku (MD, MPH) State Minister Ministry of Health
Acknowledgements The development of this guideline was initiated by his excellency Dr Kesetebirhan Admassu, former Minister of Health, after he observed the PHC guidelines from South Africa and Botswana. Earlier draft versions of this guide were informed by these guidelines. Here by, FMOH Ethiopia acknowledges the Ministries of Health of Botswana and South Africa for sharing their guidelines and experiences. FMOH Ethiopia would like to acknowledge the following for their contributions: • Clinical Services Directorate and Health Center Reform case team – for leading the development of the guideline and for follow up to their fruition. • Disease prevention and Health Promotion Directorate, Maternal and Child Health Directorates, Health Extension and Basic Health Services Directorate and other directorates of FMOH – for contributing and improving the development of this guideline in many ways. • AA Health Bureau, Arada HC, Lideta HC and Addis Ketema HC – for conducting a pretest of few pages of the guideline and for giving constructive feedbacks. • Addis Ababa University – for availing different clinicians to contribute in the guideline. • Core Technical Team (CTT) – for working diligently and persistently till the finalization of the guideline. • KTU (Knowledge Translation Unit) of the University of Cape Town Lung Institute and BMJ (British Medical Journal) - for realizing this guideline with their generous all rounded support, which included availing all necessary resources to the Core Technical Team, allowing access to the generic PACK Adult and Child guidelines, to the online evidence database, and by orienting and mentoring the national core technical team throughout the adaptation process. • The United Kingdom’s National Institute of Health Research (NIHR) - for sponsoring the contribution of KTU and BMJ. • JSI- SEUHP (USAID Strengthening Ethiopia's Urban Health Program) - for supporting the initiative by employing senior technical assistants • USAID Transform: Primary Health Care project and ICAP - for sponsoring adaptation workshops. • Health managers, clinicians and other experts (see list below) - for working on the details and content of the guide. Managerial Leads: Daniel G/Michael Desalegn Tegabu Yibeltal Mekonnen Core Technical Team: Desalegn Tegabu (Project lead) Ermias Diro (Localization coordinator) H/mariam Segni (Content expert) Hassan Mohammed (Project lead) Solomon Emyu (Localization Coordinator) Solomon Shiferaw (M&E expert) Telahun Teka (Content expert) Wubaye Walelgne (Content expert) Yibeltal Mekonnen (Project lead) Yoseph Mamo (Content expert) KTU Team: Lauren Anderson (Training lead) Ajibola Awotiwon (Adult content editor) Ruth Cornick (Editorial lead) Tracy Eastman (Project coordinator) Lara Fairall (KTU head) Sandy Picken (Child content editor) Christy-Joy Ras (Training mentor) Pearl Spiller (Design) Izak Volgraaf (Illustrations) Camilla Wattrus (Adult content editor) Contributors: Ambachew Teferra Anteneh Kassa Aschalew Worku Ashna Bowry Ayalew Marye Charlotte Hanlon Damenu Zeleke Dereje Assefa Elnathan Kebebew Khalid Abdella Mariye Asfaw Melaku Belay Meron Yakob Meseret Zerihun Mohammed Shafi Molla Gedefaw Nicola Ayers Noor Ramji Samuel Girma Solomon Worku Tigist Bacha Yared Mamushet FMOH Ethiopia also acknowledge the sources of the photographs: the Centers for Disease Control and Prevention (CDC) Public Health Image Library, BMJ Best Practice, Stellenbosch University, the University of Cape Town, Project Manhattan/Wikimedia commons and Saint Paul Hospital Millennium Medical College. Yibeltal Mekonnen (MD) Clinical Service Directorate Acting Director
How to use this Guide Ethiopia’s PHC clinical guide is an algorithmic guideline, prepared to be used as a quick and action oriented reference material for care givers in a health center; and primarily it targets health officers and nurses as care givers. It is divided into two main parts: first part for “adults”(15 years or older) and second part for children (5 to 14 years). Each part is divided into two sections: symptoms and chronic conditions (Routine Care). For management of the child aged younger than 5 years, please see the Integrated Management of New-borns and Childhood Illness (IMNCI) guidelines. To use this guide, • First consider the age of the patient and identify which part to use based on patient’s age. • In a patient presenting with one or more symptoms (Eg. Fever, cough, chest pain…), - - Start by identifying the patient’s main symptom. - - Use the Symptoms contents page to find the relevant symptom page in the guide. - - Decide if the patient needs urgent attention (in the red box) and if not, follow the algorithm to either a management plan or to consider a chronic condition in the chronic condition section of the guide. • In the patient known with a chronic condition (Eg. known TB patient), - - Use the chronic Conditions contents page to find that condition in the guide. - - Go to the colour-coded Routine Care pages for that condition to manage the patient’s chronic condition using the ‘Assess, Advise and Treat’framework. • Arrows refer you to another page in PHCG: The return arrow () guides you to a new page but suggests that you return and continue on the original page. The direct arrow () guides you to continue on another page. • The assessment tables on the Routine Care pages are arranged in 3 tones to reflect those aspects of the history, examination and investigations to consider. • Refer to the glossary for abbreviations and units used in PHCG. For further information about the PHCG, contact the Clinical Service Directorate of FMOH, via e-mail at phcgethiopia@gmail.com or via telephone +251 115 514901.
Glossary A ALP alkaline phosphatase ALT alanine aminotransferase ART antiretroviral therapy AST aspartate aminotransferase B BID twice a day BMI body mass index BP blood pressure measured in millimeters of mercury [mmHg] C CD4 count of the lymphocytes with a CD4 surface marker COPD chronic obstructive pulmonary disease CPR cardiopulmonary resuscitation CRP c-reactive protein Cu-IUD copper intrauterine device CVD cardiovascular disease D DBP diastolic blood pressure DKA diabetic ketoacidosis DMPA depot medroxyprogesterone acetate DNS dextrose in normal saline DR-TB drug-resistant tuberculosis DS-TB drug-sensitive tuberculosis DST drug susceptibility testing DVT deep vein thrombosis DW dextrose water E ECG electrocardiogram EDD estimated date of delivery eGFR estimated glomerular filtration rate ELISA enzyme-linked immunosorbent assay eMTCT elimination of mother-to-child-transmission EPTB extra pulmonary tuberculosis ESR erythrocyte sedimentation rate G GCS glasgow coma scale GGT gamma-glutamyl transferase H H202 hydrogen peroxide Hb haemoglobin HbA1c glycated haemoglobin HBsAg hepatitis B surface antigen HIV human immunodeficiency virus HPV human papillomavirus I IM intramuscular IMCI integrated management of childhood illness INR international normalized ratio IPT isoniazid preventive therapy IU international units IUD intrauterine device IV intravenous M MTB Mycobacterium tuberculosis MTB/RIF Mycobacterium tuberculosis DNA and resistance to rifampicin MU million units MUAC mid-upper arm circumference N NS normal saline NSAIDs non-steroidal anti-inflammatory drugs P PJP pneumocystis jiroveci pneumonia PCR polymerase chain reaction PEP post-exposure prophylaxis PO orally PPE papular pruritic eruption PR per rectum PTB pulmonary tuberculosis Pulse rate measured in beats per minute PVD peripheral vascular disease Q QID four times a day R RF rheumatoid factor RPR rapid plasmin reagin Respiratory rate measured in breaths per minute S SC subcutaneous SBP systolic blood pressure STI sexually transmitted infection T TAT tetanus antitoxin TB tuberculosis TBSA total body surface area TIA transient ischaemic attack TID three times a day TSH thyroid stimulating hormone V VIA visual inspection with acetic acid
Adult contents: symptoms A Abused patient 66 Abdominal pain 32 Abnormal vaginal bleeding 42 Abnormal thoughts/behaviour 64 Aggressive patient 64 Anal symptoms 35 Arm symptoms 48 B Back pain 47 Bites 52 Blackout 20 Body pain 45 Breast symptoms 31 Breathing difficulty 29 Burn/s 51 C Cardiac arrest 12 Cervical screening 40 Chest pain 28 Collapse 20 Coma 13 Condom broken 68 Confused patient 64 Constipation 35 Convulsions 15 Cough 29 D Diarrhoea 34 Disruptive patient 63 Distressed patient 65 Dizziness 21 Dyspepsia 32 Discharge, genital 36 E Ear/hearing symptoms 25 Emergency patient 12 Eye symptoms 23 Exposure to infectious fluids 68 F Face symptoms 24 Faint 20 Falls 20 Fatigue 19 Fever 17 Foot symptoms 50 Foot care 50 Fracture 14 G Genital symptoms 36 H Headache 22 Hearing problems 25 Heartburn 32 I Injured patient 14 Itch 53 J Jaundice 60 Joint symptoms 46 L Leg symptoms 49 Lump, neck/axilla/groin 18 Lump, skin 53 Lymphadenopathy 18 M Mouth symptoms 27 N Nail symptoms 61 Nausea 33 Neck pain 48 Needlestick injury 122 Nose symptoms 26 O Overweight patient 84 P Pain, back 47 Pain, body/general 45 Pain, chest 28 Pain, neck 48 Pain, skin 53 Pap smear 40 R Rape 66 Rash 53 Respiratory arrest 12 S Scrotal symptoms 36 Seizures 15 Suicidal thoughts/self harm 62 Sexual assault 66 Sexual problems 43 Sexually transmitted infection (STI) 36 Skin symptoms 53 Sleeping difficulty 67 Smoking 102 Stings 52 Stressed patient 65 Syphilis 41 T Throat symptoms 27 Tiredness 19 Traumatised patient 66 U Ulcer, genital 36 Ulcer, skin 53 Unconscious patient 13 Unsafe sex 68 Urinary symptoms 44 V Vaginal bleeding 42 Violent patient 64 Vision symptoms 23 Vomiting 33 W Weakness 19 Weight loss 16 Wheeze 30 Wound 14 Adult contents: Address the patient's general health 10
Adult contents: chronic conditions Tuberculosis (TB) Tuberculosis (TB): diagnosis 71 Drug-sensitive (DS) TB: routine care 72 HIV HIV: diagnosis 75 HIV: routine care 76 Malnutrition 70 Chronic respiratory disease Asthma and COPD: diagnosis 81 Using inhalers and spacers 81 Asthma: routine care 82 COPD: routine care 83 Chronic diseases of lifestyle Cardiovascular disease (CVD) risk: diagnosis 84 Cardiovascular disease (CVD) risk: routine care 85 Diabetes: diagnosis 86 Diabetes: routine care 87 Hypertension: diagnosis 89 Hypertension: routine care 90 Heart failure 91 Rheumatic heart disease/previous rheumatic fever 92 Stroke 93 Ischaemic heart disease (IHD): initial assessment 94 Ischaemic heart disease (IHD): routine care 95 Peripheral vascular disease (PVD) 96 Epilepsy 97 Mental health Admit the mentally ill patient 98 Depression: diagnosis 99 Depression and/or anxiety: routine care 100 Tobacco smoking 102 Alcohol/drug use 103 Psychosis 104 Dementia 106 Musculoskeletal disorders Chronic arthritis 107 Gout 108 Fibromyalgia 109 Women’s health Contraception 110 The pregnant patient 112 Routine antenatal care 114 Routine postnatal care 116 Menopause 119 Palliative care 120 Other pages Prescribe rationally 9 Protect yourself from occupational infection 122 Communicate effectively 124 Exposed to infectious fluid: post-exposure prophylaxis 68 Protect yourself from occupational stress 123 Support the patient to make a change 125
Child contents Long-term health conditions A Abdominal symptoms 143 B Breathing difficulty, child 140 Burns 133 C Cardiac arrest 128 Cardiopulmonary resuscitation (CPR) 128 Coma 131 Confusion 131 Convulsions 130 Cough 140 Cough, recurrent 142 D Dehydrated child 129 Diarrhoea 144 E Ear symptoms 138 Emergency child 127 F Fever 134 H Headache 135 Head injury 127 Hearing problems 138 I Injured child 132 L Leg symptoms 146 Limp 146 Lymphadenopathy 136 M Mouth symptoms 139 P Pallor 137 R Rash, generalised 147 Rash, localised 148 Respiratory arrest 128 Resuscitation, child 128 S Seizures 130 Shock 129 T Throat symptoms 139 U Unconscious child 131 Underweight 150 Urinary symptoms 145 W Walking problems 146 Wheeze 141 Wheeze, recurrent 142 Symptoms Malnutrition 153 Epilepsy 154 Quick reference chart 155
Adult 9 Treat the patient needing a prescription • If unsure about your medicine choice and dosing, side-effects or medication interactions, consult a medicines formulary, experienced colleagues or pharmacist. • Ensure that the prescription contains all the detail it needs - see sample prescription. Write legibly. • If the patient needs an antibiotic, try to avoid antibiotic resistance: - - Confirm that patient needs the antibiotic. - - If possible, take microbiological samples before starting antibiotic and adjust treatment with results. - - Prescribe the shortest effective course at the appropriate dose and route. Prescribe rationally Assess the patient needing a prescription Assess Note Diagnosis Confirm the patient’s diagnosis, that the medication is necessary and that its benefits outweigh the risks: consider disease severity, safety and efficacy of medication and alternatives, severity and incidence of adverse drug reactions. Other conditions It may be necessary to adjust dose (e.g. lamivudine in kidney disease) or give alternative medication (e.g. avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure or kidney disease). Other medications Check if all medication (prescribed, over-the-counter, herbal) is necessary and for possible interactions, especially if on hormonal contraception, ART, TB or epilepsy treatment. Allergies If known allergy or previous bad reaction to medication, give alternative or refer. Age If > 65 years: consider using lower medication doses (give full doses of antibiotics and ART) and avoiding unnecessary medications. If patient on diazepam, amitriptyline, theophylline, codeine, ibuprofen, amlodipine or fluoxetine or using ≥ 5 medications, consider referral to hospital. Pregnant/breastfeeding If pregnant or breastfeeding check if the medication is safe. Response to treatment • If the patient’s condition does not improve, assess adherence to treatment and consider changing the treatment or an alternative diagnosis. If on antibiotic, check for resistance. • Check for side effects and report possible adverse reaction/s to medication. Advise the patient needing a prescription • Explain why the medication is needed, what effect it will have and what will happen if it is taken incorrectly. • Explain when and how to take the medication and for how long. Ask the patient to repeat your explanation to ensure s/he understands. • Educate on the importance of adherence and that not adhering to medication may lead to relapse or worsening of the condition and possible resistance to the medication. • Advise of possible side effects to the medication and what to do if they occur. • Over-the-counter medications and herbal treatments may interfere with prescribed medication. Encourage patient to discuss with prescriber before using them. Amoxicillin 500mg PO TID for 7 days, 21 capsules
Adult 10 Address the patient's general health 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. 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 cough ≥ 2 weeks, weight loss, night sweats, fever ≥ 2 weeks, chest pain on breathing or blood-stained sputum, exclude TB 71. Family planning Every visit • Discuss patient’s contraception needs 110 and pregnancy plans. If pregnant, give antenatal care 114. • If HIV positive and planning pregnancy, advise patient to use contraception until viral load < 1000copies/mL. Sexual health Every visit • Ask about genital symptoms 36. • Ask about risky behaviour (patient or partner has new or > 1 partner, unreliable condom use or substance use 103) and sexual problems 43. Depression Every visit In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. Substance use/ abuse Every visit In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Smoking Every visit If patient smokes tobacco 102. Support patient to change 125. Older person risk Every visit if > 65 years • If patient has a change in function, confusion or strange behavior 64. • 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 106. • Consider using lower medication doses (give full doses of antibiotics and ART) and avoiding unnecessary medications. If patient on diazepam, amitriptyline, theophylline, codeine, ibuprofen, amlodipine or fluoxetine or is using ≥ 5 medications, consider referral to hospital. Pain Every visit • If patient has pain, manage on symptom page. • If patient is terminally sick and survival is predicted to be short, also give palliative care 120. CVD risk If ≥ 40 years or ≥ 2 risk factors • Assess CVD risk 84 at first visit, then depending on risk. • Risk factors: smoking, parent/sibling with premature CVD (man < 55 years or woman < 65 years), BMI > 25, waist circumference > 80cm (woman) or 94cm (man), hypertension, diabetes, cholesterol > 190g/dL. BP First visit, then depending on result Check BP 89. BMI/MUAC Yearly • BMI = weight (kg) ÷ height (m) ÷ height (m). • If BMI > 25 84. pregnant/breastfeeding and MUAC < 23cm or if not pregnant/breastfeeding and BMI < 17.5 or MUAC < 21cm, malnutrition likely 70. Diabetes screen • If ≥ 45 years • If BMI ≥ 25 and ≥ 1 other risk factor • Check glucose 86 at first visit, then depending on result. • Other risk factors: hypertension, cardiovascular disease, physical inactivity, family history of diabetes, high risk ancestry, previous gestational diabetes or big baby, previous impaired glucose tolerance or impaired fasting glucose. HIV • If status unknown • If sexually active: yearly • If pregnant: at first visit and 36 weeks Test for HIV 75. Cervical screen When needed • If HIV negative, screen 5 yearly from age 30 to 49. • If HIV positive, screen at HIV diagnosis (regardless of age) then 5 yearly. • If abnormal 40. Breast check First visit, then yearly Check for lumps in breasts 31 and axillae 18.
Adult 11 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 that not all tests, treatments and procedures help prevent or treat disease. Some provide little or no benefit and may even cause harm. • Help patient to choose lifestyle changes to improve and maintain his/her general health. Support the patient to change 125. Avoid substance abuse Limit alcohol intake < 2 drinks1 /day and avoid alcohol on at least 2 days of the week. • In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the- counter medications? If yes to any 103. Stress Assess and manage stress 65. Smoking If patient smokes tobacco 102. Physical activity • Aim for at least 30 minutes of moderate exercise (e.g. brisk walking) on most days of the week. • Increase activities of daily living like gardening, housework, walking instead of taking transport, using stairs instead of lifts. • Exercise with arms if unable to use legs. Be sun safe • Avoid sun exposure, especially between 10h00 and 15h00. • Use sunscreen and protective clothing (e.g. hat) when outdoors. Road safety • Use pedestrian crossings to cross the road. • Use a seat belt. • Avoid using alcohol/drugs if driving. Have safe sex • Have only 1 partner at a time. • If HIV negative, test for HIV between partners. • Advise partner to test for HIV. • Use condoms. Diet • Eat a variety of foods in moderation. Reduce portion sizes. • Increase fruit and vegetables. • Reduce fatty foods: eat low fat food, cut off animal fat. • Reduce salty processed foods and avoid adding salt to food. • Avoid/use less sugar. Treat preventively to maintain the patient’s general health • If woman planning pregnancy, give folic acid 400mcg PO daily until 3 months after delivery. • Review the patient’s immunisation history and give if needed: Vaccine When Note Tetanus If pregnant • Give 1 dose of tetanus vaccine at first antenatal visit (any gestation). • Repeat at 4 weeks, then 6, 18 and 30 months after first dose. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
Adult 12 The emergency patient Give urgent attention to the emergency patient: Does patient respond to your voice? Assess and manage airway, breathing, circulation and level of consciousness No: call for help Feel for carotid pulse for maximum of 10 seconds. Yes No pulse felt or unsure Start CPR: • Give cycles of 30 chest compressions and 2 breaths (at rate of at least 100 compressions/minute). • Give adrenaline 1mL (1:1000 solution) IV, followed by 5mL sterile water. Repeat every 3-5 minutes. • Check pulse: - - If definite pulse returns, stop CPR and check breathing (as adjacent). - - If no pulse, continue CPR for at least 30 minutes1 . Pulse felt Is patient breathing? No • Give 1 breath every 6 seconds. • Recheck pulse every 2 minutes. • If no pulse, start CPR (as adjacent). Airway • If airway obstructed (snoring, gurgling, noisy breathing), open with head- tilt and chin-lift. If injured, use jaw-thrust instead, keeping neck stable. • Remove foreign bodies from mouth and suction fluids. • If unconscious, insert oropharyngeal airway. If patient resists, gags or vomits, use lubricated nasopharyngeal airway instead. Breathing • If difficulty breathing or oxygen saturation < 90%, give face mask oxygen. • If respiratory rate < 9 or blue lips/ tongue,connect bag valve mask to oxygen and slowly deliver each breath with the patient. • Refer if using bag valve mask and still difficulty breathing, oxygen saturation < 90% or blue lips/tongue. • If sudden breathlessness, more resonant/decreased breath sounds/ pain on 1 side, deviated trachea: tension pneumothorax likely: refer urgently for chest tube. Circulation • Establish IV access. • If systolic BP < 90, pulse ≥ 100 or heavy bleeding, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • Stop bleeding: apply pressure and elevate limb. If bleeding still severe, apply alternate tourniquet above injury until surgical intervention or referral. Level of consciousness • Assess Glasgow Coma Score (GCS): Glasgow Coma Score (GCS) Best motor response 6 Obeys commands 5 Localises to pain 4 Withdraws from pain 3 Abnormal flexion to pain 2 Extends to pain 1 None Best verbal response 5 Orientated 4 Confused 3 Inappropriate words 2 Incomprehensible sounds 1 None Eye opening 4 Spontaneous 3 To voice 2 To pain 1 None • Add scores to give single score out of 15 Yes Manage further according to disability and symptoms: • If pupils unequal or respond poorly to light, raise head by 30 degrees. If injured, keep body straight and tilt to raise head (avoid bending spine). • Apply rigid neck collar and sandbags/blocks on either side of head if injured with: head injury and GCS < 15, neck/spine tenderness, weak/numb limb or abnormal pupils. If needing to move patient, use spine board. • If GCS ≤ 8 and none of above, place in left lateral position. • 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. • Assess patient further according to symptoms. Manage symptoms as on symptom pages. If unconscious 13. If injured 14. 1 Continue CPR for longer if temperature < 35°C, patient drowned, poisoned or took medication.
Adult 13 The unconscious patient Give urgent attention to the unconscious patient: • First assess and manage airway, breathing, circulation and level of consciousness 12. • 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 convulsions, injuries or burns, also manage on symptom pages. • If sudden diffuse rash or face/tongue swelling, anaphylaxis likely: - - Raise legs and give face mask oxygen. - - Give immediately adrenaline 0.5mL (1:1000 solution) IM into mid outer thigh. Repeat every 5-15 minutes if needed. If no response, give hydrocortisone 100mg IV and promethazine 50mg IM. - - Give normal saline 1-2L IV rapidly regardless of BP. Then, if BP < 90/60, also give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • Check blood glucose, temperature and pupils: Temperature ≤ 35°C • Remove cold/ wet clothing and cover with warm blankets. • Warm IV fluids to 40°C (avoid cold fluids). • If no response or temperature ≤ 32°C, refer to hospital. ≥ 38°C Severe pneumonia or sepsis or meningitis likely • Give ceftriaxone2 2g IV/IM or crystalline penicillin2 3-4M IU IV with chloramphenicol 500mg IV. • Check for malaria3 : if positive, give artesunate 2.4mg/kg IM or artemether 3.2mg/kg IM. • If temperature > 40°C: - - Remove clothing. - - Use fan and water spray to cool patient. - - Apply ice-packs to axillae, groin and neck. - - Stop once temperature < 39°C. Illegal drug use and/or respiratory rate < 12 Pupils If no response or overdose/poisoning with other or unknown substance, refer to hospital. Pinpoint Excessive secretions or muscle twitching Both equally dilated Unequal or respond poorly to light • Intracranial bleeding/ mass or stroke likely • Raise head by 30 degrees. • If injured, keep body straight and tilt to raise head (avoid bending spine). Blood glucose < 70mg/dL or unable to measure • Give glucose 40% 50mL IV over 2-3 minutes. Repeat if glucose still < 70mg/dL after 15 minutes. Maintain with glucose 10% solution1 . • If known alcohol user, give thiamine 100mg IV or vitamin B1+B6+B12 1 tablet PO before glucose. > 200mg/dL • Check urine for ketones: if >2+, DKA likely 87. • Otherwise, give normal saline 1L IV over 1 hour, then 500mL hourly for 4 hours, then 250mL hourly for 4 hours. Opioid overdose likely Give 100% face mask oxygen. Organophosphate poisoning likely • Give atropine 2mg IV. Repeat every 5 minutes, doubling dose of atropine each time, until secretions controlled. • Remove contaminated clothes and wash skin. Stimulant or other drug overdose likely • 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 < 90% or drop in GCS, reassess and manage airway, breathing, circulation and level of consciousness 12. 1 Add 10 vials of glucose 40% in 1L dextrose in normal saline solution at 30 drops per minute. 2 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), give chloramphenicol only and refer. 3 Test for malaria with parasite slide microscopy or if unavailable, rapid diagnostic test.
Adult 14 The injured patient Give urgent attention to the injured patient: • First assess and manage airway, breathing, circulation and level of consciousness 12. • 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 blood in urine Wound and one or more of: • Poor perfusion (cold, pale, numb, no pulse) below injury • Excessive or pulsatile bleeding • Penetrating wound to head/ neck/chest1 /abdomen Fracture and one or more of: • Poor perfusion (cold, pale, numb, no pulse) below fracture • Increasing pain, muscle tightness, numbness in limb • Suspected femur, pelvis or spine fracture • Weakness/numbness below fracture • Open fracture • > 3 rib fractures • Severe deformity Head injury and one or more of: • Any loss of consciousness • Convulsion • Severe headache • Amnesia • Suspected skull fracture • Bruising around eyes or behind ears • Blood behind eardrum • Blood or clear fluid leaking from nose or ear • Pupils unequal or respond poorly to light • Weak/numb limb/s • Vomiting ≥ 2 times • ≥ 1 other injury • Drug or alcohol intoxication • Give normal saline 1L IV hourly for 2 hours. • Once urine output > 200mL/ hour, give 500mL hourly. • Stop if breathing worsens. • Give normal saline 1L 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • If excessive/pulsatile bleeding, apply direct pressure and elevate limb. If bleeding severe and persists, apply tourniquet above injury. • Give diclofenac 75mg IM/IV and/or tramadol 100mg IV/IM. • If poor perfusion or weakness/numbness below fracture, gently re-align into normal position. • If open fracture: remove foreign material, irrigate with normal saline and hydrogen peroxide then cover with sterile saline-soaked gauze. Give ceftriaxone2 1g IV/IM and if dirty wound add metronidazole 500mg PO. • Splint limb to immobilise joint above and below fracture. • If pelvic fracture, tie sheet tightly around hips to immobilise. • If GCS < 15, neck/spine tenderness, weak/numb limb or abnormal pupils, apply rigid neck collar and sandbags/blocks on either side of head. • If pupils unequal or respond poorly to light, keep body straight and tilt to raise head (avoid bending spine). • If convulsion, give phenytoin 20mg/kg PO (crushed and diluted in water through NG Tube). Avoid giving lorazepam/diazepam. • Refer urgently. While awaiting transport, check BP, pulse, respiratory rate, oxygen saturation and GCS every 15 minutes. • If BP < 90/60, pulse > 100 or < 50, respiratory rate > 20 or < 9, oxygen saturation < 90% or drop in GCS, reassess and manage airway, breathing, circulation and level of consciousness12. 1 Avoid suturing the wound, apply 3-side flap dressing. 2 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), give single dose erythromycin 500mg PO. 3 Inject 0.1mL TAT SC and 0.1mL normal saline at separate site as control: if wheal with redness develops around TAT site, skin test positive. Refer to hospital. 4 Advise no alcohol until 24 hours after last dose of metronidazole. 5 Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. 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 66. • If open wound, give tetanus toxoid 0.5mL IM if none in past 5 years. If unavailable, check for tetanus antitoxin (TAT) hypersensitivity3 : if no reaction, give single dose TAT 3000U SC. If < 3 tetanus vaccine doses in lifetime, also give tetanus immunoglobulin 250 units IM at different site to toxoid with separate syringe. If unavailable, refer to hospital. Fracture • Splint limb to immobilise joint above and below fracture. • Give paracetamol 1g PO QID and ibuprofen5 400mg PO QID. • Refer to hospital. Head injury • Observe for 2 hours before discharging with carer. • If mild headache, dizziness or mental fogginess, concussion likely: - - Advise complete rest for 2 days. If no symptoms after 3 days, gradually increase exertion. - - Advise that recovery can take > 1 month. - - Give paracetamol 1g PO QID as needed for up to 5 days. • Advise to return immediately if any of above symptoms of severity develop. Wound • Apply direct pressure to stop bleeding. Remove foreign material, loose/dead skin. Irrigate with normal saline or if wound dirty use instead povidone iodine solution or hydrogen peroxide solution. • If sutures needed: suture, clean the overlying skin and apply non-adherent dressing for 24 hours. • Avoid suturing if > 12 hours (body), > 24 hours (head/neck), remaining foreign material, infected, gunshot or deep puncture: - - Pack wound with saline-soaked gauze and give amoxicillin/clavulanate 500/125mg PO TID for 7 days. If penicillin allergic, give instead erythromycin 500mg PO QID for 7 days. - - Review in 2 days. Suture if needed and no infection unless gunshot/deep puncture (irrigate and dress every 2 days instead). • Give paracetamol 1g PO QID as needed for up to 5 days. • Advise to return if infection (red, warm, painful, swollen, smelly, pus): start metronidazole4 500mg PO TID for 7 days and refer. • Remove sutures after 5 days (face), 4 days (neck), 10 days (leg) or 7 days (rest of body). • Refer if unable to close wound easily, weakness/numbness below injury or cosmetic concerns.
Adult 15 Seizures/convulsions Approach to the patient who is not convulsing now • Confirm with the patient and a witness that s/he indeed had a convulsion: abnormal, jerking movements of part of or the whole body, usually lasting < 3 minutes. • May have had tongue biting, incontinence, post-convulsion drowsiness and confusion. Yes If diagnosis uncertain, refer. Yes Give routine epilepsy care 97. No Refer to hospital. Stroke or TIA likely 93. Faint or syncope likely 20. Conversion Disorder (Hysteria) likely 99. 1 Add 10 vials of glucose 40% in 1L dextrose in normal saline solution at 30 drops per minute. 2 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), give chloramphenicol only and refer. 3 Test for malaria with parasite slide microscopy or if unavailable, rapid diagnostic test. Give urgent attention to the patient who is unconscious and convulsing: • Assess and manage airway, breathing, circulation and level of consciousness 12. • If current head injury 14. • Ensure the patient does not sustain additional trauma. Don’t leave patient alone or put anything in mouth. Place patient on side and give 100% facemask oxygen. • Secure IV access with normal saline or dextrose in normal saline. • Check glucose. If < 70mg/dl or unable to measure, give glucose 40% 50ml IV over 2-3 minutes. Repeat if glucose still < 70mg/dL after 15 minutes. Maintain with glucose 10% solution1 . If glucose ≥ 200mg/dL, control convulsion and stabilize patient, then 86 • If ≥ 20 weeks pregnant up to 1 week postpartum: consider eclampsia 112. • Give diazepam 10mg IV slowly over 2 minutes. Repeat after 5 minutes if convulsion continues. • If still convulsing 10 minutes after second dose of diazepam or patient does not recover consciousness between convulsions, status epilepticus likely: - - Givephenytoinorphenobarbitone20mg/kgPO(crushedanddilutedinwaterthroughNGTube).Givediazepam10mgIVatthesametimeandrepeatuptoatotaldoseof40-60mgifconvulsioncontinues. - - Add phenytoin or phenobarbitone 10mg/kg PO if convulsion persists after 60-90 minutes. - - Refer urgently to hospital. Collapse with twitching lasting < 15 seconds following hot feeling, nausea, prolonged standing or intense pain with rapid recovery Episodes of acute anxiety, fully conscious, responds irregularly, with abnormal body movement and usually after stressful experience No Yes Give routine epilepsy care 97. No Patient has previous history of head trauma, meningitis, family history, stroke or brain tumor? Approach to the patient who had convulsion but does not need same day referral Is the patient known with epilepsy? New sudden asymmetric weakness or numbness of face arm or leg; difficulty speaking or visual disturbance Refer patient same day if one or more of: • Neck stiffness/meningism, temperature ≥ 38°C, meningitis likely: give ceftriaxone2 2g IM/IV or crystalline penicillin2 4M IU IV with chloramphenicol 500mg IV • Malaria test3 positive: give artesunate 2.4mg/kg IM or artemether 3.2mg/kg IM. • HIV patient: consider CNS toxoplasmosis, CNS TB, cryptococcal meningitis or HIV associated dementia • Reduced level of consciousness for more than 1 hour after convulsions stopped: suspect complications • New sudden asymmetric weakness or numbness, difficulty speaking or visual disturbance: consider stroke • New/different headache or headache getting worse/more frequent: consider sub-arachnoid hemorrhage • BP ≥ 180/110 one hour after convulsion has stopped: consider hypertensive emergency • Substance abuse: consider overdose or withdrawal • Head injury within past 6 weeks: consider subdural hematoma • Pregnant or up to 1 week postpartum: consider eclampsia 112.
Adult 16 Weight loss Check that the patient who says s/he has unintentionally lost weight has indeed done so. Compare current weight with previous records and ask if clothes still fit. • Calculate the percentage of weight loss in the last 6 months: Investigate if ≥ 5%. • Ensure you work through steps 1-5 in this first visit. If above excluded, ask about food intake: Step 4. Food intake inadequate: look for cause/s Food intake is adequate • If any of: pulse ≥ 100, palpitations, tremor, dislike of hot weather or thyroid enlargement – thyrotoxicosis likely, refer to hospital. • In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. • In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Step 5. Consider malnutrition Check patient’s BMI and mid-upper arm circumference (MUAC): if pregnant/breastfeeding and MUAC < 23cm or if not pregnant/breastfeeding and BMI < 17.5 or MUAC < 21cm, malnutrition likely 70. Nausea and/or vomiting Loss of appetite Assess and manage stress 65. Food insecure (drought, crop failure or unemployed) Sore mouth or difficulty swallowing 33. • Eat small frequent meals. • Advise patient to eat nutrient dense foods (soya, meat, fish, nuts and seeds, beans, lentils, potatoes, rice, barley, wheat, maize). Refer to food safety net program. Oral/oesophageal candida likely 27. Step 3. Ask about symptoms of common cancers Abnormal vaginal discharge/bleeding Consider cervical cancer. Do a speculum examination and VIA 40. Breast lump/s or nipple discharge Consider breast cancer. Examine breasts and axillae 31. Amenorrhea with lower abdominal swelling Consider ovarian tumor. Refer. Change in bowel habit Consider bowel cancer. If mass on abdominal or rectal examination or stool occult blood positive, refer. Cough ≥ 2 weeks, bloody sputum, long smoking history Consider lung cancer. Arrange chest x-ray and refer. Step 1. First check for TB, HIV and diabetes Step 2. Ask about symptoms of common chronic infections • If diarrhoea 34 • If abdominal swelling in schistosomiasis endemic area, consider schistosomiasis and refer to hospital. • If fever, night sweats resident in northwestern borders of Ethiopia, consider leishmaniasis and refer to hospital Exclude TB • Start workup for TB 71. • At the same time test for HIV 75 and diabetes 86 and consider other causes below. Test for HIV Test for HIV 75. If HIV positive, give routine care 76. Check for diabetes Check glucose 86. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
Adult 17 Fever Give urgent attention to the patient with fever (temperature ≥ 38°C now or in the past 3 days) and one or more of: • Convulsion 15 • Drowsiness, confusion or agitation • Neck stiffness/meningism • Respiratory rate > 30 or difficulty breathing • BP < 90/60 • Severe abdominal or flank pain • Jaundice • Easy bleeding or bruising • Unable to sit up or walk unaided • Purple rash Management and refer urgently: • If BP < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • Give ceftriaxone1 2g IV/IM or crystalline penicillin1 4M IU IV with chloramphenicol 500mg IV. Give single dose paracetamol 1g. • Check for malaria2 : if positive, give artesunate 2.4mg/kg IM or artemether 3.2mg/kg IM; and if glucose < 70mg/dl give glucose 40% 50mL IV. Repeat if glucose still < 70mg/dl after 15 minutes. • If patient started nevirapine or abacavir in last 4 weeks, check for urgent side effects 80. Approach to the patient with fever (temperature ≥ 38°C now or in the past 3 days) not needing urgent attention • Check for associated symptoms: cough 29; sore throat 27; blocked/runny nose 26; lower abdominal pain 32; vaginal discharge 38; urinary symptoms 44; diarrhoea 34; ear pain/discharge 25; skin rash 53; joint pain/swelling 46. • Give paracetamol 1g PO TID as needed for up to 5 days. 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), give chloramphenicol only and refer. 2 Test for malaria with parasite slide microscopy or if unavailable, rapid diagnostic test. 3 Avoid if pregnant. Do a peripheral blood film examination or a malaria rapid diagnostic test Positive for malaria Advise patient to return if no better. If fever persists beyond seven days • Check adherence to treatment and repeat peripheral blood film examination. Check for associated symptoms as above and manage as on symptoms pages. • Consider other causes of fever: If fever ≥ 2 weeks, exclude TB 71; Test for HIV 75. • If cause uncertain, refer. Plasmodium falciparum or Plasmodium vivax seen Positive for Borrelia (relapsing fever) Negative for malaria and Borrelia • If none of the above, advise cold compresses and review after 2 days. • If cause uncertain, or no better after treatment, refer. • Avoid Widal and Weil-Felix tests as they are not specific and do not show new infection. • Ask about pattern of fever, personal hygiene, headache, diarrhoea/constipation and look for lice on body: • Delouse the patient, shave hair and change clothing. • Give procaine penicillin 400,000IU IM. Ensure patient does not become shocked: - - Establish IV access with normal saline. - - Check BP every 15 minutes for first 2 hours, every 30 minutes for next 4 hours, then 6 hourly. If BP < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. If breathing worsens, stop and refer. • If penicillin allergic, give instead tetracycline3 250mg PO TID for 3 days. • Repeat peripheral blood film after 12 hours: - - If negative: give tetracycline 250mg PO TID for 3 days. - - If positive: repeat procaine penicillin 400,000IU IM and check BP as above. • Discharge after 12 hours and give tetracycline3 250mg PO TID for 3 days. If signs of severity as above, refer. • Educate patient and family on personal hygiene. Both Plasmodium falciparum and Plasmodium vivax seen • Give artemether/ lumefantrine 20/120mg: 4 tabs PO BID for three days and primaquine 0.25mg/kg PO daily for 14 days. • If pregnant in 1st trimester, give quinine sulphate 10mg/kg PO TID with food for 7 days. If intermittent fever with any of: headache, lives in overcrowded setting, poor personal hygiene or body lice, typhus fever likely: • Give doxycycline3 100mg PO BID for 7-10 days or tetracycline3 250mg PO QID for 7 days or chloramphenicol 500mg PO QID for 7 days. If persistent fever with any of: diarrhoea followed by constipation or poor food hygiene, typhoid fever likely: • Give ciprofloxacin3 500mg PO BID for 10-14 days or amoxicillin 1g PO TID for 14 days. If fever ≥ 2 weeks, exclude TB 71 and test for HIV 75. Plasmodium vivax seen • Give chloroquine: PO 4 tabs on days 1 and 2, 2 tabs on day 3 and primaquine 0.25mg/kg PO daily for 14 days. • If pregnant in 1st trimester, omit primaquine. Plasmodium falciparum seen • Give artemether/ lumefantrine 20/120mg: 4 tabs PO BID for three days and single dose primaquine PO 0.25mg/kg. • If pregnant in 1st trimester, give quinine sulphate 10mg/kg PO TID with food for 7 days.
Adult 18 Lump/s in neck, axilla or groin Approach to the patient with lump/s in neck, axilla or groin • If lump is in the skin 53. • If lump is beneath the skin, first exclude thyroid mass, hernia and aneurysm: - - Lump in neck that moves up when patient swallows, thyroid mass likely: refer for further investigation. - - Lump in groin that gets bigger when patient stands up or coughs, inguinal hernia likely: refer. If severe pain or cannot be reduced, refer urgently. - - Pulsating lump, aneurysm 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 lymphadenopathy Neck Check scalp, face, eyes, ears, nose, mouth and throat. Axilla • Check arms, breasts, chest, upper abdomen and back. • If lump in breast 31. • Manage as on symptom page. • If lymph node persists > 4 weeks, refer. Ulcer 39 Look for cause: Check lower abdomen, legs, buttocks, genitals, anal region. Refer to hospital. Groin Is there risk of STI ( Age < 25 years, > 1 partner, new partner or unprotected sex in last 3 months, or partner/s with STI)? No Treat patient and partner for lymphogranuloma venereum (Bubo) • First assess and advise the patient and partner 36. • Give ciprofloxacin 500mg PO BID for 3 days and doxycycline 100mg PO BID for 14 days. • If pregnant/breastfeeding, give instead erythromycin 500mg PO QID for 14 days. • If fluctuant lymph node, aspirate pus through healthy skin in sterile manner every 3 days as needed. • Review after 14 days. If no better, refer. Has a cause been found? How to aspirate lymph node for TB microscopy and cytology • Clean skin over largest node with ethanol or povidone iodine. Hold node in fixed position with one hand so that it will not move. • Insert 22 gauge needle into node, draw back plunger 2-3mL to create vacuum. • Partially withdraw and reinsert needle at different angles several times through node (avoid withdrawing needle completely, maintain continuous vacuum). • Release vacuum pressure before withdrawing needle completely. • Remove syringe from needle, pull 2-3mL air into syringe, re-attach needle and gently spray contents of needle on to a glass slide. • Lay another slide on top and pull the slides apart to spread the material. • Allow one slide to air dry and fix other slide with cytology spray. • If enough aspirate, also send for TB and bacterial culture and sensitivity. • If aspirate unsuccessful or does not confirm a diagnosis, refer. No Is the groin lump hot and tender? No No Yes Yes Yes Localised lymphadenopathy Ask about other symptoms and look for cause (infection, skin lesion, rash, bite): • Test for HIV 75. If HIV positive, give routine care 76. • If cough ≥ 2 weeks, weight loss, night sweats or fever ≥ 2 weeks, check for TB 71. • If no TB found and symptoms persist, refer same week. • Check complete blood count and ESR. If abnormal, refer to hospital. • Review medication: atenolol, allopurinol, co-trimoxazole, antibiotics and phenytoin can cause lymphadenopathy. Consider changing medication. • If no cause found, refer. Yes Is an ulcer present?
Adult 19 Weakness or tiredness Give urgent attention to the patient with weakness or tiredness and one or more of: • If new sudden asymmetric weakness or numbness of face, arm or leg; difficulty speaking or visual disturbance: consider stroke or TIA 93. • Chest pain 28 • Respiratory rate > 30 or difficulty breathing 29. • Glucose < 70mg/dL: if known diabetes 87. If not, manage as below. • Glucose > 200mg/dL if known diabetes 87. If not 86. • Severe dehydration: decreased urine output, drowsiness/confusion, BP < 90/60, pulse ≥ 100. • Dehydration: thirst, dry mouth, poor skin turgor, sunken eyes, decreased urine output, drowsiness/confusion, BP < 90/60, pulse ≥ 100. • Worsening weakness of leg/s • If on ART, check for urgent side effects 80. Management: • If dehydrated, give oral rehydration solution. If unable to drink or BP < 90/60, give normal saline 250mL IV rapidly, 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 < 70mg/dL or unable to measure, give oral glucose 20g. If unable to take orally, give instead glucose 40% 50mL IV over 2-3 minutes. Repeat if glucose still < 70mg/dL after 15 minutes. Maintain with glucose 10% solution1 . If glucose better and patient able to take orally, encourage patient to eat and drink. If weakness/tiredness persists, refer same day. • If worsening weakness of leg/s, refer urgently. Approach to the patient with weakness or tiredness not needing urgent attention Tiredness is a problem when it persists so that the patient is unable to complete routine tasks and it disrupts work, social and family life. Look for a cause of the patient’s weakness/tiredness: • If temperature ≥ 38˚C 17. If < 38˚C but had a fever in past 3 days, exclude malaria 17. • If cough, weight loss, night sweats or fever, exclude TB 71. • Test for HIV 75. If HIV positive, give routine care 76. • Exclude pregnancy. If pregnant 112. • Assess and manage stress 65 and if patient has difficulty sleeping 67. • If patient is terminally sick and survival is predicted to be short, give palliative care 120. If none of the above: • If difficulty breathing worse on lying flat and leg swelling, heart failure likely 91. • Exclude anaemia: Check Hb: - - If Hb 11-12g/dL (woman) or 11-13g/dL (man): If no infection, cancer or bleeding, give ferrous sulphate 200mg PO BID for 1 month. Give also single dose albendazole 400mg PO. Repeat Hb after 1 month: If repeat Hb not increased by at least 1g/dL , refer to hospital. - - If Hb <11g/dL, refer for further investigation. • Exclude diabetes: check glucose 86. • Look for kidney disease: do urine dipstick. If patient has proteinuria on dipstick, diabetes, hypertension or is > 50 years, refer for further investigation. • If weight gain, low mood, dry skin, constipation or cold intolerance, hypothyroidism likely. Refer to hospital • Review medication and refer if patient taking any of: loratidine, enalapril, amlodipine, propranolol, atenolol, fluoxetine, amitriptyline, metoclopramide, valproic acid, phenytoin and spironolactone. • In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. • Screen for substance use/abuse: In the past year, has patient: 1) drunk ≥ 4 drinks2 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. If persistent weakness or tiredness and no obvious cause, refer. 1 Add 10 vials of glucose 40% in 1L dextrose in normal saline solution at 30 drops per minute. 2 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
Adult 20 Collapse/faint Approach to the patient who has collapsed/fainted not needing urgent attention • Refer patient for further investigation, including ECG. • Screen for substance use/abuse: - - If current drug or alcohol intoxication 103. - - In the past year, has patient: 1) drunk ≥ 4 drinks2 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. • Check for orthostatic hypotension: measure BP lying and repeat after standing for 3 minutes: Systolic BP drops by ≥ 20 (or ≥ 30 if known hypertension) or diastolic BP drops by ≥ 10 • This is common in the elderly. • If thirsty and pulse on standing ≥ 100, dehydration likely. Give oral rehydration solution and look for and manage cause. • Check Hb: if < 11g/dL, refer to hospital. • Review medication: amitriptyline, amlodipine, enalapril, furosemide, glyceryl trinitrate, hydrochlorothiazide and metoprolol. Consider changing medication. • Advise patient to sit first before standing up from lying down. Yes Common faint (Syncope) likely • May have had twitching of limbs that last < 15 seconds (not a convulsion). • Advise to avoid overheating, prolonged standing, crowded environment and situations where fainting has occurred previously. • Assess and manage stress 65. No Was collapse associated with a specific action (e.g. coughing, swallowing, head turning or passing urine)? No Is there known diabetes? Give routine diabetes care 87. Yes Refer to hospital. No If cause for collapse is uncertain, refer. Systolic BP does not drop by ≥ 20 (or ≥ 30 if known hypertension) and diastolic does not drop by ≥ 10 Before the collapse did patient experience flushing, dizziness, nausea, sweating? Give urgent attention to the patient who has collapsed/fainted and one or more of: • If new sudden asymmetric weakness or numbness of face, arm or leg; difficulty speaking or visual disturbance: consider stroke or TIA 93. • Unconscious 13 • Convulsion 15 • Chest pain 28 • Difficulty breathing 29 • Recent injury • Systolic BP < 90 • Pulse < 50 or irregular • Palpitations • Family history of collapse or sudden death • Known heart problem • Collapse with exercise • Vomited blood or blood in stool • Pregnant or missed/overdue period with abdominal pain and vaginal bleeding • Severe back or abdominal pain • Sudden diffuse rash or face/tongue swelling: anaphylaxis likely Management: • If glucose < 70mg/dL or unable to measure, give oral glucose 20g. If unable to take orally, give instead glucose 40% 50mL IV over 2-3 minutes. Repeat if glucose still < 70mg/dL after 15 minutes. Maintain with glucose 10% solution1 . • If glucose > 200mg/dL 86. • If anaphylaxis likely: - - Raise legs and give face mask oxygen. - - Give immediately adrenaline 0.5mL (1:1000 solution) IM into mid outer thigh. Repeat every 5-15 minutes if needed. If no response, give hydrocortisone 100mg IV and promethazine 50mg IM. - - Give normal saline 1-2L IV rapidly regardless of BP. • If BP < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • Refer same day. Yes 1 Add 10 vials of glucose 40% in 1L dextrose in normal saline solution at 30 drops per minute. 2 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
Adult 21 Dizziness/vertigo Approach to the patient with dizziness not needing urgent attention • Ask about ear symptoms. If present 25. If hearing loss, refer same week. • Ask about fainting/collapse attacks. If present, do ECG. If ECG abnormal, refer same day. • Screen for substance use/abuse: - - If current drug or alcohol intoxication 103. - - In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. • Review medication: antidepressants, hypertension and epilepsy treatment, furosemide and efavirenz can cause dizziness. Refer. • If diabetic, check glucose 87. • Check Hb: if < 11g/dL, refer to hospital same week. • Check BP: if > 140/90 89. Assess for orthostatic hypotension: measure BP lying and repeat after standing for 3 minutes: • If none of the above, refer to hospital. • Refer if no cause is found, dizziness/vertigo persists despite above treatment or uncertain of diagnosis. Systolic BP drops by ≥ 20 (or ≥ 30 if known hypertension) or diastolic BP drops by ≥ 10 Orthostatic hypotension likely • This is common in the elderly. • If thirsty and pulse on standing ≥ 100, dehydration likely. Give oral rehydration solution and look for and manage cause. • Advise patient to sit first before standing up from lying down. Systolic BP does not drop by ≥ 20 (or ≥ 30 if known hypertension) and diastolic BP does not drop by ≥ 10 Ask patient to breathe rapidly for 2 minutes. Are symptoms reproduced? Yes Yes Refer to hospital. Hyperventilation likely • Reassure and encourage patient to breathe at a normal rate. • Assess and manage stress 65. Sudden dizziness/vertigo lasts seconds, precipitated by head movements Positional vertigo likely Reassure patient that dizziness is self-limiting and usually resolves within 6 months. Sudden dizziness/vertigo lasts hours/days with nausea/vomiting. May have preceding flu-like illness. Vestibular neuritis likely • If nausea/vomiting, give metoclopramide 10mg PO TID as needed for up to 5 days. • Encourage to be mobile as soon as possible • If no better after 2 weeks, or if hearing loss or tinnitus occurs, refer. No No Ask about associated symptoms and length of dizziness/vertigo. Is there hearing loss, headaches, visual symptoms or tinnitus (ringing/buzzing in ear/s)? 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. Give urgent attention to the patient with dizziness (spinning/feeling of rotation of self or surroundings) and one or more of: • If new sudden asymmetric weakness or numbness of face, arm or leg; difficulty speaking or visual disturbance: consider stroke or TIA 93. • BP < 90/60 • Pulse < 50 or irregular • Chest pain 28 • Difficulty breathing, especially on lying flat with leg swelling 91 • Recent head injury • Unable to stand without support • New sudden severe dizziness/ vertigo with nausea/vomiting, abnormal eye movements or walk Management: • If BP < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • Refer same day.
Adult 22 Headache Approach to the patient with headache not needing urgent attention Is headache disabling and recurrent with nausea or light/noise sensitivity, that resolves completely? Yes Migraine likely • Give immediately, and then as needed: ibuprofen3 400mg PO QID with food or paracetamol 1g PO QID for up to 5 days. • If nausea, also give metoclopramide 10mg PO TID as needed up to 5 days. • Give oral hydration. • Advise patient to recognise and treat migraine early, rest in dark, quiet room. • Advise regular meals, keep hydrated, regular exercise, good sleep hygiene. • Keep a headache diary to identify and avoid migraine triggers like lack of sleep, hunger, stress, some food or drink. • Avoid oestrogen-containing contraceptives 110. • If ≥ 2 attacks/month, refer for medication to prevent migraines. No Pain when pushing on forehead or cheek/s, recent common cold, runny/blocked nose? Yes • Give amoxicillin/clavulanate 500/125mg PO TID for 7-10 days. • If penicillin allergic, give instead azithromycin 500mg PO daily for 3 days, if available or refer. No • Give amoxicillin 500mg PO TID for 7 days. • If penicillin allergic, give instead doxycycline5 100mg PO BID for 7 days. • In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. • 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 100.. Constant aching pain, tender neck muscles > 50 years, pain over temples Giant cell arteritis likely Check ESR. If > 30mm/h, give single dose prednisolone 60mg PO and refer same day. • Warn patient to avoid overusing analgesics. • If uncertain of diagnosis or poor response to treatment, refer. Give urgent attention to the patient with headache and one or more of: • Sudden severe headache • New/different headache, or headache that is getting worse and more frequent • Headache that wakes patient or is worse in the morning • Temperature ≥ 38°C, neck stiffness/meningism or vomiting • Worsening/persistent headache in HIV patient recently started on ART • BP ≥ 180/110 and not pregnant 89 • Pregnant or 1 week post-partum, and BP ≥ 140/90 112 • Decreased level of consciousness • Confusion • Sudden dizziness • Vision problems (e.g. double vision) or eye pain 23 • Following a first convulsion • Recent head trauma • Sudden weakness or numbness of face, arm or leg 93 • Speech disturbance • Pupils different in size Management: • If temperature ≥ 38°C or neck stiffness/meningism, give ceftriaxone1 2g IV/IM or crystalline penicillin1 4M IU IV with chloramphenicol 500mg IV. If malaria test2 positive, also give artesunate 2.4mg/kg IM or artemether 3.2mg/kg IM. • Refer urgently. Sinusitis likely • Give paracetamol 1g PO QID as needed for up to 5 days. • If tooth infection, swelling over sinus or around eye, refer. • If patient has recurrent sinusitis, test for HIV 75. • If nasal discharge for > 10 days or symptoms worsen after initial improvement, give antibiotic: - - Is there risk of severe infection (> 65 years, alcohol abuse or impaired immunity4 )? Yes No • If using analgesia > 2 days/week for ≥ 3 months it can cause headaches: - - Advise against regular use and to cut down on amount used. - - Headache should improve within 2 months of decreased use. • Consider muscular neck pain or giant cell arteritis: 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), give chloramphenicol only and refer. 2 Test for malaria with parasite slide microscopy or if unavailable, rapid diagnostic test. 3 Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. 4 Known with HIV, diabetes or cancer, pregnant or receiving chemotherapy or corticosteroids. 5 Avoid if pregnant. Muscular neck pain likely 48.
Adult 23 Eye/vision symptoms Give urgent attention to the patient with eye/vision symptoms and one or more of: • If new sudden asymmetric weakness or numbness of face, arm or leg; difficulty speaking or visual disturbance: consider stroke or TIA 93. • BP ≥ 180/110 and not pregnant 89 • Pregnant or up to 1 week post-partum, and BP ≥ 140/90: treat as severe pre-eclampsia 112. • Yellow eyes: jaundice likely 60. • Single painful red eye • Sudden loss or change in vision (including blurred or reduced vision) • New onset hazy cornea • Painful red skin with blisters involving eye, eyelid or nose: herpes zoster (shingles) likely • Whole eyelid swollen, red and painful: orbital cellulitis likely • Penetrating eye trauma • Foreign body that is metal, or from hammering, mechanical saw, welding, grinding or explosion • Chemical burn to eye/s: immediately wash eye/s for at least 15 minutes continuously with normal saline or clean water. • If painful eye with redness, blurred vision, haloes around light, dilated unreactive pupil, headache or nausea/ vomiting, acute glaucoma likely Manage and refer urgently to ophthalmology centre: • If orbital cellulitis likely, give ceftriaxone1 2g IV/IM. Approach to the patient with eye/vision symptoms not needing urgent attention Red or swollen eyelid margins with crusting Blepharitis likely • Apply warm/ cool compress for 5-10 minutes BID. • Advise to gently wash eyes with baby shampoo. to remove crusts. If no better, give erythromycin eye drops 1 drop daily for 2 weeks. • If no better after 2 weeks, refer. • Exclude diabetes 86 and hypertension 89. • Test for HIV 75. • Refer for visual assessment. Superficial foreign body • Wash eye with clean water or normal saline and clean corners of eye with damp cotton- tipped bud. Advise regular hydration • Attempt removal of foreign body • Refer to hospital if: - - Unable to remove foreign body as above - - Damage to eye - - Abnormal vision or eye movement - - No better 2 days after removal of foreign body Gradual change in vision Yes: Is there eczema, allergic rhinitis or asthma and both eyes involved? No: Is the discharge pus or clear? Clear Viral conjunctivitis likely • Advise cool compresses. • Advise patient to wash hands regularly and not share towels or bedding. Patient can return to work after 1 week. • Give normal saline or clean water eye washes up to 4 times per day If no better after 2 days, refer. 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid ceftriaxone and refer. Pus Bacterial conjunctivitis likely If no yellow bumps: • Give chloramphenicol 1% ointment QID or gentamycin 0.3% eye drops 1 drop 4-6 hourly for 10-15 days. • Advise patient to wash hands regularly, not share towels/bedding. • Patient can return to work after 2 days. Check under upper eyelid for yellows bumps: if present, trachoma likely. Refer same day. © BMJ Best Practice Yes Allergic conjunctivitis likely • Advise cool compresses and normal saline eye drops as needed. • Help to identify and advise to avoid allergens that worsen/ trigger symptoms. • Avoid steroid eye drops • Give oxymetazoline eye drops 1 drop 3-4 times a day for 5 days. • Give loratadine 10mg PO daily or chloropheniramine 4mg PO at night as needed. • If no better after 4 weeks, refer. No Localised cause likely • Wash eye with clean water. • Identify and remove the cause. • If no better after 24 hours, refer. Eye/s discharging or watery Is there prominent itch?
Adult 24 Face symptoms Give urgent attention to the patient with face symptoms and one or more of: • If 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 93. • New facial swelling with abnormal urine dipstick: kidney disease likely • Sudden face/tongue swelling with difficulty breathing, BP < 90/60 or collapse, anaphylaxis likely • Painful red facial swelling and temperature ≥ 38°C: facial cellulitis likely Management: • If anaphylaxis likely: - - Raise legs and give face mask oxygen. - - Give immediately adrenaline 0.5mL (1:1000 solution) IM into mid outer thigh. Repeat every 5-15 minutes if needed. If no response, give hydrocortisone 100mg IV and promethazine 50mg IM. - - Give normal saline 1-2L IV rapidly regardless of BP. Then, if BP < 90/60, also give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • Refer urgently. Approach to the patient with face symptoms not needing urgent attention Face pain Pain of cheek or jaw and on tapping or biting on involved tooth. May be swollen. Gum/tooth infection likely • Give paracetamol 1g PO QID as needed for up to 5 days. • If temperature ≥ 38°C or difficulty opening mouth, give amoxicillin 500mg PO TID for 5 days and metronidazole1 500mg PO TID for 5 days. If penicillin allergic, replace amoxicillin with doxycycline2 100mg PO BID for 5 days. • Advise good oral hygiene and a soft diet for a few days. • Refer to dentist same week. Sudden progressive weakness of 1 side of face and unable to wrinkle forehead or close eye. May have impaired taste or dry eye. Bell’s palsy likely • Give prednisolone as soon as possible: give 60mg PO daily for 5 days. Then reduce dose by 10mg daily. If no better after 3 weeks, refer. • If severe/complete weakness, also give aciclovir 400mg PO 5 times a day for 10 days. • Protect eye: - - Advise patient not to rub eye. - - Keep eye moist with drops. - - Cover eye with transparent eye shield during the day. - - Tape eyelid closed at night. • Refer same day if: - - Otitis media - - Any change in hearing - - Recent head trauma - - Damage to cornea - - Unsure of diagnosis Swelling of face Painless swelling in patient on enalapril Painful swelling of one/both sides of face with low-grade fever, headache, body pain. Parotitis (mumps) likely • Give paracetamol 1g PO QID as needed for up to 5 days. • Advise patient s/he can return to work after 5 days and that symptoms usually resolve within 1 to 2 weeks. • Refer if: - - Neck stiffness/ meningism - - Painful scrotal swelling - - Loss of hearing Pain when pushing on forehead or cheek/s, headache, recent common cold, runny/blocked nose Yes No Sinusitis likely • Give paracetamol 1g PO QID as needed for up to 5 days. • If neck stiffness/meningism, tooth infection or swelling over sinus/around eye, refer. • If patient has recurrent sinusitis, test for HIV 75. • If nasal discharge for > 10 days or symptoms worsen after initial improvement, give antibiotic: - - Is there risk of severe infection (> 65 years, alcohol abuse or impaired immunity3 )? Angioedema likely • Stop enalapril and never start it again. • Give loratadine 10mg PO daily until swelling resolved. • Referto hospital for review of medication. • Advise patient to return urgently should difficulty breathing occur or symptoms worsen and that s/he should never take enalapril again. • Give amoxicillin/clavulanate 500/125mg PO TID for 7-10 days. • If penicillin allergic, give instead azithromycin 500mg PO daily for 3 days, if available or refer. • Give amoxicillin 500mg PO TID for 7 days. • If penicillin allergic, give instead doxycycline2 100mg BID for 7 days. If rash on face 53. 1 Advise no alcohol until 24 hours after last dose of metronidazole. 2 Avoid if pregnant. 3 Known with HIV, diabetes or cancer, pregnant or receiving chemotherapy or corticosteroids.
Adult 25 Ear/hearing symptoms 1 Cleaning the ear (dry mopping): roll a piece of clean paper towel or absorbent cloth 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 the ear. 2 Known with HIV, diabetes or cancer or receiving chemotherapy or corticosteroids. Itchy ear Otitis externa likely • Clean ear1 . • Give paracetamol 500mg PO QID as needed for up to 5 days. • If severe pain, temperature ≥ 38°C, impaired immunity2 give cloxacillin 500mg PO QID for 5 days. If penicillin allergy, give instead erythromycin 500mg PO QID for 5 days. • If no response after 2 days, refer. Referred pain likely • Look for cause: - - If dental problem, refer to dentist. - - If throat problem 27. - - If pain in temporo- mandibular joint, check for joint problem 46. - - If painful swelling of one/ both sides of face, consider mumps likely 24. Acute otitis media likely • Give paracetamol 500mg PO QID as needed for up to 5 days. • Clean ear1 if discharge. • Give amoxicillin 500mg PO TID for 5 days. If penicillin allergic, give instead erythromycin 500mg PO QID for 5 days. • Refer if: - - No response to antibiotics after 5 days - - Recurrent otitis media • Refer urgently if: - - Painful swelling behind ear - - Neck stiffness/ meningism Chronic suppurative otitis media likely • Clean ear1 3 times a day. The ear can heal only if dry. • Give hydrogen peroxide solution 3% 5-10 drops into affected ear BID. • Refer if: - - No better after 2 weeks - - Foul-smelling discharge or yellow/white deposit on eardrum, cholesteotoma likely. - - Large perforation - - Hearing loss - - Pain in ear • Refer urgently if: - - Painful swelling behind ear - - Neck stiffness/meningism • If poor response to treatment, check for TB 71 and HIV 75. Painful ear Is ear itchy, painful, discharge from ear, difficulty hearing or tinnitus (ringing/buzzing in ear/s)? Then look in ear. Discharge from ear Difficulty hearing or tinnitus Wax • Syringe ear with warm water and/ or dilute hydrogen peroxide. If unsuccessful after 3 attempts or causes pain, stop and refer. • If hearing does not improve after wax removal, refer. • Look for and if possible remove cause: - - Ask about prolonged exposure to loud noise. - - Review medication: aspirin, NSAIDs and furosemide. • Refer if: - - Sudden onset - - One-sided - - Dizziness/vertigo - - Patient taking kanamycin - - No cause found or no better 2 weeks after removing cause. • If insect, instil oil and if possible remove using forceps. • Otherwise, syringe ear with warm water. • If unsuccessful after 3 attempts or causes pain, stop and refer. Normal looking ear Foreign body • If tinnitus, refer to hospital. • If itchy/painful ear or discharge from ear, see adjacent column/s. • Check for wax and foreign body: Redness and/or pus in ear canal © University of Cape Town Normal drum and canal © University of Cape Town Symptoms < 2 weeks; red or bulging eardrum. May have fever and/or difficulty hearing. © University of Cape Town Symptoms ≥ 2 weeks; perforated eardrum. Painless, may have difficulty hearing © University of Cape Town How to syringe an ear Fill a large syringe (50-200mL) with warm water. Ask patient to hold container under ear against neck to catch water. Gently pull ear upwards and backwards to straighten ear canal. Place tip of syringe at ear canal opening (no further than 8mm into canal) and direct water spray upwards in ear canal.
Adult 26 Nose symptoms • Advise patient to avoid contact with others to prevent spread, use tissues when sneezing/coughing and dispose of these carefully, and to wash hands regularly. • Give paracetamol 500mg PO QID or ibuprofen1 400mg PO TID needed for up to 5 days. • Explain that antibiotics are not necessary. • Advise patient to return if symptoms persist > 4 days. Common cold likely Influenza (flu) likely Sore throat or fever Body aches/muscle pains or chills Pain when pushing on forehead or cheek/s, headache, recent common cold Runny or blocked nose Ask about duration and associated symptoms. Recurrent episodes of sneezing and itchy nose on most days for > 2 weeks. May have itchy eyes, ears or throat. Allergic rhinitis likely • Advise patient to identify and avoid allergens that worsen/ trigger symptoms. • Give loratadine 10mg daily for up to 5 days or cetirizine 10mg daily only when symptoms worsen. • If symptoms occur on ≥ 4 days per week for > 1 month, give beclometasone nasal spray long term 100mcg (2 sprays) in each nostril daily. Once symptoms controlled, use lowest effective dose to maintain control. • If no better with above treatment and symptoms debilitating, refer. • Firmly pinch nostrils together for 10 minutes. • Check BP: - - If < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. - - If ≥ 140/90 89. • If still bleeding: - - Insert cotton strips or swabs saturated with mixture of lidocaine 4% and xylometazoline 0.05% into bleeding nostril/s for 15 minutes. - - If bleeding persists, refer. • If patient has recurrent episodes: - - Advise patient to apply petroleum jelly or saline spray inside nostrils and avoid nose-picking or rubbing, contact sports and trauma to nose. - - Advise patient to avoid aspirin and NSAIDs (e.g. ibuprofen) as they may prolong bleeding. - - Educate patient to firmly pinch nostrils together if bleeding occurs. Bleeding nose Yes No • Give amoxicillin/ clavulanate 500/125mg PO TID for 7-10 days. • If penicillin allergic, give instead azithromycin 500mg PO daily for 3 days if available or refer. • Give amoxicillin 500mg PO TID for 7 days. • If penicillin allergic, give instead doxycycline3 100mg PO BID for 7 days. Sinusitis likely • Give paracetamol 1g PO QID as needed for up to 5 days. • If neck stiffness/meningism, tooth infection, swelling over sinus or around eye, refer. • If patient has recurrent sinusitis, test for HIV 75. • If nasal discharge for > 10 days or symptoms worsen after initial improvement, give antibiotic: - - Is there risk of severe infection (> 65 years, alcohol abuse or impaired immunity2 )? Yes No 1 Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. 2 Known with HIV, diabetes or cancer, pregnant or receiving chemotherapy or corticosteroids. 3 Avoid if pregnant.
Adult 27 Mouth and throat symptoms Give urgent attention to the patient with mouth/throat symptoms and one or more of: • Unable to open mouth – consider Ludwig’s angina, dental infections/abscess, jaw dislocation or tetanus • Unable to swallow at all – consider severe tonsillitis with abscess, severe oesophageal thrush Management: • Refer same day. Approach to the patient with mouth/throat symptoms not needing urgent attention • Ask about dry mouth and swallowing problems (difficulty or painful swallowing). If food/liquid gets stuck with swallowing, consider oesophageal cancer or stricture, refer. • Examine the mouth and throat for redness, white patches, blisters, ulcers or cracks. • Advise the patient with a sore mouth/throat to avoid spicy, hot, sticky, dry or acidic food and to eat soft, moist food. • Advise to keep mouth and teeth clean by brushing and rinsing regularly. Red throat Viral pharyngitis likely • Give paracetamol 1g PO QID as needed for up to 5 days. • Rinse with salt water or H2O2 3% mouthwash after meals • Reassure that antibiotics are not necessary. Bacterial pharyngitis/ tonsillitis likely • Give paracetamol 1g PO QID as needed for up to 5 days. • Rinse with salt water or H2O2 3% mouthwash after meals • Give single dose benzathine penicillin 1.2MU IM or amoxicillin 500mg PO QID for 10 days; If penicillin allergic give instead erythromycin 500mg PO QID for 10 days. If > 4 episodes in 1 year, refer for ENT assessment. White patches on cheeks, gums, tongue, palate; may have cracks in corners of mouth If difficulty or pain on swallowing, oesophageal candida likely • Give fluconazole 200mg PO daily for 14 days. • If no response, refer. Oral thrush/candida likely • Test for HIV 75 and diabetes 86. • Give miconazole oral gel 60mg or nystatin 500 000IU tablet PO QID for 7 days. Keep in mouth as long as possible. • If patient uses inhaled corticosteroids, ensure s/he uses spacer and rinses mouth with water after use 81. • If patient is terminally sick and survival is predicted to be short, give palliative care 120. Painful blisters on lips/mouth Herpes simplex likely • Apply tetracaine 0.5% on blisters or gentian violet 0.5% solution painted in mouth TID and paracetamol 1g PO QID up to 5 days. • Give aciclovir 400mg PO TID for 7 days if: - - HIV patient - - Blisters for ≤ 12 hours or new blisters forming - - Ulcers are extensive, recurrent or present for > 1 month - - Severe pain • Avoid touching the lesions and kissing. • Advise frequent hand washing. Painful ulcer/s in mouth/throat Red, cracked corners of mouth If no better or uncertain of cause: • Check hemoglobin. • Test for HIV 75 and diabetes 86. • If still uncertain, refer. Dry mouth • If thirst, urinary frequency or weight loss, check for diabetes 86. • If runny or blocked nose 26. • Look for and treat oral candida as in adjacent column. • Review medication: furosemide, amitriptyline, chlorpheniramine antipsychotics and morphine can cause dry mouth. Consider changing medication. • Advise patient to sip fluids frequently. Sucking on oranges, pineapple, lemon or passion fruit may help. • If patient is terminally sick and survival is predicted to be short, give palliative care 120. Aphthous ulcer/s likely • Apply triamcinolone acetonide 0.1% (Oropaste®) TID on the lesions for 7 days or crushed prednisolone 5mg tablet BID until healed • Apply tetracaine 0.5% on ulcers • Give paracetamol 1g PO QID as needed. • Rinse with chlorhexidine 0.12% solution 10ml BID • Test for HIV 75 • Refer if: - - Not healed within 2 weeks - - Ulcer diameter > 1cm Angular cheilitis likely • Apply petroleum jelly (Vaseline®) TID. • If crusts and blisters around mouth, impetigo likely 59. • If very itchy, contact dermatitis likely. Identify and remove irritant. • If using inhaled corticosteroids, advise to rinse mouth after use. Are there 2 or more of: • Fever • No cough • Pus/patches on tonsils • Tender neck lymph nodes No Yes
Adult 28 Chest pain Give urgent attention to the patient with chest pain and one or more of: • Respiratory rate > 30 or difficulty breathing • BP ≥ 180/110 or < 90/60 • Pulse irregular, ≥ 100 or < 50 • Severe pain • New pain or discomfort in centre or left side of chest • Pain radiates to neck, jaw, shoulder/s or arm/s • Nausea or vomiting • Pallor or sweating • Known with ischaemic heart disease • At risk of heart attack (diabetes, smoker, hypertension, high cholesterol, known CVD risk > 20%, family history) Is chest pain worse on palpating the chest or when patient lies down or breathes deeply? Yes No Assess for ischaemic heart disease 94 Manage and refer urgently: • If oxygen saturation < 90%, oxygen saturation machine 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: refer for urgent chest tube. • If BP < 90/60, give normal saline 250mL IV rapidly. Repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • If BP ≥ 180/110, repeated after 5 minutes to confirm, give single dose metoprolol 25mg PO and refer. • If temperature ≥ 38°C, give ceftriaxone1 1g IV/IM. 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid ceftriaxone and refer. 2 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. If uncertain of diagnosis, refer same week. 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 94. • If cough, fever or pain on breathing deeply 29. • Ask about site of pain and associated symptoms: Retrosternal or epigastric pain with eating, hunger or lying down/bending forward Tender at costochondral junction, no fever or cough Burning pain on one side of body with or without rash Dyspepsia (heartburn) likely • Advise to avoid caffeine and if heartburn at night, prop up head of bed and avoid eating late at night. Stop NSAIDS (e.g. ibuprofen), aspirin. • Ask about smoking. If patient smokes tobacco 102. Support patient to change 125. • If drinks alcohol ≥ 4 drinks2 /session 103. • If waist circumference > 80cm (woman) or 94cm (man), encourage weight loss and assess CVD risk 84. • Give omeprazole 20mg PO daily for 4 weeks. • Refer same week if any of: no better after 14 days of omeprazole, new onset pain and > 50 years, pain on swallowing, persistent vomiting, weight loss, loss of appetite, early fullness, blood in stool or occult blood positive or abdominal mass. Herpes zoster (shingles) likely 54. Musculoskeletal problem likely • Give ibuprofen 400mg PO TID with food up to 10 days (avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • If pain persists > 4 weeks, refer.
Adult 29 Cough or difficulty breathing Approach to the patient with cough or difficulty breathing not needing urgent attention • Test for HIV 75. If on ART, check for urgent side effects 80. • Ask about duration of cough or difficulty breathing: If wheeze/tight chest and no rash or face/tongue swelling 30. Relieve cough or difficulty breathing in the patient needing palliative care 120: • If thick sputum, give steam inhalations. If more than 30mL/day, try deep fast breathing with postural drainage. • If excess thin sputum, give hyoscine 10mg TID. If annoying dry cough, give dextromethorphan syrup 10mg/5ml or diphenhydramine syrup 10mg/5mL three times a day. • Exclude TB 71. • Consider asthma and COPD 81 and other cause for cough or difficulty breathing: Cough or difficulty breathing ≥ 2 weeks Cough or difficulty breathing < 2 weeks Acute bronchitis or common cold likely • Reassure patient antibiotics are not necessary. • Advise to return if symptoms worsen or fever develops. Pneumonia likely Yes Give amoxicillin1 1g PO TID and doxycycline3 100mg PO BID for 5-7 days. • If symptoms worsen after 2 days of antibiotics, refer. • If not better after 7 days of antibiotics, consider TB 71 • If no cause found, refer to hospital. HIV with CD4 < 200cells/mm3 with dry cough, worsening breathlessness on exertion Pneumocystis pneumonia likely Refer to hospital for x ray and inpatient treatment. Smoker • If patient smokes tobacco 102. • Has patient lost weight? Consider lung cancer. Refer to hospital. Coughing sputum most days of 3 months for ≥ 2 years, chronic bronchitis likely. Refer to hospital for COPD workup Recent common cold, no difficulty breathing Post-infectious cough likely Advise that cough should resolve within 8 weeks. No Give doxycycline3 100mg PO BID for 7 days. Is there risk of severe infection (> 65 years, alcohol abuse or impaired immunity2 )? Sputum, chest pain, pulse ≥ 100 or temperature ≥ 38°C? No No Yes Yes Give urgent attention to the patient with cough and/or difficulty breathing and one or more of: • Breathless at rest or while talking • Difficulty breathing worse on lying flat and leg swelling: heart failure likely 91. • Rapid deep breathing with glucose > 200mg/dl: consider DKA 86. • Sudden diffuse rash or face/tongue swelling: anaphylaxis likely • Temperature ≥ 39°C • Respiratory rate > 30 • Coughs ≥ 1 tablespoon fresh blood • Confused or agitated • BP < 90/60, shock • Swelling and pain in one calf Manage and refer urgently: • Give face mask oxygen (if known COPD give 24-28% face mask oxygen). Temperature ≥ 38°C, pneumonia likely Give ceftriaxone1 1g IV/IM or amoxicillin1 1g PO. Sudden breathlessness, more resonant/ decreased breath sounds/pain on one side, deviated trachea, tension pneumothorax likely Arrange urgent chest tube. If BP < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. Sudden diffuse rash or face/tongue swelling, anaphylaxis likely • Raise legs and give immediately adrenaline 0.5mL (1:1000 solution) IM into mid outer thigh. Repeat every 5-15 minutes if needed. If no response, give hydrocortisone 100mg IV and promethazine 50mg IM. • Give normal saline 1-2L IV rapidly, regardless of BP. 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid and refer. 2 Known with HIV, diabetes or cancer, pregnant or receiving chemotherapy or corticosteroids. 3 If pregnant, give instead erythromycin 500mg PO QID for 5 days.
Adult 30 Wheeze/tight chest 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? Mild or moderate No No Yes Yes • Give inhaled salbutamol via spacer1 400-800mcg (4- 8 puffs). If no better, repeat salbutamol every 20 minutes during first hour. • If known asthma or COPD, give prednisolone 40mg PO. If unable to take oral medication, give instead hydrocortisone 100mg IV. • Give face mask oxygen between each dose of salbutamol (if known COPD, give 24-28% face mask oxygen). • Monitor response regularly: Improving or no change at 1 hour Check respiratory rate. Can patient talk normally? • Refer urgently. • While awaiting transport: - - Give inhaled salbutamol 400-800mcg (4-8 puffs) every 20 minutes via spacer1 . - - Give face mask oxygen between doses (if known COPD, give 24-28% face mask oxygen). - - Give hydrocortisone 100mg IV if not already given. Severe Worsening despite treatment Able to talk normally and respiratory rate < 20 Unable to talk normally or respiratory rate > 20 Wheeze/tight chest resolved • If first episode of wheeze/tight chest, assess for asthma and COPD 81. • If known asthma/COPD, give routine care: if asthma 82, if COPD 83. Wheeze/tight chest still present • Repeat salbutamol hourly or as needed. • Is wheeze/tight chest still present at 3 hours? Continue salbutamol and refer. • If sudden diffuse rash or face/tongue swelling, anaphylaxis likely 29. • If difficulty breathing worse on lying flat and leg swelling, heart failure likely 91. 1 If conventional spacer unavailable, make a hole in the bottom of a 500mL plastic bottle to fit the size and shape of inhaler spray opening.
Adult 31 Breast symptoms Approach to the patient with a breast symptom who is not breastfeeding Ensure the breastfeeding HIV patient and her baby receive routine HIV care 76 and 116. Approach to the patient with a breast symptom who is breastfeeding Painful/cracked nipple/s Usually in first few days of breastfeeding due to poor latching • Avoid soap on nipples. • Advise patient to continue breastfeeding and help patient to latch properly. • Advise patient to apply breastmilk to nipples after feeding and expose to the air. • Advise HIV patient to stop feeding from the breast, express and heat-treat1 the milk, and cup-feed baby until cracks have healed. Painful breast/s Is there a breast lump? No Temperature ≥ 38°C or body pain? Yes Mastitis likely • Give cloxacillin 500mg PO QID for 10 days. If penicillin allergic, give instead erythromycin 500mg PO QID for 14 days. • Give paracetamol 1g PO QID as needed for up to 5 days. • Advise warm compresses and, if HIV negative, frequent breastfeeds. • Advise HIV patient to stop feeding from the breast, express and heat-treat1 the milk, and cup-feed baby until mastitis resolves. • If no better after 2 days, refer. No No Yes Engorgement likely Blocked duct likely Breast abscess likely • Give single dose ceftriaxone2 1g IM and refer same day. • Advise HIV patient to stop feeding from the breast, express and heat-treat1 the milk, and cup-feed baby until abscess resolves. • Advise frequent breastfeeding, warm compresses and to gently massage breast. • Advise to return to clinic if worse/no better. Yes Temperature ≥ 38°C or body pain? Breast lump/s Both breasts, with/without pain One breast This is likely to be cyclical. • Reassure. • If on hormonal contraceptive, consider non-hormonal method 110. • If symptoms change/worsen, refer. No Yes Re-examine breast on day 7 of menstrual cycle. If lump persists, refer same week. Rash on breast • Check for breast lump. • Check axilla for lymph node 18. • Check for nipple discharge • If none of the above 53 Refer same week. Breast pain • Reassure patient that breast cancer rarely causes pain. • Advise a well-fitting bra. • If pregnant, reassure and give antenatal care 114. • Give paracetamol 1g PO QID as needed for up to 5 days. • May be a side effect of hormonal contraceptive. If no better after 3 months, change method 110. Nipple discharge Any one of: blood-stained or one-sided discharge, patient ≥ 50 or a man, skin/ nipple changes, breast/axillary lump? One breast Both breasts • Confirm that this is not obesity. If BMI > 25 assess CVD risk 84. • Review medication: efavirenz and amlodipine can cause breast enlargement. Consider changing medication. Refer same week. Yes Refer same week. No • If pregnant, reassure and give antenatal care 114. • Review medication: haloperidol, antidepressants, oral contraceptive and metoclopramide can cause nipple discharge. Consider changing medication. • If discharge persists, refer. Breast enlargement/feels different 1 Heat-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. 2 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid ceftriaxone and refer. Any one of: man, patient > 30 years, family history of breast cancer, irregular fixed lump, skin/nipple changes, nipple discharge or axillary lymph node?
Adult 32 Abdominal pain (no diarrhoea) Give urgent attention to the patient with abdominal pain and one or more of: • Unable to pass urine and distended abdomen: consider acute urinary obstruction 44 • Chest pain: consider heart attack 28 • Pregnant or up to 1 week post-partum and BP ≥ 140/90: consider pre-eclampsia 112 • Recent abortion/delivery: consider puerperal sepsis 116 • Pregnant and vaginal bleeding, consider ectopic pregnancy or abortion 112 • If drowsiness, confusion, nausea/vomiting, rapid deep breathing: consider DKA, check glucose 86. • If on ART, check for urgent side effects such as lactic acidosis 80. • Peritonitis (guarding, rigidity or rebound tenderness): consider acute abdomen • Jaundice (yellow eyes): consider bile duct infection, hepatitis • Temperature ≥ 38°C: consider severe infection of any abdominal organ/structure • No stool or flatus for last 24 hours with/without vomiting: consider intestinal obstruction • Sudden severe upper abdominal pain spreading to back with nausea/vomiting: consider perforated duodenal ulcer or pancreatitis • Pulsatile abdominal mass: consider abdominal aortic aneurysm • Severe pain just before or during menses, severe dysmenorrhea likely Manage and refer urgently: • If temperature ≥ 38°C, jaundice or peritonitis, give single dose ceftriaxone1 1g IV or IM. • If severe dysmenorrhea, give single dose tramadol 50mg IM. If pain subsides, manage below, otherwise refer. Approach to the patient with abdominal pain not needing urgent attention • If sexually active woman with lower abdominal pain and abnormal vaginal discharge 38. • If pain just before or during menses, dysmenorrhea likely: if abdominal mass refer. Otherwise reassure patient and give ibuprofen 400mg PO TID, starting at onset of pain for few days of menses every month for 4 to 6 months. If no better, refer. • If the patient has urinary symptoms 44. If the patient is constipated 35. • Do stool microscopy: - - If positive give the following treatment: • If giardiasis, give single dose tinidazole 2g PO. • If amoebiasis, give metronidazole 500mg PO TID for 5-7 days. • If strongyloidiasis, give albendazole 400mg PO BID for 3 days. • If other parasites, give albendazole 400mg PO once daily for 3 days. - - If stool microscopy negative, manage below: Yes Dyspepsia (heartburn) likely • Advise to avoid caffeine and if heartburn at night, prop up head of bed and avoid eating late at night. • Stop NSAIDS (e.g. ibuprofen), aspirin. • Ask about smoking. If patient smokes tobacco 102. Support patient to change 125. • If drinks alcohol ≥ 4 drinks2 /session 103. • If waist circumference > 80cm (woman) or 94cm (man), encourage weight loss and assess CVD risk 84. • Avoid serologic H pylori tests as they are not specific and not useful for management decisions. • Give omeprazole 20mg BID for 4 weeks. Refer if any of: no better after 14 days of omeprazole, new onset pain and > 50 years, pain on swallowing, persistent vomiting, weight loss, loss of appetite, early fullness, blood in stool or occult blood positive, abdominal mass or uncertain of diagnosis. No Has patient lost weight? Does patient have epigastric pain which is worse with eating, hunger or lying down/bending forward? • Give paracetamol 1g PO QID as needed for up to 5 days. • Review regularly until pain resolves or a cause is found. Yes Does patient have any of: cough, night sweats, fever or HIV? No Consider cancer. Refer same week. Yes • Tapeworm or worm segments: give single dose praziquantel 600mg PO or albendazole 400mg PO once daily for 3 days. • Other worm or unsure: give single dose albendazole 400mg. • Educate on personal hygiene. No If pain is recurrent and relieved when passing stool, with constipation and/ or diarrhoea and bloating, irritable bowel syndrome likely. Refer to hospital. No Does the patient report worms? Yes Exclude TB 71. 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid ceftriaxone and refer. 2 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
Adult 33 Nausea or vomiting Give urgent attention to the patient with nausea or vomiting and one or more of: • Headache: consider brain bleeding, meningitis, abscess or tumor22 • Chest pain: consider heart attack 28 • Sudden severe upper abdominal pain spreading to back: consider perforated duodenal ulcer or pancreatitis • Signs of severe dehydration: decreased urine output, drowsiness/confusion, BP < 90/60, pulse ≥ 100 • Peritonitis (guarding, rigidity or rebound tenderness): consider acute abdomen • Vomiting blood: consider gastric/duodenal ulcer or oesophageal bleeding • Jaundice (yellowish eyes): consider hepatitis, bile duct obstruction or gall bladder infection • Abdominal pain/distention and no stools or flatus: consider intestinal obstruction. • If drowsiness, confusion, abdominal pain, rapid deep breathing: consider DKA, check glucose 86. • If pregnant, signs of severe dehydration and ketone in urine, hyperemesis gravidarum likely. • If on ART, check for urgent side effects such as lactic acidosis 80. Management: • Secure IV line with normal saline and advise patient not to take anything by mouth • If severe dehydration, give normal saline 1L IV rapidly, repeat until systolic BP > 90. Stop if breathing worsens. • If hyperemesis gravidarum, give normal saline as above: add 2 vials of glucose 40% and 2 ampoules of vitamin B complex in each 1L bag. Also give chlorpromazine 25mg IM or promethazine 25mg IM. • Refer urgently. Approach to the patient with nausea or vomiting not needing urgent attention • Exclude pregnancy. • If associated dizziness 21. • Review medication: NSAIDs (e.g. ibuprofen), metformin, contraceptives, hormone therapy, theophylline, chemotherapy and morphine can cause nausea/vomiting. If on TB medication 73 or ART 80. • Screen for substance use/abuse: in the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. • If patient is terminally sick and survival is predicted to be short, also give palliative care 120. Does patient have epigastric pain which is worse with eating, hunger or lying down/bending forward? Dyspepsia (heartburn) likely • Advise to avoid caffeine and if heartburn at night, prop up head of bed and avoid eating late at night. • Stop NSAIDS (e.g. ibuprofen), aspirin. • Ask about smoking. If patient smokes tobacco 102. Support patient to change 125. • If waist circumference > 80cm (woman) or 94cm (man), encourage weight loss and assess CVD risk 84. • Give omeprazole 20mg BID for 4 weeks. Refer if any of: no better after 14 days of omeprazole, new onset pain and > 50 years, pain on swallowing, persistent vomiting, weight loss, loss of appetite, early fullness, blood in stool or occult blood positive, abdominal mass or uncertain of diagnosis. No Viral infection or food poisoning likely • If new onset vomiting, usually with diarrhoea, cramping abdominal pain, loss of appetite, body pains and weakness, reassure patient that vomiting/diarrhoea should resolve within 1-3 days. • Give metoclopramide 10mg TID as needed for up to 5 days. • If vomiting/diarrhoea, give oral rehydration solution. • Advise patient to drink lots of fluids, eat small frequent meals as able and avoid fatty food. • Refer if any of: - - Vomiting persists > 3 days - - Not tolerating oral fluids or needing urgent attention as above - - Nausea persists > 2 weeks - - Uncertain of cause Yes 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
Adult 34 Give urgent attention to the patient with diarrhoea and one or more of: • Dehydration: thirst, dry mouth, poor skin turgor, sunken eyes, decreased urine output, drowsiness/confusion, BP < 90/60 or postural drop of systolic BP > 20mmHg, pulse ≥ 100 • Large volumes of watery stools: cholera likely Management: • Give oral rehydration solution (ORS). If unable to drink or BP < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. If no improvement after IV rehydration, refer to hospital. • If cholera likely: Isolate patient and follow standard infection prevention precautions 122; manage according to degree of dehydration: - - If no/some dehydration, give oral rehydration solution. - - If unable to drink or severe dehydration, give Ringer’s lactate IV: 30mL/kg over 30 minutes followed by 70ml/kg over 2 and ½ hours and single dose doxycycline1 300mg. - - Discuss with the head of the facility and/or Woreda Health Office and review after 6 hours: • If no dehydration and < 3 liquid stools in past 6 hours, consider discharge. Give enough ORS for home treatment for 2 days. Advise patient to return if vomiting, diarrhea worsens or drinking/ eating poorly. • If still dehydrated or > 3 liquid stools in past 6 hours, continue rehydration. If patient is known with diabetes, heart disease or has no urine output, refer to hospital. Diarrhoea Approach to the patient with diarrhoea not needing urgent attention • Confirm patient has diarrhoea: ≥ 3 watery or loose stools/day. Ask about duration of diarrhoea. • Do stool microscopy for ova or parasite and inflammatory cells. • Advise patient to take more fluids, eat small frequent meals when able and avoid sweet/caffeinated drinks. • Give oral rehydration solution to prevent dehydration. If patient is terminally sick and survival is predicted to be short, give palliative care 120. Positive Negative If diarrhoea persists despite treatment or cause is not clear, refer to hospital. Review stool microscopy result. Avoid antibiotics. Diarrhoea for ≤ 2 weeks HIV negative/unknown HIV positive Diarrhoea for > 2 weeks Knowing the patient’s HIV status helps in the management. Test for HIV 75. • Avoid antibiotics. • Review medication: omeprazole, NSAIDs (e.g. ibuprofen) and metformin can cause diarrhoea. Consider change of medication if diarrhoea persists. • Give loperamide 4mg PO initially, then 2mg after each loose stool, maximum 16mg/day. • Give routine HIV care 76. • Lopinavir/ritonavir can cause ongoing diarrhoea. • ART not started or ART failed, treat for possible Isospora belli and microsporidiosis with co-trimoxazole 2 tablets of 960mg PO BID for 21 days and albendazole 400mg PO BID for 14 days. • Give loperamide 4mg PO initially, then 2mg after each loose stool, maximum 16mg/day. Review in 2 weeks if diarrhoea still present. If diarrhoea for > 2 weeks, test for HIV 75. • Give metronidazole2 500mg PO TID for 5-7 days. • If no response within 2 days, add ciprofloxacin1 500mg BID for 5 days Amoebic trophozoite and RBC/WBC seen • Give ciprofloxacin 500mg PO BID for 5 days. • If pregnant, give instead azithromycin 1g PO daily for 5 days. RBC/WBC only seen • If amoebiasis, give metronidazole2 500mg PO TID for 5-7 days. • If giardiasis, give single dose tinidazole2 2g PO. • If strongyloidiasis, give albendazole 400mg PO BID for 3 days. • If other parasites, albendazole 400mg PO daily for 3 days. Ova or parasite only seen 1 Avoid if pregnant. 2 Advise no alcohol until 24 hours after last dose of metronidazole/tinidazole.
Adult 35 Constipation Anal symptoms Give urgent attention to the patient with constipation and: • No stools or flatus/wind in the last 24 hours with abdominal pain/distention and vomiting Management: • Refer same day. Give urgent attention to the patient with anal symptoms and one or more of: • Extremely painful lump on anus • Unable to pass stool because of anal symptoms Management: • 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). • Ask about regular use of enemas or laxatives. • Exclude pregnancy. If pregnant 112. • If weakness/tiredness, weight gain, low mood, dry skin or cold intolerance, hypothyroidism likely. Refer to hospital • If patient is terminally sick and survival is predicted to be short, give palliative care 120. • If > 65 years, bed-bound or receiving palliative care, check for impaction (solid immobile bulk of stool in rectum). If impacted, gently remove stool from rectum using lubrication. Follow with liquid paraffin 10ml TID per-rectum as needed. If bleeding or severe pain, stop and refer. • Advise a high fibre diet (vegetables, fruit, wholemeal cereals, 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 bisacodyl 5mg daily at night, increasing to maximum of 15mg as needed for 3-5 days. If on codeine/morphine, continue bisacodyl 5-10mg daily at night. • If no response after 1 week of laxative use, recent change in bowel habits, weight loss, blood in stool or occult blood positive, or uncertain cause for constipation, refer. Assess patient with anal pain, bleeding, discharge or itch/irritation. If patient has anal sex, also ask about genital symptoms 36. Crack/s Lump/pile Ulcer/s • Advise as for constipation above and to take sits baths. • If constipated, give bisacodyl as above. • Give bismuth compound one suppository BID for 5 days. • Advise as for constipation above and to avoid straining. • Apply hydrocortisone 1% cream BID for 5 days. If no better with treatment, refer. Treat as for genital ulcer 39. Perianal warts Red/raw skin Suspected worms Treat as for genital warts 40. • Advise good hygiene. • Look for contact cause. If diarrhoea 34. • Apply petroleum jelly to raw areas. If severe itching, also apply hydrocortisone 1% cream BID for 5 days. • Give single dose mebendazole 100mg and repeat dose 14 days later. If pregnant, give instead pyrantel pamoate 11mg/kg and repeat dose 14 days later. • Treat family members at the same time.
Adult 36 Genital symptoms 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), omit ceftriaxone and increase azithromycin dose to 2g orally. 2 Avoid if pregnant. Assess the patient with genital symptoms and his/her partner/s Assess Note Symptoms Ask about genital discharge, rash, itch, lumps, ulcers and manage as below. Manage other symptoms as on symptom pages. STI risk Ask if patient or his/her regular partner has new or multiple partner/s, unreliable condom use or substance abuse 103. Abuse Ask about sexual assault. If yes 66. Ask if patient is unhappy in relationship. If yes 65. Family planning Assess patient’s contraception needs 110 and discuss infertility. Exclude pregnancy. If pregnant 112. Examination • Woman: examine abdomen for masses, look for genital discharge, ulcers, rash, lumps. Do bimanual palpation for cervical tenderness or pelvic masses and speculum examination for cervical abnormalities. • Man: look for discharge, inguinal lymph nodes, ulcers, scrotal swelling or masses. HIV If status unknown, test for HIV 75. Syphilis Test for syphilis if patient has an STI, is pregnant, was raped or whose partner has an STI. If positive 41. Cervical screen • If HIV negative, screen 5 yearly from age 30 to 49. If HIV positive, screen at HIV diagnosis (regardless of age) then 5 yearly. If abnormal 40. • Do cervical screen once an abnormal discharge has been treated 38. If cervix looks suspicious of cancer, refer same week. Advise the patient with genital symptoms and his/her partner/s • Discuss safe sex: provide male and female condoms, advise patient to stick to one partner at a time. • If patient has a sexually transmitted infection (STI) : - - Educate patient about cause and that an STI increases risk of HIV transmission. Urge patient to adhere to treatment and abstain from sex for duration of treatment and until at least 1 week after treatment. - - Stress importance of partner treatment and issue partner notification slip with the patient’s diagnosis for each partner. Treat the patient with genital symptoms and his/her partner/s Scrotal swelling/pain 37 Ulcer/s 39 Lump/s Groin 18 Skin 40 Discharge Man 37 Woman 38 Itch Discharge in woman 38 Glans penis 37 Pubic area 40 Patient’s diagnosis Treat the patient’s partner/s according to the patient’s diagnosis as well as the partners’ symptoms (if any) Cervicitis (Vaginal discharge) Give partner ciprofloxacin 500mg PO stat or ceftriaxone1 250mg IM and azithromycin 1g PO stat or doxycycline 100mg PO BID for 7 days. Pelvic inflammatory disease (Lower abdominal pain) Give partner ciprofloxacin 500mg PO stat or ceftriaxone1 250mg IM and azithromycin 1g PO stat or doxycycline 100mg PO BID for 7 days. Male urethritis (Urethral discharge) Give partner ciprofloxacin2 500mg PO stat or ceftriaxone1 250mg IM and azithromycin 1g PO stat or doxycycline2 100mg PO BID for 7 days. Epididymitis/epididymo-orchitis (Scrotal swelling) Give partner ciprofloxacin2 500mg PO stat or ceftriaxone1 250mg IM and azithromycin 1g PO stat or doxycycline2 100mg PO BID for 7 days. Genital ulcer disease Give partner single dose benzathine benzylpenicillin 2.4MU IM and either ciprofloxacin2 500mg PO BID for 3 days or single dose azithromycin 1g PO or erythromycin 500mg PO QID for 7 days. If penicillin allergic, replace benzylpenicillin with doxycycline2 100mg PO BID for 14 days. RPR positive Give partner single dose benzathine benzylpenicillin 2.4MU IM. If penicillin allergic, give instead doxycycline 100mg PO BID for 14 days. If pregnant, avoid doxycycline 41. Balanitis/balanoposthitis Give female partner clotrimazole vaginal tablet 200mg inserted at night for 3 days or clotrimazole 1% vaginal cream applied once at night for 7 days. Pubic lice Give partner permethrin 1% or 5% thin film to be applied for 10 minutes then washed off 40. Inguinal bubo (swelling) without ulcer Give partner doxycycline 100mg PO BID for 14 days. If pregnant, give instead erythromycin 500mg PO QID for 14 days.
Adult 37 Genital symptoms in a man Approach to the man with genital symptoms not needing urgent attention First assess and advise the patient and his partner/s 36. Male urethritis likely • Give single dose: ceftriaxone 250mg IM or spectinomycin 2g IM or ciprofloxacin 500mg PO and • Give single dose azithromycin 1g PO or doxycycline 100mg PO BID for 7 days. • If partner has cervicitis/vaginitis, also give single dose metronidazole1 2g PO. • Treat patient’s partner/s 36. Balanitis/balanoposthitis likely • Advise patient to wash daily with water, avoid soap. Retract foreskin while washing then dry fully. • Give clotrimazole cream BID for 7 days. • Offer referral for medical male circumcision, especially if persistent/ recurrent or difficulty retracting foreskin. • Treat patient’s partner/s 36. • Advise patient to return in 7 days if symptoms persist: - - If adherence poor, repeat treatment. - - Test for diabetes 86 and HIV 75. • If still no better, refer. Give urgent attention to the man with genital symptoms and one or more 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 reduced with swollen and very painful glans: paraphimosis likely • Prolonged erection > 4 hours: priapism likely Management: • If torsion of testicle or priapism likely: refer urgently. • If paraphimosis likely: - - If glans blue/black: refer urgently. - - If not, attempt manual reduction: apply lidocaine 2% gel to glans, then wrap glans in gauze. Apply increasing pressure for 10-15 minutes until foreskin can be replaced over glans. If unsuccessful, refer urgently. Advise patient to return in 7 days if symptoms persist: • If not adherent or was re-exposed, repeat treatment. • If fully adherent and no re-exposure: - - Give single dose ceftriaxone 250mg IM and - - Single dose azithromycin 2g PO and - - Single dose metronidazole1 2g PO (if not already given) or tinidazole1 1g PO once daily for 3 days. - - If severe penicillin allergy2 , omit ceftriaxone and refer. Painless swelling Pain with/without swelling Urethral discharge © University of Cape Town Scrotal symptoms © University of Cape Town Painful, itchy or smelly glans © University of Cape Town 1 Advise no alcohol until 24 hours after metronidazole or last dose of tinidazole. 2 Penicillin allergy with angioedema, anaphylaxis or urticaria. • If firm lump, testicular cancer likely: refer to hospital. • If soft lump, hydrocele likely: if large or uncomfortable, refer to hospital; otherwise advise patient to return if it becomes larger, painful or uncomfortable. Epididymitis/epididymo-orchitis likely • Give single dose ceftriaxone 250mg IM or spectinomycin 2g IM or ciprofloxacin 500mg PO and • Give doxycycline 100mg PO BID for 14 days. • Treat patient’s partner/s 36. • For pain, give paracetamol 1g PO QID as needed for up to 5 days. If no response, also give ibuprofen 400mg PO TID with food for up to 5 days (avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • If no better after 7 days, refer.
Adult 38 Vaginal symptoms Is there lower abdominal pain or cervical motion tenderness? If abnormal vaginal bleeding 42. If vaginal discharge or mass, manage below. Vaginal discharge • It is normal for a woman to have a vaginal discharge. Abnormal discharges are itchy or different in colour or smell. Not all women with a discharge have an STI. • First assess and advise the patient and her partner/s 36. If the vulva is red, scratched and inflamed or cheese/curd-like discharge, vaginal candida likely: • Give clotrimazole vaginal tablet 200mg inserted at night for 3 days or single dose fluconazole 150mg PO. • If severe, give instead single dose fluconazole 150mg PO and repeat after 3 days. If patient known with cervical cancer, and survival is predicted to be short, give palliative care 120. Vaginal mass Vaginal/uterine prolapse likely • If cough 29; constipation 35; menopause 119. • Examine to confirm prolapse. If unsure, refer. • If no ulcer on prolapse, refer for surgery. • If ulcer present on prolapse: - - Apply oestrogen cream or crushed oral contraceptives in petroleum jelly daily for 1 month. - - Advise patient to reinsert prolapse regularly and avoid strenuous activity. - - Review after 1 month: If healed, refer for surgery. If not healed, refer for further evaluation. No Treat for vaginitis (trichomoniasis/bacterial vaginosis): • Give metronidazole1 500mg PO BID for 7 days. • If recurrent vaginitis, also give partner single dose metronidazole1 2g PO. Does patient have any of: < 25 years, > 1 partner, new partner and unprotected sex in last 3 months, ever traded for sex or partner/s with STI? Review in 7 days: • If ongoing discharge: examine cervix for cancer and do cervical screen40. • If ongoing vaginal candida also test for diabetes 86 and HIV 75. • Refer same week. Give urgent attention to the patient with vaginal discharge and lower abdominal pain/cervical motion tenderness and any of: • Recent miscarriage/delivery/abortion • Pregnant or missed/overdue period • Peritonitis (guarding, rigidity or rebound tenderness) • Abnormal vaginal bleeding • Temperature ≥ 38°C • Abdominal mass Management: • If BP < 90/60, give normal saline 1L IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • Give ceftriaxone 1g IV and metronidazole1 500mg IV infusion/orally. If severe penicillin allergy3 , omit ceftriaxone and refer. • Refer same day for surgical/gynaecological assessment. Approach to the patient with lower abdominal pain or cervical motion tenderness not needing urgent attention: Lower abdominal pain only, no cervical motion tenderness Check urine dipstick. If WBC/nitrites positive, urinary tract infection likely 44. If WBC/nitrites negative, treat below. Also treat for cervicitis (gonorrhoea & chlamydia): • Give single dose ceftriaxone 250mg IM and • Give doxycycline2 100mg PO BID for 7 days or single dose azithromycin 1g PO, if available. • If severe penicillin allergy3 , omit ceftriaxone and increase azithromycin to 2g. • Treat the patient’s partner/s 36. Cervical motion tenderness with or without lower abdominal pain Pelvic inflammatory disease likely • Give single dose ceftriaxone 250mg IM or if severe penicillin allergy3 , give instead single dose ciprofloxacin 500mg PO and • Give doxycycline 100mg PO BID for 14 days and metronidazole1 500mg PO BID for 14 days. • For pain, give paracetamol 1g PO QID as needed for up to 5 days. If no response, also give ibuprofen 400mg PO TID with food for up to 5 days (avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • Treat the patient’s partner/s 36. • Review within 3 days. If no better, refer same day. 1 Advise no alcohol until 24 hours after last dose of metronidazole. 2 Avoid if pregnant and give single dose azithromycin 1g PO instead. 3 Penicillin allergy with angioedema, anaphylaxis or urticaria. Yes Yes No
Adult 39 • First assess and advise the patient and his/her partner/s 36. • The patient may have blister/s, sore or ulcer. Also treat for early syphilis and chancroid: • Give single dose benzathine benzylpenicillin 2.4MU IM or if penicillin allergic and not pregnant/breastfeeding, doxycycline 100mg PO BID for 14 days and • Give single dose azithromycin 1g PO or ciprofloxacin 500mg PO BID for 3 days or erythromycin 500mg PO QID for 7 days. - - If penicillin allergic and pregnant/breastfeeding, give ceftriaxone 1g IM daily for 8-10 days. - - If penicillin allergic, do baseline RPR. Advise patient to return for repeat RPR in 6 and 12 months. If RPR positive after 12 months, refer. • If vaginal/urethral discharge, also treat patient and partner/s for gonorrhoea (chlamydia already covered for above): give single dose ceftriaxone2 250mg IM. No No Check if patient also has hot tender swollen inguinal nodes (discrete, movable and rubbery). Also treat patient and partner/s for lymphogranuloma venereum: • Give ciprofloxacin 500mg PO BID for 3 days and doxycycline 100mg PO BID for 14 days. If pregnant/breastfeeding, give instead erythromycin 500mg PO QID for 14 days. • If fluctuant lymph node (hernia and aneurysm excluded), aspirate pus through healthy skin in sterile manner every 3 days as needed. Avoid making incisions. • Review after 14 days. If no better, refer. © University of Cape Town Yes Yes If no better after 7 days, refer. First episode, solitary or non-vesicular ulcer? Genital ulcer Treat for herpes: • Start as soon as possible after onset of symptoms: - - If first episode, give aciclovir 400mg PO TID for 10 days. - - If recurrent episode, give aciclovir 400mg PO TID for 5 days. If impaired immunity1 , give aciclovir 400mg PO TID for 10 days. • For pain: - - Advise sitz baths as needed (sit for 10 minutes in lukewarm water with no salts). - - Give lidocaine 2% gel applied topically to lesions TID as needed. - - Give paracetamol 1g PO QID as needed for up to 5 days. If no response, also give ibuprofen 400mg PO TID with food for up to 5 days (avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • Keep lesions clean and dry. • Explain that herpes infection is lifelong and that herpes transmission can occur even when asymptomatic. Advise patient to use condoms and to abstain from sex when symptomatic. The likelihood of HIV transmission is increased when there are ulcers. • If recurrent episodes are severe or > 6 in 1 year or cause distress, refer © University of Cape Town 1 Known with HIV or lymphoma, pregnant or receiving chemotherapy or corticosteroids. 2 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), omit ceftriaxone and refer.
Adult 40 Other genital symptoms Cervical screening First assess and advise patient and partner/s 36. • A cervical screen detects cervical abnormalities which occur before cancer develops. Cervical cancer is caused by certain types of human papilloma virus (HPV) which is usually transmitted sexually. • Visual inspection with acetic acid (VIA) is the cervical screening method that is recommended at health centers and should be performed by trained personnel. • Women who smoke are more likely to have cervical abnormalities. If patient smokes tobacco 102. Support patient to change 125. • If HIV-negative and asymptomatic, do a cervical screen from age 30, then 5 yearly if the result is normal till age 49. • If HIV-positive and asymptomatic, do a cervical screen at HIV diagnosis (regardless of age), then 5 yearly if the result is normal. • No screening needed if age ≥ 50, > 30 weeks pregnant or previous total hysterectomy for benign case. Inform patient of symptoms of cervical cancer (abnormal vaginal bleeding, vaginal discharge, postcoital/contact bleeding) and advise her to return should they occur. Manage according to VIA: • If normal: arrange repeat VIA after 5 years. • If VIA abnormal, treat with cryotherapy using double freeze (3 minutes freeze, 5 minutes defrost, 3 minutes freeze) technique. • After treatment, continue screening every year. • If suspicious of cancer, refer same week. Lumps Itchy rash in pubic area Molluscum contagiosum • Papules with central dent • Usually self- limiting and no treatment required. • If HIV positive, should resolve with ART. • If no response to treatment, refer. Pubic lice • Treat patient and partner/s • Apply thin film of permethrin 1% or 5% cream to affected areas and adjacent hairy areas. Wash off after 10 minutes. Avoid mucous membranes, urethral opening and raw areas. Repeat after 7 days if needed. • Wash all clothes, sheets and blankets in very hot water. • Iron all clothing • Shave pubic area Genital warts • Test for syphilis. If positive 41. • Choose treatment based on availability and/or patient choice. • Patient administered: - - Apply imiquimod 5% cream directly to warts. Wash off after 6-10 hours. Apply 3 times weekly for 16 weeks. - - Alternatively, apply podophyllotoxin 0.5% cream BID for 3 days followed by 4 days of no treatment. Repeat cycle up to 4 times. • Provider administered: - - Apply Vaseline® to surrounding normal skin and then apply trichloroacetic acid 30-90% solution directly to warts weekly until wart resolves. - - Alternatively, apply podophyllin resin 10-25% directly to warts. Wash after 1-4 hours. Repeat weekly until wart resolves. • Do cervical screen. © University of Cape Town • If warts > 1cm, multiple, in vagina or on cervix, pregnant or medications not available, refer. • Reassure patient that most warts resolve spontaneously within 2 years. Scabies • Treat patient, partner/s and household contacts • Apply permethrin 5% from the neck down. Wash off after 8-14 hours. Avoid mucous membranes, urethral opening and raw areas. • Repeat after 1 week if needed. © BMJ Best Practice • Wash clothes in hot water or iron clothes after normal wash.
Adult 41 Positive syphilis result Approach to the patient with a positive RPR result First assess and advise the patient and his/her partner/s 36. Does patient have a genital ulcer or signs of secondary syphilis1 ? • Treat for late syphilis: - - Give benzathine benzylpenicillin 2.4MU IM weekly for 3 weeks. - - If penicillin allergic and not pregnant/breastfeeding, give instead doxycycline 100mg PO BID for 28 days. - - If penicillin allergic and pregnant/breastfeeding, give instead erythromycin 500mg PO QID for 30 days. • Repeat RPR in 6, 12 and 24 months. If positive RPR at 24 months, refer. • Treat partner/s36. Is there a negative RPR from the last 2 years? • Treat for early syphilis: - - Give single dose benzathine benzylpenicillin 2.4MU IM. - - If penicillin allergic and not pregnant/breastfeeding, give instead doxycycline 100mg PO BID for 14 days. - - If penicillin allergic and pregnant/breastfeeding, give instead ceftriaxone 1g IM daily for 8-10 days. • Repeat RPR in 6 and 12 months. If RPR positive at 12 months, refer. • Treat partner/s 36. • Treat for late syphilis: - - Give benzathine benzylpenicillin 2.4MU IM weekly for 3 weeks. - - If penicillin allergic and not pregnant/breastfeeding, give instead doxycycline 100mg PO BID for 28 days. - - If penicillin allergic and pregnant/breastfeeding, give instead erythromycin 500mg PO QID for 30 days. • Repeat RPR in 6, 12 and 24 months. If RPR positive at 24 months, refer. • Treat partner/s 36. Manage the newborn of the RPR positive mother: • If baby well and mother fully treated > 1 month before delivery: give single dose benzathine benzylpenicillin 50 000 units/kg IM. • If signs of congenital syphilis2 , or mother not fully treated or treated < 1 month before delivery, refer to hospital. Is previous RPR result available? 1 The signs of secondary syphilis occur 4-8 weeks after the primary ulcer and include a generalized rash (including palms and soles), flu-like symptoms, flat wart-like genital lesions, mouth ulcers and patchy hair loss. 2 Signs of congenital syphilis are rash (red/blue spots or bruising especially on soles and palms), jaundice, pallor, distended abdomen, swelling, low birth weight, runny nose/respiratory distress, hypoglycaemia. No No No Yes Yes Yes
Adult 42 Abnormal vaginal bleeding (AVB) Give urgent attention to the patient with vaginal bleeding and one or more of: • Pregnant 112 • BP < 90/60 • Postpartum 116. • Following miscarriage/abortion 112 • Pallor with pulse ≥ 100, respiratory rate > 30, dizziness/faintness or chest pain Management: • If BP < 90/60, give normal saline 1L IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • Refer urgently. Approach to the patient with abnormal vaginal bleeding not needing urgent attention • Do a bimanual palpation for pelvic masses, a speculum examination to visualise cervix and a cervical screen 40. If abnormal, refer. • If > 40 years, ask about menopausal symptoms: hot flushes, night sweats, vaginal dryness, mood changes, difficulty sleeping and sexual problems 119. If new bleeding occurs > 1 year after final period, refer same week. • If patient is not menopausal determine the type of bleeding problem: Heavy regular bleeding (interferes with quality of life) or clots or bleeding > 7 days each period Periods have irregular pattern (< 21 days or > 35 days between periods) Bleeding after sex • Assess for STI 36. • If assault or abuse 66. • If weight change, pulse ≥ 100, tremor, weakness/ tiredness, dry skin, constipation or intolerance to cold or heat, refer to hospital. • Give combined oral contraceptive: ethinylestradiol/ levonorgestrel 30/150mcg for 6 months. • If pregnancy desired, refer instead. Refer the patient within 2 weeks if: • Unsure of diagnosis • Bleeding > 1 week after STI treatment, or after diarrhoea/vomiting stop • Bleeding persists after 3 months on treatment. • Abnormal cervix on speculum examination (suspicious of cancer) Oral contraceptive: • Ensure correct use. • If ≥ 2 days diarrhoea/ vomiting, advise condom use (continue for 7 days once diarrhoea/vomiting has resolved). • If on ART, rifampicin or phenytoin, change to injection/IUD. • If on ethinylestradiol/ levonorgestrel 30/150mcg, change to ethinylestradiol/ norethisterone 35mcg/1mg for 3 cycles. Injectable contraceptive or subdermal implant: • Reassure (common in first 3 months). • If bleeding persists, give combined oral contraceptive: ethinylestradiol/ levonorgestrel 30/150mcg for 3 cycles. • If combined oral contraceptive contraindicated (heart disease, thrombo-embolic conditions, liver disease, migraine headache, genital tract cancer), give instead ibuprofen 400mg PO TID with food for 5 days (avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease). Spotting between periods • Assess for STI 36. • If on hormonal contraceptive, manage according to method: Has the patient been bleeding elsewhere (gums, easy bruising, purple rash)? Yes • Check complete blood count. • Refer to hospital same week. No • If Hb ≤ 12g/dL, give ferrous sulphate 200mg (65mg elemental iron) 1 tablet PO TID until 3 months after Hb reaches 12g/dL. • Give combined oral contraceptive: ethinylestradiol/ levonorgestrel 30/150mcg for 3 cycles 110. • If combined oral contraceptive contraindicated (heart disease, thrombo-embolic conditions, liver disease, migraine headache, genital tract cancer), or pregnancy desired, give instead ibuprofen 400mg PO TID with food for 5 days (avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • If on injectable contraceptive or subdermal implant: reassure (common in first 3 months). If bleeding persists, give combined oral contraceptive or ibuprofen as above. • Refer the patient: - - Same week if mass in abdomen - - If no better after 3 months on treatment - - If excessive bleeding after IUD insertion
Adult 43 Sexual problems Problems getting or maintaining an erection Does patient often wake with an erection in the morning? No • Assess and manage CVD risk 84. • Review medication: propranolol, atenolol, hydrochlorothiazide, spironolactone, fluphenazine decanoate, fluoxetine and amitriptyline can cause sexual problems. Consider changing medication. • Screen for substance use/ abuse: In the past year, has patient: 1) drunk ≥ 4 drinks1 / session, 2) used khat or illegal drugs or 3) misused prescription or over-the- counter medications? If yes to any 103. • If patient smokes tobacco 102. Support patient to change 125. • Assess and manage stress 65. • If no better once chronic condition/s stable and treatment optimised, refer. Yes • If genital symptoms 36. • If urinary symptoms 44. • Review medication: herbal medication, antidepressants and schizophrenia treatment can cause painful ejaculation. Consider changing medication. • If no cause found or painful ejaculation or erection continues, refer. Superficial pain • If genital symptoms 36. • If urinary symptoms 44. • Ask about vaginal dryness: - - If woman > 40 years, ask about menopausal symptoms: hot flushes, night sweats, mood changes and difficulty sleeping 119. - - Review medication: oral or injectable contraceptive, antidepressants and hypertension treatment can cause vaginal dryness. Consider changing medication. • Advise patient to use lubricant during sex. Ensure it is condom- compatible, avoid using petroleum jelly with condoms. Deep pain • If genital symptoms 36. • Refer if: - - Heavy, painful or prolonged periods - - Infertility - - Abdominal/pelvic mass • Assess and manage stress 65. • Ask about relationship problems, anxiety/ fear about sex, unwanted pregnancy, infertility and performance anxiety. • If sexual assault or abuse 66. • In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. • Discuss condom use. Ensure patient knows how to use condoms correctly. Pain with sex (vaginal) Painful erection orejaculation Loss of libido Ask if pain with sex or if problem with erections. Assess and manage in adjacent columns. • Assess and manage stress 65. • Review medication: phenytoin, metoprolol, hydrochlorothiazide, spironolactone, chlorpromazine, fluphenazine decanoate, risperidone, fluoxetine, amitriptyline and lopinavir/ ritonavir can cause loss of libido. Consider changing medication. • In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. • Screen for substance use/abuse: In the past year, has patient: 1) drunk ≥ 4 drinks1 / session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. • Ask about relationship problems, anxiety/ fear about sex, unwanted pregnancy, infertility and performance anxiety. • If woman > 40 years, screen for menopause 119. • If sexual assault or abuse 66. • Assess the patient’s contraception needs 110. Is the pain superficial or deep? • Assess and manage stress 65. • If sexual assault or abuse 66. Ask about problems getting or maintaining an erection, pain with sex, painful ejaculation or loss of libido: If sexual problems do not improve, refer to hospital. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
Adult 44 Urinary symptoms Give urgent attention to the patient with urinary symptoms and one or more of: • Unable to pass urine with lower abdominal discomfort/distention • Flank pain with leucocytes/nitrites on urine dipstick and any of: vomiting, BP < 90/60, pulse ≥ 100, temperature > 39°C, pregnant, ≥ 60 years or chronic illness: complicated pyelonephritis likely. Manage and refer urgently: • If unable to pass urine, insert urinary catheter. • If complicated pyelonephritis likely, give ceftriaxone1 1g IV/IM. If pyelonephritis not complicated, treat below. If unsure about diagnosis or severe pain, refer. If BP < 90/60, give normal saline 250mL IV rapidly, 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 pyelonephritis not complicated: send urine for microscopy. Give ciprofloxacin 500mg PO BID for 10 days and paracetamol 1g PO QID. If no better after 2 days, refer. • Ask about blood in urine, burning urine and flow problem. Check urine dipstick. Blood in urine Has patient been in bilharzia area? Woman Is patient pregnant, catheterised, known with diabetes or urinary tract problem? Flow Problem Check dipstick and microscopy to exclude urinary tract infection. Leakage of urine Urinary incontinence likley • Review use of furosemide • Look for vaginal atrophy 119. • Ask about constipation 35. • Advise patient to cut down alcohol and caffeine and to do pelvic muscle exercises3 . • If patient has vaginal prolapse or no response to above measures, refer. Poor stream or difficulty passing urine Benign Prostatic hyperplasia likely. • Review use of amitriptyline. • Refer for assessment. Man No discharge Are there leucocytes and nitrites on midstream urine? Discharge Burning urine or leucocytes/nitrites on urine dipstick If symptoms do not resolve or recurrent urinary tract infections, refer to hospital. Yes Schistosomiasis likely • Give single dose praziquantel 40mg/kg. • To prevent re- infection advise patient to avoid contact with contaminated water. No Does patient have burning urine? No Leucocytes/nitrites on urine dipstick? No No No No Kidney stone likely Refer for investigation. Yes Yes Yes Yes Simple urinary tract infection likely • Give ciprofloxacin 500mg PO BID for 3 days or norfloxacin 400mg PO BID for 3 days. Acute prostatitis likely • Give ciprofloxacin 500mg PO BID for 21 days. • Give ibuprofen 400mg PO TID with food for up to 5 days (avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease). Urethral discharge syndrome likely 37. Check for tender prostate. Complicated urinary tract infection likely • Give ciprofloxacin 500mg PO BID for 7 days. • If pregnant, give instead cefalexin 500mg PO BID or amoxicillin2 500mg PO TID for 7 days . 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria) and able to take orally, give instead ciprofloxacin 500mg PO (avoid if pregnant). 2 If penicillin allergic give instead co-trimoxazole 960mg PO BID for 7 days. 3 Repeated contraction and relaxation of pelvic floor muscles. If no response to treatment, refer.
Adult 45 Body/general pain Approach to the patient who aches all over • Check temperature and weight. • Ask about a sore throat, runny/blocked nose or fever in the past 3 days. • If on ART, check for urgent side effects 80. Normal Screen for a joint problem: 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 temperature ≥ 38°C or fever in the past 3 days 17. • If weight loss ≥ 5% of body weight in past 3 months 16. • If sore throat 27. • If runny/blocked nose 26. Unable to do all actions comfortably Examine the joints. Joints are warm, tender, swollen, have limited movement. Arthritis likely 107 Joints are normal. < 3 months • Give paracetamol 1g PO QID as needed for up to 5 days. • Advise patient to return if no better after 2 weeks. Any result abnormal Refer for further assessment. Results all normal • Assess and manage stress 65. • Consider fibromyalgia 109. • Test for HIV 75. • Assess and manage stress 65. • Review patient's medication. If on simvastatin or lovastatin and muscle pain/cramps and weakness, refer to hospital. • If patient is terminally sick and survival is predicted to be short, give palliative care 120. • Ask about duration of pain: Able to do all actions comfortably ≥ 3 months • Give paracetamol 1g PO QID as needed for up to 5 days. Advise to avoid long term regular use. • Check ESR ,urine protein, blood glucose and Hb. • If weakness/tiredness, weight gain, low mood, dry skin, constipation or cold intolerance: hypothyroidism likely. Refer to hospital.
Adult 46 Joint symptoms Give urgent attention to the patient with a joint symptom and: • Short history of single warm, swollen, extremely painful joint with limited range of movement Management: • If recent trauma, immobilise and if available arrange x-ray. • If known with gout, manage as acute gout 108. • Refer urgently. Approach to the patient with a joint symptom not needing urgent attention Check if problem is in the joint: 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. Able to do all actions comfortably Unable to do all actions comfortably Has there been recent trauma? Joint problem unlikely ≥ 6 weeks Chronic arthritis likely 107 No Yes < 6 weeks Recent genital discharge or painless non-itchy skin rash? Musculoskeletal sprain/strain likely • Rest and elevate joint. • Apply ice. • Apply pressure bandage. • Give paracetamol 1g PO QID as needed for up to 5 days. If no response, give ibuprofen 400mg PO TID with food as needed for up to 7 days (avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • Advise patient to mobilise joint after 2-3 days, if not too painful. • Advise to avoid traditional practices like massage. • Review after 1 week: if no better, refer and if available arrange x-ray. Sudden onset of 1-3 warm, extremely painful, red, swollen joints (often big toe or knee)? • If generalised body pain 45. • If back pain 47. • If neck pain 48. • If arm symptoms 48. • If leg symptoms 49. • If foot symptoms 50. Yes No No • Give paracetamol 1g PO QID as needed for up to 5 days. If no response, give ibuprofen 400mg PO TID with food as needed (avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • Test for HIV 75. • Review after 1 month or sooner if joint pain worsens. If worsens, refer. Yes Acute gout likely 108 Gonococcal arthritis likely • Usually involves wrists, ankles, hand and feet. • Refer patient same day. • Treat patient’s partner/s as for cervicitis/male urethritis 36. Ask about duration of joint pain
Adult 47 Back pain Approach to the patient with back pain not needing urgent attention • If pyelonephritis not complicated: send urine for microscopy, culture, sensitivity. Give ciprofloxacin 500mg PO BID for 10 days and paracetamol 1g PO QID as needed. If no better after 2 days, refer same day. • Does patient have any of: cough, weight loss, night sweats or fever? Yes Yes Any of: > 50 years, pain progressive or for > 6 weeks, previous cancer, back surgery or trauma, osteoporosis, oral steroid use, HIV, IV drug use or deformity? Exclude TB 71 and • If available, do back x-ray. • Check ESR. • Refer to hospital. Any of: < 40 years, sleep disturbed by pain, pain better with exercise, does not get better with rest? Mechanical back pain likely • Measure waist circumference: if > 80cm (woman) or > 94cm (man) assess CVD risk 84. • Assess and manage stress 65. • Reassure patient that back pain is very common, normally not serious and will get better on its own. • Advise patient to be as active as possible, continue normal activity and avoid resting in bed. • Advise patient that regular exercise may prevent recurrence of back pain. • Give diclofenac2 /misoprostol 50mg/200mg PO BID or ibuprofen2 400mg PO TID with food for up to 5 days or paracetamol 1g PO QID as needed for up to 5 days . • If degenerative disc disease, consider indomethacin1 25mg PO or 100mg PR BID. • If pain persists > 4 weeks or unable to cope with daily activities, refer for physiotherapy. • If pain persists > 6 weeks, do back x-ray if available and refer to hospital. • If bladder/bowel disturbance, numbness or weakness develops, refer urgently. Inflammatory back pain likely Yes No No No • If available, do back x-ray • Check ESR. • Refer to hospital. Unsure 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid ceftriaxone and refer. 2 Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. Give urgent attention to the patient with back pain and one or more of: • Bladder or bowel disturbance - retention or incontinence • Numbness of buttocks, perineum or legs • Leg weakness or difficulty walking • Recent trauma and x-ray unavailable or abnormal • Sudden severe upper abdominal pain with nausea/vomiting: pancreatitis likely • Any palpable abdominal mass • If flank pain or fever, check urine dipstick: - - If leucocytes/nitrites, pyelonephritis likely. If also vomiting, BP < 90/60, pulse ≥ 100, temperature > 39°C, pregnant, ≥ 60 years or chronic illness: complicated pyelonephritis likely - - If blood with sudden, severe, one-sided pain radiating to groin: kidney stone likely Management: • If pancreatitis likely: give Ringer’s lactate 1L IV rapidly regardless of BP, then give 1L 4 hourly. Stop if breathing worsens. • If abdominal mass: if ruptured abdominal aortic aneurysm suspected avoid giving IV fluids as raising blood pressure may worsen rupture even if BP < 90/60 • If complicated pyelonephritis likely: give ceftriaxone1 1g IV/IM. If pyelonephritis not complicated: 44. If unsure about diagnosis or severe pain, refer. If BP < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • If kidney stone likely: give normal saline 1L IV 6 hourly and ibuprofen2 800mg PO. • Refer urgently.
Adult 48 Neck pain Arm symptoms Give urgent attention to the patient with neck pain and one or more of: • Neck stiffness/meningism and temperature ≥ 38°C: give ceftriaxone1 2g IV/IM or crystalline penicillin1 4M IU IV with chloramphenicol 500mg IV. • Neurological symptoms in arms/legs: weakness, numbness, clumsiness, stiffness, change in gait or difficulty with co-ordination • Recent trauma and x-ray unavailable/abnormal x-ray, or neurological symptoms: immobilise neck with rigid collar and sandbags/blocks on either side of head. Management • Refer urgently. Approach to the patient with neck pain not needing urgent attention Any of: < 20 years, > 55 years, pain progressive or for > 6 weeks, previous cancer/TB/neck surgery, osteoporosis, oral steroid use, HIV, diabetes, IV drug use or unexplained weight loss/fever? Yes • Arrange cervical spine x-rays if available. • Check ESR and refer to hospital. Painful shoulder Referred pain likely Ask about neck pain (see above), cough/difficulty breathing 29, abdominal pain 32, pregnancy 112. Wrist/hand pain: intermittent, worse at night, relieved by shaking. May be numbness/tingling in 1st, 2nd and 3rd fingers or weakness of hand. Carpal tunnel syndrome likely Refer. Elbow pain with or after elbow flexion/extension. May have decreased grip strength. Tennis or Golfer’s elbow (medial/lateral epicondylitis) likely • Advise patient to apply ice to elbow and rest arm. • Give ibuprofen2 400mg PO TID with food for 10 days. • If no better after 6 weeks or worsens, refer. Pain at base of thumb worsened by thumb or wrist movement or catching/locking of finger Tenosynovitis of hand/wrist likely • Rest and splint joint. • Give ibuprofen2 400mg PO TID with food for up to 14 days. • If no better after 6 weeks or worsens, refer. • Give paracetamol 1g QID PO as needed for up to 5 days. • If no arm pain, refer to hospital for physiotherapy. • If no response after 6 weeks, weakness/numbness in arm or hand develops or pain worsens, do cervical spine x-rays if available and refer. No Approach to the patient with arm symptoms not needing urgent attention Give urgent attention to the patient with arm symptoms and one or more of: • Arm pain with chest pain 28. • Recent trauma with pain and limited movement: immobilise, arrange x-ray if available and refer. • If arm/hand cold, pale, decreased pulses or numb or open fracture, refer urgently. • If new sudden weakness of arm, may have difficulty speaking or visual disturbance: consider stroke or TIA 91. Check if problem is in the joint: patient to place hands behind head; then behind back. Bury nails in palm and open hand. Press palms together with elbows lifted. If unable to do all actions comfortably 46. 1 If severe penicillin allergy with previous angioedema, anaphylaxis or urticaria, give chloramphenicol only and refer. 2 Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease.
Adult 49 Leg 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 46. • If the problem is also in the foot 50. Approach to the patient with leg symptoms not needing urgent attention • If constant burning pain, pins/needles or numbness of legs and feet that is worse at night, peripheral neuropathy likely 50 • Review patient’s medication. If on simvastatin and muscle pain/cramps and weakness, refer to hospital. • Is there leg swelling? No Yes 1 Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. Yes Yes Pain in buttock radiating down back of lower leg Muscle pain in legs or buttocks on exercise that is relieved by rest No No No No Both legs swollen Is there difficulty breathing worse on lying flat? One leg swollen Has there been a recent injury? Irritation of sciatic nerve likely • Give paracetamol 1g PO BID and ibuprofen1 400mg PO TID with food only as needed for up to 1 month (avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • Advise patient to be as active as possible, continue normal activity and avoid resting in bed. • Advise patient to return and refer same day if: - - Retention or incontinence of urine or stool - - Numbness of buttocks, perineum or legs - - Leg weakness - - Difficulty walking • If no better after 1 month, refer. Musculoskeletal sprain/strain likely • Ensure patient can bear weight on leg, otherwise refer same day. • Rest and elevate leg. • Apply ice. • Apply pressure bandage. • Advise patient to mobilise leg after 2-3 days, if not too painful. • Give paracetamol 1g PO QID for up to 5 days or give ibuprofen1 400mg PO TID with food up to 7 days (avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • Review after 1 week: if no better, refer to hospital. Heart failure likely 91. Examine skin: are there any painful areas, ulcers, lumps or changes in skin colour? • If pregnant 112. • Check for kidney disease on urine dipstick: if blood or protein, refer to hospital. • If weight loss and MUAC < 21cm, malnutrition likely 70. • If none of the above or unsure, refer to hospital. Yes Yes 53 18 Check for groin lump/s. Refer same week. Peripheral vascular disease likely 96. Give urgent attention to the patient with leg symptoms and one or more of: • Unable to bear weight following injury 14. • Swelling and pain in one calf: deep venous thrombosis likely, especially if BMI > 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 Management: • Refer same day.
Adult 50 Foot symptoms Give urgent attention to the patient with foot symptoms and one or more of: • Unable to bear weight following injury 14. • 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, gangrene or ulceration: critical limb ischaemia likely • On ART and symptoms rapidly worsening over a few weeks, sensation decreased, and/or arms involved: stop ART Management: • Refer same day. 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 46. In the patient with diabetes or PVD, identify the foot at risk. Review more frequently the patient with diabetes or PVD and one or more of: • Skin: callus, corns, cracks, wet soft skin between toes 55, ulcers 59. • Foot deformity: check for bunions (see above). If foot deformity, refer to hospital. • Sensation: light prick sensation abnormal after 2 attempts • Circulation: absent or reduced foot pulses Advise the 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. • Moisten dry cracked feet daily with Vaseline®. Avoid moisturising between toes. • Tell your health worker at once if you have any cuts, blisters or sores on the feet. • Avoid walking barefoot or wearing shoes without socks. Change socks/stockings daily. Inspect inside shoes daily. • Clip nails straight, file sharp edges. Avoid cutting corns/calluses yourself or chemicals/plasters to remove them. • Avoid testing water temperature with feet or using hot water bottles or heaters near feet. Approach to the patient with foot symptoms not needing urgent attention Generalised foot pain Constant burning pain, pins/needles or numbness of feet worse at night Peripheral neuropathy likely • Test for HIV 75. If HIV positive, give routine care 76. • Exclude diabetes 86. • Give amitriptyline 10-75mg at night and paracetamol 1g PO QID. If no response, add ibuprofen 400mg PO TID with food up to 5 days (avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • Refer same week if one-sided, other neurological signs or loss of function. • Check if patient is on IPT, TB treatment or ART: - - If on IPT or TB treatment: give pyridoxine 75mg daily. Localised pain Ensure that shoes fit properly. Heel pain, worse on starting walking Foot deformity Foot pain with muscle pain in legs or buttocks Bony lump at base of big toe; may have callus, redness or ulcer Bunion likely • Advise pain relief as needed: apply ice, give paracetamol 1g PO QID or ibuprofen 400mg PO TID with food for up to 5 days (avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • Advise to wear comfortableshoes when possible. • If severe pain, ulcer or other foot deformity refer. Plantar fasciitis likely • Advise patient to avoid bare feet and to apply ice. • If BMI > 25, assess CVD risk 84. • Give as needed: paracetamol 1g PO QID or ibuprofen 400mg PO TID with food for up to 5 days (avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • Refer to hospital for physiotherapy. Peripheral vascular disease likely 96.
Adult 51 Burn/s Give urgent attention to the patient with burn/s: Give facemask oxygen if: • Burns to face, neck or upper chest • Cough, difficulty/noisy breathing or hoarse voice: inhalation burn likely • Patient drowsy or confused • Oxygen saturation < 90% • Percentage total body surface area (%TBSA burnt) > 15% Remove any sources of heat: • Remove burnt or hot clothing. Immerse burnt skin in cool water or apply cool, wet towels for 30 minutes. • Cover patient with clean, dry sheet to prevent hypothermia. Calculate size and depth of burn: • Calculate percentage total body surface area (%TBSA) burnt using adjacent guide. • If red, blistered, painful, wet: partial thickness burn likely • If white/black leathery, painless, dry: full thickness burn likely Assess and manage fluid needs if %TBSA burnt >10%: • Insert a large-bore IV line in area away from burned skin. If > 15 %TBSA or deep/electrical , insert a second IV line. • Give Ringer’s lactate IV: - - Calculate total volume needed over next 24 hours (mL) = %TBSA burnt x weight(kg) x 4 - - Give half this volume in the first 8 hours after burn. Calculate the hourly volume (mL) = total volume ÷ 2 ÷ 8 • Insert a urine catheter and document urine output every hour. Give medication: • If pain severe, give tramadol 100mg IV/IM. If pain not severe, give paracetamol 1g PO QID. • Give tetanus toxoid 0.5mL IM if none in past 5 years. If unavailable, check for tetanus antitoxin (TAT) hypersensitivity1 : if no reaction, give single dose TAT 3000U SC. If < 3 tetanus vaccine doses in lifetime, also give tetanus immunoglobulin 250 units IM at different site to toxoid with separate syringe. If unavailable, refer to hospital. Give wound care: • Do not rupture blisters. • Cover burn with a non-adherent dressing or wrap in clean, dry sheet and blanket. Keep as sterile as possible. Refer same day the patient with any of: Calculate % total body surface area (TBSA): • Head 9% • Neck 1% • Front 18% • Back 18% • Each arm 9% • Each leg 18% 9% 9% 9% 1% 18% 18% Front 18% Back 18% - - Burn covering > 10% TBSA - - Full-thickness burn of any size - - Burn involves face/neck/hands/feet/genitals/joint - - Circumferential burn of limbs/chest - - Inhalation/electric/chemical burn - - Other injuries • While awaiting transport, monitor vital signs: BP, pulse, respiratory rate, oxygen saturation, level of consciousness and urine output. • Write a referral letter and include details of how burn occurred, vital signs, fluid calculation, details of fluid and other medications given. • Review daily below if not needing same day referral. Review daily the patient with a burn not needing same day referral: • Clean with water and mild soap. Dress wound daily: apply silver sulfadiazine 1% cream and cover with non-adherent dressing. Check for infection (red, warm, painful, swollen, smelly or pus). • Give paracetamol 1g PO QID as needed for up to 5 days. If increased pain/anxiety with dressing changes, give tramadol 100mg IM while changing dressing. • Refer if signs of infection, pain despite medication or burn not healed within 2 weeks. 1 Inject 0.1mL TAT SC and 0.1mL normal saline at separate site as control: if wheal with redness develops around TAT site, skin test positive. Refer to hospital.
Adult 52 Bites and stings Approach to the patient with a bite/sting not needing urgent attention Give tetanus toxoid 0.5mL IM if none in past 5 years. If unavailable, check for tetanus antitoxin (TAT) hypersensitivity1 : if no reaction, give single dose TAT 3000U SC. If < 3 tetanus vaccine doses in lifetime, also give tetanus immunoglobulin 250 units IM at different site to toxoid with separate syringe. If unavailable, refer to hospital. Human or animal bite/s • Remove loose/dead skin and clean wound with soap and water. Irrigate under pressure with normal saline for 15 minutes. Avoid suturing the wound. • Consider rabies risk if bite/scratch or licking of eyes/mouth/broken skin by a dog, feral cat, hyena, rat or other animal or any contact with bat: - - Clean wound thoroughly with povidone iodine or hydrogen peroxide or chlorhexidine solution. - - Give rabies vaccine 1 ampoule IM into shoulder/upper arm muscle immediately and repeat on day 3. If patient unimmunised or unsure, repeat vaccine on day 7 and 14 and if impaired immunity1 , also give a 5th dose on day 28. If unavailable, refer to hospital. - - If patient unimmunised, also give rabies immunoglobulin 20 units/kg immediately. Inject most into wound, and the rest IM at a distant site. • If impaired immunity2 or bite is deep, infected, involves hand/head/neck/genitals or bite from cat or human: give amoxicillin/clavulanate3 500/125mg PO TID and metronidazole4 500mg PO TID for 7 days. • If human bite has broken the skin, also assess need for HIV and hepatitis B post-exposure prophylaxis 68. • Give paracetamol 1g PO QID as needed for up to 5 days. • If bite infected and no response to antibiotics, refer. Insect/spider/scorpion bite or sting • Remove stinger. Clean wound with soap and water. Apply ice pack for pain/swelling. • If itch and rash, give loratadine 10mg PO daily and ranitidine 150mg PO daily for 3 days. If no response, give prednisolone 60mg PO daily for 5 days. • If pain, give ibuprofen5 400mg PO TID with food for up to 5 days. • If very painful scorpion sting, inject lidocaine 2% 2mL around site. 1 Inject 0.1mL TAT SC and 0.1mL normal saline at separate site as control: if wheal with redness develops around TAT site, skin test positive. Refer to hospital. 2 Known with HIV, diabetes, cancer,pregnancy or receiving chemotheraphy or corticosterroid. 3 If penicillin allergy give instead clindamycin 300mg QID and cotrimoxazole 160/800mg BID for 7 days. 4 Advise no alcohol until 24 hours after last dose of metronidazole. 5 Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. Give urgent attention to the patient with a bite/sting and one or more of: • Snake bite (even if bite marks not seen) • Sudden diffuse rash or face/tongue swelling with difficulty breathing, BP < 90/60 or collapse: anaphylaxis likely • 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 Management: • If snake bite: - - Reassure patient. - - Remove jewellery and immobilise bitten limb. Avoid applying tourniquet or trying to suck out venom. - - Discuss anti venom with doctor if available. • If anaphylaxis likely: - - Raise legs and give face mask oxygen. - - Give immediately adrenaline 0.5mL (1:1000 solution) IM into mid outer thigh. Repeat every 5-15 minutes if needed. If no response, give hydrocortisone 100mg IV and promethazine 50mg IM. - - Give normal saline 1-2L IV rapidly, regardless of BP. Then if BP < 90/60, also give fluids as below. - - Remove stinger. • If BP < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • If excessive or pulsatile bleeding, apply direct pressure and elevate limb. If bleeding severe and persists, apply tourniquet above injury. • Remove loose/dead skin and clean wound with soap and water. Irrigate under pressure with normal saline for 15 minutes. Avoid suturing the wound. • Give tetanus toxoid 0.5mL IM if none in past 5 years. If unavailable, check for tetanus antitoxin (TAT) hypersensitivity1 : if no reaction, give single dose TAT 3000U SC. If < 3 tetanus vaccine doses in lifetime, also give tetanus immunoglobulin 250 units IM at different site to toxoid with separate syringe. If unavailable, refer to hospital. • Refer urgently.
Adult 53 No rash Localised Generalised 56 Pain 54 Lump/s 58 Generalised, non-itchy rash 57 Ulcers 59 Crusts 59 Changes in skin colour 60 Skin symptoms 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), give chloramphenicol only and refer. Give urgent attention to the patient with skin symptoms and one or more of: • Sudden diffuse rash or face/tongue swelling with difficulty breathing, BP < 90/60 or collapse: anaphylaxis likely • Purple rash with fever, headache, neck stiffness/meningism, nausea/vomiting or confusion: meningococcal disease likely • Extensive blisters • If on abacavir, check for abacavir hypersensitivity reaction 80. • Serious drug reaction likely if on any medication and one or more of: - - Temperature ≥ 38°C - - BP < 90/60 - - Jaundice - - Vomiting/abdominal pain/diarrhoea - - Involves mouth, eyes or genitals - - Blisters, peeling or raw areas © St. Paul's Hospital Millennium Medical College © University of Cape Town Management: • Anaphylaxis likely: - - Raise legs and give face mask oxygen. - - Give immediately adrenaline 0.5mL (1:1000 solution) IM into mid outer thigh. Repeat every 5-15 minutes if needed. If no response, give hydrocortisone 100mg IV and promethazine 50mg IM. - - Give normal saline 1-2L IV rapidly, regardless of BP. • Meningococcal disease likely: give ceftriaxone1 2g IV or crystalline penicillin1 4M IU IV with chloramphenicol 500mg IV. • Serious drug reaction likely: stop all medication and refer urgently. If peeling or raw skin, also manage as for burns before referral 51. • If BP < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • Refer urgently. Approach to the patient with skin symptom/s not needing urgent attention If rash is extensive, recurrent or difficult to treat, test for HIV 75. Itch 55 Rash
Adult 54 Painful skin Furuncle/carbuncle/boil/abscess likely • Advise patient to wash with soap and water, keep nails short, and avoid sharing clothing or towels. • If fluctuant, incise and drain. • If multiple lesions, extensive surrounding infection or impaired immunity1 , give cloxacillin 500mg PO QID for 7 days. If penicillin allergic, give instead erythromycin 500mg PO QID for 7 days. • Give paracetamol 1g PO QID as needed for up to 5 days. • If recurrent boils or abscesses: - - Test for HIV 75 and diabetes 86. - - Wash once with chlorhexidine 5% solution from neck down. • Refer if: - - Difficult area to drain (face, genitals, hands) - - No response to treatment within 2 days Cellulitis likely • Give cloxacillin 500mg PO QID for 7 days. If penicillin allergic, give instead erythromycin 500mg PO QID for 7 days. • Give paracetamol 1g PO QID as needed for up to 5 days. Sudden swelling of skin with redness, pain and warmth Are borders poorly or clearly defined? • Refer if: - - Temperature ≥ 38°C - - BP < 90/60 or pulse > 100 - - Confused - - Face or eye involvement - - Blisters or grey/black skin - - Poorly controlled diabetes or stage 4 HIV - - No response to treatment within 2 days Erysipelas likely • Give cloxacillin 500mg PO QID for 5 days. If penicillin allergic, give instead erythromycin 500mg PO QID for 5 days. • Give paracetamol 1g PO QID as needed for up to 5 days. Herpes zoster (shingles) likely • Test for HIV 75. • Advise to keep lesions clean and dry, and avoid skin contact with others until crusts have formed. • Apply calamine lotion to rash 4 times a day as needed. • Give aciclovir 800mg 5 times a day for 7 days if ≤ 3 days since onset of rash (or if ≤ 1 week since onset of rash if impaired immunity1 ). • For pain: - - Give paracetamol 1g PO QID for up to 5 days. - - If needed add tramadol 50mg PO BID for 5 days. - - If poor response or pain persists after rash has healed, give amitriptyline 25mg at night. Increase by 25mg every week to 75mg if needed. • If infected, give cloxacillin 500mg PO QID for 7 days. If penicillin allergic, give instead erythromycin 500mg PO QID for 7 days. • Refer same day if: - - Eye, ear or nose involvement - - Signs of meningitis (headache, temperature ≥ 38°C, neck stiffness/meningism) - - Rash involves more than one region Firm, red, warm lump which softens in the centre to discharge pus © University of Cape Town Poorly-defined borders © University of Cape Town Painful blisters in a band along one side © University of Cape Town Clearly-defined borders CDC Public Health Image Library 1 Known with HIV, diabetes or cancer or receiving chemotherapy or corticosteroids.
Adult 55 Itch with localised rash Itch with no rash Intense itch on scalp or in pubic area Tinea (ringworm) likely • If extensive or involves nails, test for HIV 75. If HIV positive, give routine care 76. • Advise to keep skin clean and dry and avoid sharing towels/clothes. • Apply clotrimazole or ketoconazole cream twice a day. Use for 1 week after rash has cleared. • If rash on scalp or no response to terbinafine, give griseofulvin 500mg daily until cured (up to 8 weeks) or fluconazole 200mg PO daily for 2-4 weeks. Tinea pedis (Athlete's foot) likely • Apply clotrimazole or ketoconazole cream twice a day. Continue for 1 week after rash has cleared. • Advise to wash and dry feet well. • Encourage open shoes/sandals. Lichen Planus likely • Apply liquid paraffin once daily. • Apply betamethasone ointment over the lesion once daily for 1-2 weeks. Pityriasis rosae likely • Apply liquid paraffin once daily. • Reassure patient that it should resolve within 3 weeks. • If persists after 3 weeks, apply momethason ointment once daily for 1 to 2 weeks. Confirm there is no rash, especially scabies, lice or other insect bites. Is the skin very dry? No Did the patient start any new medications in the weeks before the itch started? Yes Medication side-effect likely • Continue the medication only if no rash and treatment still necessary. • For itch, give loratadine 10mg or cetirizine 10mg PO daily for 5 days. • Advise patient to return immediately if rash develops. No • Advise to avoid hot baths and soap (wash with aqueous cream instead). • Moisturise skin twice a day. • Give loratadine 10mg or cetirizine 10mg PO daily for 5 days. • If itch persists, refer Yes Dry skin (xeroderma) likely • Advise to avoid soap (wash with aqueous cream instead). • Moisturise skin twice a day. • For itch, give loratadine 10mg or cetirizine 10mg PO daily. Lice likely Look for lice or eggs in hair and small red dots from bites. • Apply malathion 1% lotion to scalp. Rinse after 2 hours. Repeat after 1 week. • Soak all combs and brushes in permethrin for at least 2 hours. • Wash clothes and linen in very hot water. • Treat household contacts if infected or share a bed. If pubic lice, also treat sexual partners. Psoriasis likely • Apply betamethasone 0.1% ointment twice a day. For face, use hydrocortisone 1% cream only. Reduce to once a day when improvement seen. Stop as soon as better. • Advise to avoid using soap and to moisturise skin 3 times a day. • If extensive or no better after 1 month, refer. Slow-growing ring-like patch/es with raised edge © University of Cape Town Scaling moist lesions between toes or on soles of feet CDC Public Health Image Library Itchy flat purple papules/plaques © St. Paul's Hospital Millennium Medical College Oval shaped plaques with scales at the edges over trunk, arms and thighs © St. Paul's Hospital Millennium Medical College Well demarcated, pink, raised plaques covered with silvery scales, usually on elbows, knees, trunk and scalp © St. Paul's Hospital Millennium Medical College
Adult 56 Generalised itchy rash Scabies likely • Apply permethrin 5% cream or benzyl benzoate 25% lotion or sulphur 5-10% ointment. Avoid eyes and mouth. Wash off after 12 hours. Repeat for 3 consecutive nights. • Treat all household contacts and sexual partners at the same time, even if asymptomatic. • Wash linen and clothing in very hot water and dry well. • For itch, give loratadine 10mg or diphenhydramine 25-50mg PO daily until itch subsides. Papular pruritic eruption (PPE) likely • Test for HIV 75. If HIV positive, give routine care 76. • May temporarily worsen when starting ART. • First treat for scabies in adjacent column. • Moisturise skin twice a day. • Apply betamethasone 0.1% cream twice a day. For face, use instead hydrocortisone 1% cream. • For itch, give loratadine 10mg or cetirizine 10mg or diphenhydramine 25-50mg PO daily until itch subsides. Eczema likely • Moisturise skin twice a day and immediately after bathing. • Avoid frequent bath with soap. • Apply hydrocortisone 1% cream twice a day until improved (up to 4 weeks). If poor response, apply betamethasone 0.1% cream twice a day (avoid face). • For itch, give loratadine 10mg or cetirizine 10mg or diphenhydramine 25-50mg PO daily until itch subsides. • If infected, treat with cloxacillin 500mg PO QID for 7 days. If penicillin allergic, give instead erythromycin 500mg PO QID for 7 days. • If patient also has asthma, give routine asthma care 82. Urticaria likely Commonly due to allergy to food/medication/insect sting If sudden rash with difficulty breathing, BP < 90/60 or collapse, anaphylaxis likely 53. Approach to the patient not needing urgent attention: • Identify and remove cause. • Give loratadine 10mg or cetirizine 10mg PO daily until rash resolved. • If no response after 24 hours, give prednisolone 40mg PO daily for 5 days. • Advise patient to return immediately if any symptoms of anaphylaxis occur. • If recently started new medication, check for drug reaction 57. • If no response to treatment, refer. Widespread, very itchy rash with burrows, in web-spaces of hands/feet, axillae and genitals. Especially itchy at night. © University of Cape Town Itchy bumps on extremities or lower trunk. Skin often remains hyperpigmented. © University of Cape Town Itchy, thickened, hyperpigmented rash with associated allergic rhinitis, allergic conjunctivitis and other allergies. © St. Paul's Hospital Millennium Medical College © Very itchy, red, raised wheals that appear suddenly and usually disappear within 24 hours © St. Paul's Hospital Millennium Medical College
Adult 57 Generalised non-itchy red rash Is patient taking any medication? Yes No • Check patient does not need urgent attention 53. • If bleeding from gums or purple rash, do complete blood count and refer immediately. • Patient may have fever, headache, lymphadenopathy, muscle pain. • If pain or fever, give paracetamol 1g PO QID as needed for up to 5 days. • Test for syphilis and HIV 75. Yes No Is patient taking ART, TB treatment, co-trimoxazole or IPT? Rash may be part of HIV seroconversion illness. HIV negative HIV positive No • If itchy, give loratadine 10mg or cetirizine 10mg PO daily and and apply hydrocortisone 1% cream to rash twice a day. • Refer if: - - Any markers of severity develop. - - Rash does not improve within 2 weeks of stopping/ changing medication. Yes • If on abacavir, check for hypersensitivity reaction 80. If likely, stop ART and refer same day. • If itchy, give loratadine 10mg PO daily and apply hydrocortisone 1% cream to rash twice a day. • Check ALT and review result within 24 hours: Treat patient for early syphilis 41. If no better after 1 week, refer. ALT ≥ 100U/L or patient unwell Manage as serious drug reaction Stop all drugs and refer same day 53. ALT < 100U/L and patient well • Continue medication. • If on nevirapine: - - If on once daily dose, avoid increasing until rash resolved. - - Repeat ALT after 1 week. If ≥ 100U/L, refer same day. - - If rash persists > 4 weeks after starting nevirapine, switch medication 79. • If on co-trimoxazole prophylaxis1 : stop it until rash resolved. Consider re-starting co-trimoxazole or changing instead to dapsone 100mg daily. • Review patient within 2 days. • Advise patient to return urgently if markers of severity develop. • If rash no better after 2 weeks, refer to hospital. Secondary syphilis likely Rash often on palms and soles. May have wart-like lesions on genitals and patchy hair loss. Syphilis test positive If generalised non-itchy rash and no obvious cause, refer. • If risk of HIV infection in past 4 weeks, repeat HIV test after 4 weeks. • Encourage patient to follow safe sex practices. Give routine HIV care 76. Are there any markers of severity? • Temperature ≥ 38°C • BP < 90/60 • Difficulty breathing • Face or tongue swelling • Abdominal pain • Vomiting or diarrhoea • Involves mouth, eyes or genitals • Blisters, peeling or raw areas • Severe rash • Jaundice Drug reaction likely • Rash may be mild, patchy spots or widespread (like burns). • Can be caused by any medication. Common causes are antibiotics, anticonvulsants, antiretrovirals (especially nevirapine), TB medication, co-trimoxazole and NSAIDs (e.g. ibuprofen). © University of Cape Town 1 If on co-trimoxazole treatment for pneumocystis pneumonia (PJP), toxoplasmosis or Isospora belli diarrhoea, refer to hospital. © University of Cape Town
Adult 58 Refer same week the patient with a mole that: • Is irregular in shape or colour • Changed in size, shape or colour • Differs from surrounding moles • Is > 6mm wide • Bleeds easily • Itches Warts likely • Usually on hands, knees or elbows but can occur anywhere. • Plantar warts on the soles of the feet are thick and hard with black dot/s. • Reassure patient that warts often disappear spontaneously. • If treatment desired, apply salicylic acid 5% 1-2 drops to wart every night and cover with a plaster. • Advise patient to soak in warm water for 5 minutes then scrape wart with nail file between treatments. • Continue to apply salicylic acid for a week after wart has come off. • If warts are extensive, refer. Molluscum contagiosum likely May be extensive in HIV. • Test for HIV 75. • Reassure patient that lesions may resolve spontaneously after several years or with ART. • If intolerable, remove with curettage or apply podophyllum 15% for 4 hours, then wash off. Repeat podophyllum weekly for up to 6 weeks. • If podophyllum not available, protect surrounding skin with petroleum jelly and apply KOH 5-10% solution with cotton tip applicator daily for 2-3 weeks. • If extensive or no resolution after 4 years and intolerable for patient, refer. Kaposi’s sarcoma likely Lesions vary from isolated lumps to large ulcerating tumours and may also appear in mouth and on genitals. • Test for HIV 75. If HIV positive, give routine care and ART 76. • Refer for biopsy to confirm diagnosis and for further management. Rosacea likely • Advise to avoid aggravating factors. • Apply zinc oxide ointment every morning. • Give doxycycline1 100mg PO daily for 1 month or azithromycin 250mg PO 3 times a week for 6 weeks. • Refer if no improvement or diagnosis uncertain. Acne likely May involve chest, back and upper arms • Advise patient to wash skin with mild soap twice a day and to avoid picking, squeezing and scratching. • Apply benzoyl peroxide 5% cream twice a day after washing. Continue for 2 weeks after lesions have gone. Avoid in pregnancy. • If benzoyl peroxide not available, apply clindamycin 1% gel and tretinoin 0.025- 0.05% cream once daily. • If red, swollen and extensive lesions over chest and back, also give doxycycline 100mg PO daily for at least 3 months. Doxycycline may interfere with oral contraceptive. Advise patient to use condoms as well. Avoid in pregnancy. • In woman needing contraception, advise combined oral contraceptive 110. • Advise patient that response may take several weeks to months. • If severe or no response after 6 months of treatment, refer. Round, raised papules with rough surfaces © University of Cape Town Small, skin-coloured bumps with pearly central dimples © University of Cape Town Painless, purple/brown lumps on skin © BMJ Best Practice Painless lumps on face and extremities with overlying scales or central ulcer © St. Paul's Hospital Millennium Medical College Oily skin with white/blackheads © University of Cape Town Red lumps on face If painful, firm, red, warm lump which softens in the centre to discharge pus, boil/abscess likely 54. Dry skin with redness and visible vessels on face Cutaneous leish- maniasis likely Do slit skin smear microscopy and refer to leishmaniasis treatment center. Skin lump/s 1 Avoid if pregnant.
Adult 59 Ulcers and crusts Ulcer/s Is patient usually in bed and is ulcer in common bedsore site (see below)? No No • If genital ulcer 39. • If elsewhere on body and no obvious cause like trauma, refer to exclude skin cancer. Pulses reduced or muscle pain in legs/buttocks on exercise that is relieved by rest Bedsore likely • Relieve pressure on ulcer and reposition patient every 2 hours. • Clean ulcer daily and cover with non- adherent dressing. • If infected (skin red, warm or tender), apply silver sulfadiazine 1% cream to ulcer until infection better. • Give paracetamol 1g PO QID as needed for up to 5 days. If needed, add tramadol 50mg PO BID for 5 days. • Refer to dietician to ensure adequate calorie and protein intake. • Refer if: - - Fat, bone, muscle or tendon visible - - Yellow/grey/black tissue - - Extensive or worsening infection - - Ulcer not healing with treatment • If patient is terminally sick and survival is predicted to be short, also give palliative care 120. Does patient have diabetes 86? Yes No • If cough ≥ 2 weeks, weight loss, night sweats or fever ≥ 2 weeks, exclude TB 71. • Refer for further assessment. Diabetic ulcer likely • Avoid pressure/weight-bearing on ulcer. • Give foot care advice 50. • Clean ulcer daily and cover with non-adherent dressing. • If infected (skin red, warm, painful), give erythromycin 500mg PO QID and ciprofloxacin1 500mg PO BID for 10 days. • Give diabetes routine care 86. • Refer if - - Fever, pus or extensive infection - - Ulcer > 2cm, or tendon or bone visible - - Ulcer no better after 2 weeks of treatment Venous stasis ulcer likely • Encourage exercise. • Advise elevating leg when possible and to avoid prolonged standing. • Apply compression bandage from foot to knee. • Assess and manage CVD risk 84. • Clean ulcer daily and cover with non-adherent dressing. • Refer if: - - Recurrent ulcers - - No better after 3 months Peripheral vascular disease (PVD) likely • Clean ulcer daily and cover with non-adherent dressing. • Avoid compression bandage. • Give PVD routine care 96, and refer to hospital. If sudden severe leg pain at rest with numbness, weakness, pallor or no pulse, refer urgently. Yes Yes No Yes Pulses normal and no muscle pain in legs or buttocks on exercise Is there red/brown darkening of skin around ulcer, spidery veins? Check leg and foot pulses and if patient has muscle pain in legs or buttocks on exercise. Is ulcer on the leg or foot? Impetigo likely Often around mouth or nose. May complicate insect bites, scabies or skin trauma. • Test for HIV 75. • Impetigo is contagious: - - Advise patient to avoid close contact with others and to wash with soap and water twice a day. - - Advise contacts to avoid sharing towels and to add a spoon of potassium permanganate solution (1:10 000) to bathwater 2-3 times a week. • Apply fusidic acid cream to lesions and nostrils 3 times a day for 7 days. • If extensive or no response to above treatment, add cloxacillin 500mg PO QID for 7 days. If penicillin allergic, give instead erythromycin 500mg PO QID for 7 days. • Refer if: - - Cellulitis or abscess - - Temperature ≥ 38°C - - No response to antibiotic Blisters which dry to form honey coloured crusts © St. Paul's Hospital Millennium Medical College © BMJ Best Practice 1 Avoid if pregnant.
Adult 60 Changes in skin colour Melasma likely • Hormones and sunlight will worsen melasma: - - Advise patient to apply sunscreen daily and avoid sun exposure. - - Avoid oral contraceptive, rather use alternative contraception 110. - - If pregnant, advise patient lesions may resolve up to 1 year after pregnancy. • Avoid facial products other than bland emollients. • Often difficult to treat. If not responding to above and intolerable for patient, refer. Tinea versicolor likely • Apply selenium sulfide 2% or ketoconazole 2% shampoo to neck, trunk, arms and legs. Leave for 10 minutes, then wash off. Repeat daily for 1 week. • Advise that colour may take months to return to normal. • If scale persists or frequent relapses, give single dose fluconazole 400mg PO. • Recurrence is common and the patient may need frequent treatment. If diagnosis is uncertain, refer. Yellow skin Lightening of skin Is skin smooth or scaly? Is skin smooth or scaly? Smooth Smooth Is there decreased sensation on the skin lesion? No Vitiligo likely • Advise patient to use camouflage cosmetics. • If patient requests treatment and lesions are limited, apply betamethasone 0.1% cream twice a day for at least 3 months (avoid face). Stop if skin thinning, stretch marks or bruising occur. • If extensive or no response to treatment, refer to hospital. • If distressing to patient, refer for psychological support. Yes © St. Paul's Hospital Millennium Medical College Leprosy likely Do baciliary index, morphology index and manage accordingly. Scaly Jaundice likely Refer urgently the patient with jaundice and one or more of: • Temperature ≥ 38°C • Hb < 11g/dL • BP < 90/60 • Severe abdominal pain • Drowsy or confused • Easy bruising or bleeding • Pregnant • Alcohol dependent 103 or recent alcohol binge (≥ 5 drinks1 / session) • Using any medication or illegal drugs Approach to the patient with jaundice not needing urgent referral: • Send blood for ALT, AST, GGT, ALP, complete blood count. • Advise patient to return immediately if any above markers of severity develop. • Review patient with results within 2 days. If ALT/AST raised, send blood for hepatitis serology and refer. Refer. Yes No No Flat, brown patches on cheeks, forehead and upper lip © University of Cape Town Light or dark patches with fine scale. Usually on trunk. © University of Cape Town © University of Cape Town 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. Is ALP/GGT predominantly raised? Red-brown discolouration. May have breaks in skin/ ulcers, spidery veins. © BMJ Best Practice Yes Venous stasis likely • Encourage exercise. • Advise elevating leg when possible and to avoid prolonged standing. • Apply compression bandage from foot to knee. • Assess and manage CVD risk 84. • If ulcer: - - Clean daily and cover with non- adherent dressing. - - If no better after 3 months or recurrent ulcers, refer. Darkening of skin Is darkened area only on lower leg/s?
Adult 61 Nail symptoms Pain, redness and swelling of nail folds, there may be pus. © BMJ Best Practice Chronic paronychia likely Usually associated with excessive exposure to water and irritants like nail cosmetics, soaps and chemicals. • Advise patient to avoid water and irritants and to wear gloves if unavoidable. • Apply betamethasone 0.1% cream to swollen nail beds twice a day for 3 weeks. • If no response, apply miconazole 2% cream twice a day for 4 weeks. • If no response, refer. Acute paronychia likely Often with history of trauma, such as nail biting or pushing the cuticle. • Advise patient to stop trauma to nail. • If any pus, incise and drain. • Advise warm saline soaks for 20 minutes twice a day. • Apply fusidic acid 1% cream after soaking. • If severe pain, pus, infection beyond nail fold or temperature ≥ 38°C, give cloxacillin 500mg PO QID for 7 days. If penicillin allergic, give instead erythromycin 500mg PO QID for 7 days. • If no response, refer. Fungal infection likely • Test for HIV 75. • Fungal nail infection is difficult to treat. • Treat if: - - Previous cellulitis on affected limb - - Diabetes - - Painful nail - - Cosmetic concerns • Send nail clippings for microscopy to confirm diagnosis before starting treatment. • If fungal infection confirmed, give fluconazole 400mg PO once weekly for 6-9 months for finger nails and 12-18 months for toe nails. Has there been recent trauma to nail? Yes Haematoma likely • Treat if injury < 2 days old and painful: - - Clean nail with povidone iodine solution. - - Hold finger secure and gently twist a large bore needle into nail over centre of haematoma. Stop when blood drains through hole. - - Cover with sterile gauze dressing. • Review medication: chloroquine, fluconazole, ibuprofen, lamivudine, phenytoin and zidovudine can cause discolouration of nails. Consider changing medication. • Refer same week to exclude melanoma (picture above) if: - - New dark spot on 1 nail which is getting bigger quickly and no recent trauma - - Discolouration extends into nail folds - - Band on nail that is: • > 4mm wide • Getting darker or bigger • Has blurred edges • Nail is damaged. No Disfigured nail with swollen nail bed and loss of cuticle © University of Cape Town White/yellow disfigured nails © University of Cape Town Blue/brown/black discolouration of nail CDC Public Health Image Library If nails long and dirty and patient unkempt, screen for mental health problem and abuse/neglect 66.
Adult 62 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? No: does patient have current thoughts or plans to commit suicide? Yes Yes Yes: is patient agitated, violent, distressed or uncommunicative? No No No: has patient had thoughts or plans of self-harm or suicide in past month or performed act of self-harm or suicide in past year? High risk of self-harm or suicide Low risk of self-harm or suicide Manage patient as below. • Remove any possible means of self-harm (firearms, knives, pills). • If aggressive or violent, ensure safety: assess patient with other staff, use security personnel or police if needed. Sedate only if necessary 63. • Refer urgently. - - While awaiting transport, monitor closely. Avoid leaving patient alone. If patient refuses admission, consider involuntary admission 98. Yes • First assess and manage airway, breathing, circulation and level of consciousness 12. • If oral overdose or harmful substance in past 1 hour and patient fully conscious, give activated charcoal 100g in 500mL water via nasogastric tube. Avoid if paraffin, petrol, corrosive poisons, iron, lithium or alcohol. • If opioid (morphine/codeine) overdose and respiratory rate < 12: give 100% face mask oxygen and naloxone 0.4mg IV immediately. Repeat every 2-3 minutes, increasing dose by 0.4mg each time until respiratory rate > 12, maximum 10mg. • If exposed to carbon monoxide (exhaust fumes): give 100% face mask oxygen. • If no response, or overdose/poisoning with other or unknown substance, refer to hospital. 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. Assess the patient whose risk of self-harm or suicide is low Assess When to assess Note Depression Every visit • If known depression 100. • In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. Substance use/abuse Every visit In the past year has the patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Other mental illness Every visit If hallucinations, delusions, disorganised speech, disorganised or catatonic behaviour, refer to mental health professional same day. Stressors Every visit • Assess and manage stress 65. • Help identify psychosocial stressors. Ask about trauma, sexual abuse/violence 66, family or relationship problems, financial difficulty, bereavement, chronic ill-health. Chronic condition Every visit • If chronic pain, assess and manage pain 45 and underlying condition. • If patient is terminally sick and survival is predicted to be short, also give palliative care 120. • Discharge into care of family, if possible. Review patient at least weekly for 2 months. 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 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
Adult 63 Give urgent attention to the aggressive/disruptive patient with one or more of: • Angry behaviour • Loud, aggressive speech • Challenging, insulting or provocative behaviour • Frequently changing body position, pacing • Tense posturing like gripping arm rails tightly, clenching fists • 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 or a potentially harmful object (e.g.: stick, stone etc). Assess with other staff in a safe spacious room with at least two doors for entry and exit. 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. - - 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 64, especially if patient disorientated/confused as sedatives may worsen the condition. • 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 98. If needed, sedate the aggressive/disruptive patient: Try to avoid IM or IV medication, especially if > 65 years. Will patient accept oral medication? • Monitor and record temperature, BP, respiratory rate and pulse rate and level of consciousness every 15 minutes for the first hour and every 30 minutes until patient alert and walking. • If haloperidol used and painful muscle spasms, acute dystonic reaction likely, give benzhexol 2-5mg, if needed can be given PO TID. • Once patient is calmer, reassess for underlying cause and manage further 64. No Yes Patient calm Exact cause unknown Patient calm Give haloperidol 2-5mg (2mg if elderly) IM or diazepam 10mg IV slowly (avoid IM). If confused (without alcohol withdrawal), avoid diazepam if possible. Give haloperidol 2-5mg (2mg if elderly) IM. Alcohol/drug withdrawal Partial response Repeat same dose of IM medication used above. No response • If diazepam used above, give haloperidol 2-5mg (2mg if > 65 years) IM. • If haloperidol used above, give diazepam 10mg IV slowly (avoid IM). Stimulant drug intoxication Alcohol intoxication Psychosis Patient still aggressive/disruptive after 30 minutes Decide which medication to sedate patient according to likely cause: Assess after 30 minutes: • Give diazepam 5mg PO or haloperidol 2-5mg (2mg if > 65 years) PO. • Assess response after 30 minutes: Patient refuses oral medication Refer the mentally ill aggressive patient same day to hospital: document history, details of involuntary admission, and time and dose of medication given. Aggressive/disruptive patient
Adult 64 Abnormal thoughts or behaviour 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 106. • If unsure of diagnosis, refer for further assessment. 1 Add 10 vials of glucose 40% in 1L dextrose in normal saline solution at 30 drops per minute. 2 If severe penicillin allergy with previous angioedema, anaphylaxis or urticaria, give chloramphenicol only and refer. 3 Test for malaria with parasite slide microscopy or if unavailable, rapid diagnostic test. Give urgent attention to the patient with abnormal thoughts or behaviour and one or more of: • Sudden onset of abnormal thoughts or behaviour • Recent onset of abnormal thoughts or behaviour Management: • If aggressive/disruptive, assess and manage 63. Sedate only if absolutely needed: if patient confused sedatives may worsen the condition. • If new sudden asymmetric weakness or numbness of face, arm or leg; difficulty speaking or visual disturbance: consider stroke or TIA 93. • Just had a convulsion 15. • If difficulty breathing, respiratory rate > 30, oxygen saturation < 90% or oxygen saturation machine not available, give face mask oxygen. • If glucose < 70mg/dL or unable to measure, give oral glucose 20g. If unable to take orally, give instead glucose 40% 50mL IV over 2-3 minutes. Repeat if glucose still < 70mg/dL after 15 minutes. Maintain with 10% glucose solution1 . • If known alcohol user, give thiamine 100mg IV before glucose. If glucose ≥ 200mg/dL 86. • If thirst, dry mouth, poor skin turgor, sunken eyes, decreased urine: give oral rehydration solution. If unable to drink or BP < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • If suicidal thoughts or behaviour 62. • 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 98. • Look for delirium, mania, psychosis, intoxication, withdrawal or poisoning and manage before referral: Varying levels of consciousness over hours/days and/or temperature ≥ 38°C Abnormally happy, energetic, talkative, irritable or reckless Mania likely Lack of insight with ≥ 1 of: • Hallucinations (seeing/ hearing things which are not there for others around the patient) • Delusions (unusual/ bizarre beliefs) • Disorganised speech or behaviour Dilated pupils, restlessness, paranoia, nausea, sweating or pulse ≥ 100, BP ≥ 140/90 Smells of alcohol, slurred speech, incoordination, unsteady gait Known alcohol/drug user who has stopped/reduced intake with tremor, sweating, nausea, severe restlessness/ agitation or hallucinations Exposure via ingestion/ inhalation/ absorption of medication/ unknown substance Psychosis likely Stimulant drug intoxication likely If pulse irregular, chest pain or BP ≥ 140/90, refer urgently to hospital. If aggressive 63. Alcohol intoxication likely • Give thiamine 100mg IV/IM. • Give normal saline 1L 6 hourly. • Check for head injury. Alcohol/drug withdrawal likely • If no other sedation given, give diazepam 10mg PO or IV. • If alcohol withdrawal, also give thiamine 100mg PO or IV/IM and oral rehydration solution. • If ≥ 8 hours since last alcohol, refer to hospital for detoxification. Poisoning Refer to hospital. Delirium likely • Give single dose ceftriaxone2 2g IV/IM or crystalline penicillin2 4M IU IV with chloramphenicol 500mg IV. • If malaria test3 positive, also give artesunate 2.4mg/kg IM or artemether 3.2mg/kg IM. Refer urgently unless: • Patient with known chronic psychosis who is otherwise well: give routine psychosis care 104. • Patient with known diabetes and low glucose, not on glicazide or insulin: if abnormal thoughts/behaviour resolve following oral or IV glucose, no need to refer, give routine diabetes care 87. • Patient with known alcohol use who is otherwise well: if abnormal thoughts/behaviour resolve once sober, no need to refer 103.
Adult 65 Stressed or distressed patient Give urgent attention to the stressed or distressed patient with: • Suicidal thoughts or behaviour 62. Assess the stressed or distressed patient: if known with depression, give routine care 100. Assess Note Symptoms Manage symptoms on symptom pages. If patient has multiple physical complaints consider depression 99. Stressors • Help identify psychosocial stressors. Ask about family or relationship problems, financial difficulty, bereavement, chronic ill-health. Ask about loneliness in older person. • If patient is terminally sick and survival is predicted to be short, also give palliative care 120. Trauma/abuse 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 66. If patient being abused 66. Anxiety • If excessive worry causes impaired function/distress for at least 6 months with ≥ 3 of: muscle tension, restless, irritable, difficulty sleeping, poor concentration, tired: generalised anxiety likely 100. • If anxiety impairs function and is induced by a particular situation/object (phobia) or has no obvious cause with repeated sudden fear with physical symptoms (panic) 100. Depression In the past month, has patient felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. Substance abuse In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Women’s health • If recent delivery, give postnatal care 116. • If woman > 40 years, ask about menopausal symptoms: hot flushes, night sweats, vaginal dryness, mood changes, difficulty sleeping and sexual problems 119. Medication Review medication: prednisolone, efavirenz, metoprolol, metoclopramide, theophylline and estrogen containing oral contraceptives can cause mood changes. Consider changing medication or alternative contraceptive and antihypertensive. If persistent symptoms on efavirenz for > 6 weeks, change ART 79. Advise the stressed or distressed patient • 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 If patient has difficulty sleeping 67. Access support Encourage patient to connect with friends, family, spiritual leaders and community groups like Edir, Mahber, Senbete. Get active Advise regular exercise. Do a relaxing breathing exercise each day. Spend time with supportive friends or family. Encourage patient to do activities s/he enjoyed previously. Encourage patient to take time to relax: • Do relaxing breathing in a quiet place for 10 minutes everyday: sit comfortably, breathing slow, steady breaths through nose. Time breathing with counting: 1, 2, 3 in; 1, 2, 3 pause; 1, 2, 3 out. • Support problem solving: List main problems and identify an important but solvable problem. Support the patient to identify steps to solving the problem. Agree on specific steps that the patient will try in the next week. At follow-up, review, trouble-shoot and set new goals. • 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. • For tips on how to communicate effectively 124. Offer to review the patient in 1 month. If no better, refer to available counsellor, psychiatric nurse/psychologist or social worker. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
Adult 66 Traumatised/abused patient Review the traumatised/abused patient • If sexually assaulted, review within 3 days 69. Also check syphilis after 1 month. • Offer to review the traumatised/abused patient who has not been sexually assaulted in 3 months. 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. • Encourage patient to report case to the police and to apply for protection order. Respect patient’s wishes if s/he declines to do so. 1 Advise no alcohol until 24 hours after metronidazole. 2 If patient taking ART, rifampicin or phenytoin, offer copper intrauterine device instead or increase single dose levonorgestrel to 3mg. 3 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. Give urgent attention to the traumatised/abused patient with one or more of: • Injuries needing attention 14 • Immediate risk of being harmed and in need of shelter • Suicidal thoughts or behaviour 62 • Recent sexual assault: - - If severe vaginal or anal bleeding, refer urgently. - - Aim to prevent HIV, hepatitis B, STIs and pregnancy urgently: Prevent STIs • Give single doses of ceftriaxone 250mg IM, metronidazole1 2g PO and doxycycline 100mg PO BID for 7 days. • If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), omit ceftriaxone and give instead single dose spectinomycin 2g IM. Prevent HIV and hepatitis B 68. Prevent pregnancy • Do pregnancy test. If pregnant 112. • If not pregnant, not on reliable contraception and ≤ 5 days since rape, give emergency contraception: - - Give single dose levonorgestrel 1.5mg2 PO. If patient vomits < 2 hours after taking, repeat dose or - - Insert copper intrauterine device instead 110. • If > 5 days since rape and emergency contraception not given, repeat pregnancy test 6 – 8 weeks after last menses. If pregnant 112. Also assess and support the patient needing urgent attention 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 sexual assault 36. Family planning Every visit Assess patient’s contraception needs 110. If pregnant 112. Mental health Every visit • Assess and manage stress 65. • In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. • In the past year, has patient: 1) drunk ≥ 4 drinks3 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. • 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. HIV First visit Test for HIV 75. Syphilis (if sexual assault) If negative: repeat after1 month If positive 41.
Adult 67 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 patient has a chronic condition, give routine care. • Ask about snoring or restless legs. If present, refer for assessment. • If pulse ≥ 100, weight loss, palpitations, tremor, dislike of hot weather or thyroid enlargement, thyrotoxicosis likely, refer to hospital. • If patient is terminally sick and survival is predicted to be short, also give palliative care 120. Review medication: • Over-the-counter decongestants, salbutamol, theophylline, fluoxetine and efavirenz can cause difficulty sleeping. Consider changing medication. • Reassure patient that difficulty sleeping from efavirenz is usually self-limiting and resolves within 4 weeks on ART. If > 4 weeks, refer to hospital. Assess substance use/abuse: • In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Screen for possible stressors and mental health problem: • Screen for mental health problem (depression, anxiety, post-traumatic stress disorder and phobias) and manage stress 65. • If abnormal thoughts or behaviour 64. • 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 106. Ask about menopausal symptoms: • If woman > 40 years, ask about menopausal symptoms: hot flushes, night sweats, vaginal dryness, mood changes and sexual problems 119. 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. If very tired, nap for no longer than 30 minutes. - - Encourage routine: get up at the same time every day (even if tired) and go to bed at 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, get out of bed and 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 clinician and patient can help. If still no better after 1 month on medication, refer patient for further assessment. Treat the patient with difficulty sleeping: If problems with daytime functioning, daytime sleepiness, irritability, anxiety or headaches that do not improve with 1 month of sensible sleep habits: reassess for mental health and substance use problems and consider promethazine 25mg or amitriptyline 12.5-25mg PO at night for short-term symptom-relief. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
Adult 68 Exposed to infectious fluid: post-exposure prophylaxis Fluids transmit infection through 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. Give urgent attention to the patient exposed to infectious fluid: Does patient have one or more of the following? • Exposure to blood, blood-stained fluid/tissue, pleural/pericardial/peritoneal/amniotic/synovial/cerebrospinal fluid, vaginal secretions, semen or breast milk • Human bite that broke the skin Yes No No Yes • Give immediate attention: - - 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 or normal saline. - - If sexual assault 66. • Assess need for HIV post-exposure prophylaxis: • Reassure that HIV and hepatitis B transmission is unlikely. • Avoid giving HIV or hepatitis B post-exposure prophylaxis. • If unsure, refer to hospital. Patient known HIV positive Positive • Send blood for HBsAg, hepatitis C antibody. If sexual exposure, also check syphilis. • Avoid giving HIV post-exposure prophylaxis, give routine HIV care 76. Yes Reassure that hepatitis B transmission is unlikely. No or not sure Give 1st dose of hepatitis B vaccine 1mL IM. • Give HIV post-exposure prophylaxis (PEP) only if ≤ 72 hours since exposure (ideally within 1 hour): • Give tenofovir/lamivudine 300/300mg and efavirenz 600mg PO daily for 28 days. • If known kidney disease, give zidovudine/lamivudine 300/150mg PO BID instead of tenofovir/lamivudine . • If source on ART, start PEP as above and refer to hospital to adjust PEP if needed. • Send blood for HBsAg, hepatitis C antibody and creatinine1 . If sexual exposure, also check syphilis. Assess need for hepatitis B post-exposure prophylaxis: has patient received 3 doses of hepatitis B vaccine? Assess source: if s/he agrees, test for HIV 75, HBsAg and hepatitis C antibody. If sexual exposure, check syphilis. Review patient and blood results within 3 days 69. Negative, one positive and one negative or patient refuses HIV test Patient HIV negative or unknown: do HIV test 75. Was there sexual contact, sharps injury, splash to eye, mouth, nose or broken skin? 1 If giving zidovudine, check complete blood count instead of creatinine.
Adult 69 Review the patient on post-exposure prophylaxis Review patient within 3 days, at 2 weeks, 6 weeks, 3 months and 6 months. • Check adherence and ask about side effects from HIV post-exposure prophylaxis 80. Advise patient to report side effects promptly if they occur. • Advise patient to use condoms for 3 months until results confirmed. • If assault or abuse 66. • Check bloods according to table and review results as below: Assess When to assess Note HIV If negative: at 6 weeks, 3 months Test for HIV 75. If positive, stop HIV post-exposure prophylaxis and give routine HIV care 76. HBsAg If negative: at 6 months If positive, refer. Hepatitis C antibody If negative: at 6 weeks, 3 months If positive, refer. Syphilis (if sexual exposure) If negative: repeat after 1 month If positive 41. eGFR1 (by referral to hospital) If on tenofovir: at 2 weeks, 6 weeks • If initial eGFR < 50mL/min/1.73m3 : stop tenofovir/lamivudine, give instead zidovudine/lamivudine 300/150mg PO BID and check complete blood count. • If repeat eGFR < 50mL/min/1.73m3 : refer. Complete blood count If on zidovudine: at 2 weeks, 6 weeks If Hb < 7g/dL or neutrophils < 0.75 x 109 /L, refer. Source blood results (if done) - • If HIV negative, discontinue HIV post-exposure prophylaxis. • If HIV positive, give source routine HIV care 76. Continue HIV post-exposure prophylaxis. • If HBsAg or hepatitis C antibody positive, refer source and patient to hospital. • If syphilis positive 41. 1 Calculate eGFR = [(140 - age) x weight (kg)]/[72x creatinine (mg/dL)]. If patient is a woman, multiply by 0.85. Approach to the patient who is HBsAg negative Has patient received 3 doses of hepatitis B vaccine? Yes No or not sure Reassure that hepatitis B transmission is unlikely. Source HBsAg positive or not known Source HBsAg negative If not already given, give 1st dose of hepatitis B vaccine 1mL IM. • At 4 weeks: Give patient 2nd dose of hepatitis B vaccine 1mL IM. • At 8 weeks: Give patient 3rd dose of hepatitis B vaccine 1mL IM. Refer to hospital. Check source HBsAg result.
Adult 70 Malnutrition: routine care Assess the patient with malnutrition Assess When to assess Note Symptoms Every visit Manage symptoms as on symptom page. Ask about diarrhoea 34 and vomiting 33 and manage on symptom pages. Diet At diagnosis Check variety and quantity of food. If patient not getting at least 2 meals a day or eating a balanced diet, refer to nutrition support programme. TB screening Every visit Exclude TB 71. Family At diagnosis Ensure that patient’s family and children are screened for malnutrition. Oedema Every visit If swelling of feet, hands or face develops or does not resolve with feeding, refer. Weight/BMI Every visit If not gaining weight or losing weight, refer. Discharge the non-pregnant patient when BMI > 17.5. MUAC Monthly Discharge the pregnant/breastfeeding patient when MUAC is > 23. Substance use At diagnosis In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Pallor At diagnosis Look for pallor and if possible check Hb. If < 7gdL, refer. HIV At diagnosis Test for HIV 75. If HIV positive, give routine HIV care 76. Family planning Every visit Assess patient’s contraception needs 110. If pregnant 112. Diagnose malnutrition The patient has malnutrition if not pregnant and BMI < 17.5 or MUAC < 21 or if pregnant/breastfeeding and MUAC < 23 or if oedema of both feet with no other cause. Advise the patient with malnutrition • Provide nutrition counselling: advise the patient to eat a healthy balanced diet and about preparing food and water in a hygienic way. • Advise the patient not to share Plumpy nut® with others, how to open packets, to store it in a cool place and avoid keeping it once opened. • How to link to other services, programs or initiatives as appropriate. Treat the patient with malnutrition • Give single dose mebendazole 500mg PO or single dose albendazole 400mg PO. • Give Ready to Use Therapeutic Food (RUTF) (Plumpy nut®) two 100g sachets three times a day. Review the patient with malnutrition monthly until BMI and MUAC are normal stop RUTF. Ensure ongoing follow-up from available nutrition support programme. Give urgent attention to the patient with malnutrition and one or more of: • Hb < 7g/dL • Respiratory rate ≥ 30 29 • BP < 90/60 • Jaundice • Extensive skin lesions • Very weak, lethargic or unconscious Management • If BP < 90/60, give normal saline 250mL IV. Avoid or stop if breathless. • Refer urgently. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela
Adult 71 Tuberculosis (TB): diagnosis Check for TB in the patient with any of the following: cough ≥ 2 weeks, weight loss, drenching night sweats, fever ≥ 2 weeks, chest pain on breathing, blood-stained sputum. Approach to presumed TB patient not requiring urgent attention: • Test for HIV 75. • Assess risk factors for drug resistant (DR) TB: previously treated for TB, close contact with another DR-TB patient or known high risk MDR settings (correctional facilities, military barracks, homeless shelters, refugee camps, dormitories or nursing homes). • Decide which test the patient needs: Does patient have abdominal pain, swelling, diarrhoea, headache or lymph node ≥ 2cm? Send 2 spot sputum samples for AFB Both sputum AFB negative • Give doxycycline4 100mg PO BID for 7 to 10 days or clarithromycin 500mg PO BID for 5 to 7 days. • If antibiotic use in last 3 months, add amoxicillin 1g PO TID for 5 to 7 days. • Advise patient to return if no better or symptoms worsen. At least one sputum positive for AFB Send single sputum sample for Xpert MTB/RIF assay Review Xpert MTB/RIF assay results3 MTB detected Rifampicin sensitive Diagnose drug-sensitive TB Give routine DS-TB care and start DS-TB treatment same day 72: Diagnose rifampicin-resistant TB Refer to hospital. Rifampicin resistant MTB not detected Presumed Pulmonary TB (PTB) Any of: risk factors for DR TB, HIV positive or recent 2 sputum samples negative2 ? No No Yes Yes Presumed Extra-pulmonary TB (EPTB) 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid and refer. 2 If patient previously tested negative for AFB and no better after antibiotic therapy. 3 If unsuccessful or error result seen, repeat with new sample. 4 Avoid if pregnant. Give urgent attention to the presumed TB patient with one or more of: • Respiratory rate > 30 • Breathless at rest or while talking • Confusion or agitation • Coughs ≥ 1 tablespoon fresh blood Management: • Give ceftriaxone1 1g IV/IM. If unavailable, give amoxicillin1 1g PO. • Give face mask oxygen. • Refer same day. TB TB MALNUTRITION
Adult 72 Drug-sensitive (DS) TB: routine care Assess the patient with DS-TB at diagnosis, at 2 weeks and then once a month throughout DS-TB treatment. Assess When to assess Note Symptoms Every visit • If respiratory rate > 30, breathless at rest or while talking, or confused/agitated, give urgent attention 71. • Expect gradual improvement on TB treatment. If symptoms worsen or do not improve after 1 month of treatment, refer to hospital. Contacts At diagnosis and if contact symptomatic • Trace and screen symptomatic contacts, HIV positive contacts and contacts < 5 years of age for TB. • Exclude TB and administer 6 months IPT to asymptomatic contacts < 5 years of age and to HIV positive contacts. Family planning Every visit Assess contraception needs to avoid pregnancy during TB treatment 110. If oral contraceptive, give higher estrogen dose (50 mcg). If on subdermal implant, advise consistent condom use. Alternatively, offer switch to intrauterine contraceptive device (IUCD). Adherence Every visit Review adherence on the TB treatment card. Manage the patient who interrupts TB treatment 74. Side effects Every visit Ask about side effects on treatment 73. Substance use/abuse At diagnosis; if adherence poor In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Weight Every visit Expect weight gain on treatment and adjust TB treatment dose accordingly 73. If losing weight, refer same week to hospital. BMI/MUAC At diagnosis and week 8 • BMI = weight (kg) ÷ height (m) ÷ height (m). • If pregnant/breastfeeding and MUAC < 23cm or if not pregnant/breastfeeding and BMI < 17.5 or MUAC < 21cm, malnutrition likely 70. Glucose At diagnosis Check glucose 86. HIV At diagnosis or if status unknown Test for HIV 75. If HIV positive and not already on ART, start ART once tolerating TB treatment 76: • If CD4 ≤ 50 cells/mm3 or stage 4, start ART within 2 weeks. If TB meningitis, start ART after 4-6 weeks of TB treatment. • If CD4 > 50 cells/mm3 and not stage 4, start ART between 2-8 weeks of TB treatment. Sputum specimen for microscopy, if smear positive at diagnosis End of month 2, month 5 and month 6 • IIf smear negative at end of month 2, change to continuation phase. • If smear positive at end of month 2, manage as on month 2 smear positive algorithm 74. Sputum specimen for Xpert MTB/RIF, if HIV positive, smear negative or EPTB End of month 2, month 5 and month 6 • If drug sensitive, continue treatment. • If drug resistant, diagnose DR-TB, stop DS-TB treatment and refer to hospital for DR-TB treatment. Treatment outcome End of treatment Manage according to smear status at diagnosis: • Smear positive at diagnosis: - - If AFB negative at month 5 and month 6, assign“Cure”outcome. - - If AFB positive at either month 5 or month 6, assign“Treatment failure”outcome and refer to hospital. - - If smear result does not fit any of the criteria above, assign“Treatment completed”outcome. • Smear negative at diagnosis or patient with extrapulmonary TB: If patient completed full course of TB treatment, assign“Treatment completed”outcome. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. Advise and treat the patient with TB 73.
Adult 73 Advise the patient with TB • Arrange TB/HIV education and refer for community or workplace adherence support. • Support the patient with poor adherence. Educate on adherence and the dangers of resistance and arrange adherence support. If treatment interrupted 74. • Educate patient about TB treatment side effects below and to report these promptly if they occur. • Advise patient s/he will no more be infectious after 2 weeks of effective treatment. • Advise the patient misusing alcohol, khat and/or using illegal or misusing prescription or over-the-counter medication to stop. • Alcohol, khat and drug misuse interferes with recovery and adherence 103. If patient smokes tobacco 102. Support patient to change 125. Review the patient with DS-TB at diagnosis, at 2 weeks and then once a month throughout DS-TB treatment. Treat the patient with TB • Treat the patient with TB 7 days a week for 6 months: - - Give intensive phase RHZE for 8 weeks. - - Change to continuation phase RH at 8 weeks to complete 6 months of TB treatment. If sputum smear positive at end of 2 months, manage further 74. • If TB meningitis, TB spine or TB of hip or knee, extend continuation phase to 10 months. • If TB meningitis or TB pericarditis, also give prednisolone 60mg PO daily for first 4 weeks, then gradually taper off over the next 4 weeks. • Give pyridoxine 25mg PO daily until treatment completed. Intensive phase: 8 weeks Continuation phase: 4 months Weight RHZE (150/75/400/275) RH 30-37kg 2 tablets 2 tablets (150/75) 38-54kg 3 tablets 3 tablets (150/75) 55-70kg 4 tablets 2 tablets (300/150) ≥ 71kg 5 tablets 2 tablets (300/150) R - rifampicin H - isoniazid Z - pyrazinamide E - ethambutol Manage the TB/HIV co-infected patient: • If TB diagnosed while patient on IPT, stop IPT and start TB treatment. • Avoid starting nevirapine with DS-TB treatment. If already on nevirapine, consider switching medication 79. Look for and manage TB treatment side effects Jaundice and vomiting Most TB medications Stop all medications and refer same day. Skin rash/itch Most TB medications Assess and manage 53. Loss of colour vision Ethambutol Refer same day. Nausea/poor appetite Rifampicin Take treatment at night. Give metoclopramide 10mg PO TID up to 5 days. Joint pain Pyrazinamide Give ibuprofen 400mg PO TID up to 5 days (avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease). Orange urine Rifampicin Reassure. Burning feet Isoniazid Increase pyridoxine to 75mg PO daily.
Adult 74 Manage the patient with a positive sputum smear at the end of month 2 • Look for explanation for result: ask about alcohol, khat or drug use 103, stress 65 and side effects. Give increased adherence support and educate the patient about the risks of poor adherence 73. • Send 1 sputum specimen for Xpert MTB/RIF. Indicate on the request form that the patient’s sputum at end of month 2 is smear positive. Review results: Rifampicin sensitive or Xpert MTB/RIF not available Manage the patient who interrupts TB treatment • Trace the patient and look for explanation for treatment interruption. Ask about alcohol, khat or drug use 103, stress 65 and side effects. • Give increased adherence support and educate the patient about the risks of poor adherence 73. • Manage treatment interruption according to duration of interruption: Interrupted for < 1 month MTB detected Sensitive Resistant • Continue TB treatment. • Ensure patient makes up missed doses by adding the missed days at the end of treatment. Sensitive Resistant Refer to hospital for DR TB treatment. Rifampicin resistant TB Refer to hospital for treatment Restart full course of DS-TB treatment. MTB not detected Refer to hospital Interrupted for 1-2 months • Send sputum for Xpert MTB/RIF. • Continue treatment while awaiting results. Interrupted for ≥ 2 months • Register patient as lost to follow up. • Send sputum for Xpert MTB/RIF and manage patient according to result: Change to continuation phase. At the end of month 5 and month 6, send sputum specimen for smear. Rifampicin resistant Smear positive Smear negative Assign treatment failure. • Stop treatment • Refer to hospital Assign cured/completed Stop treatment at 6 months. Diagnose rifampicin-resistant TB Refer to hospital for treatment.
Adult 75 HIV: diagnosis Decide who to test for HIV • Pregnant woman and her partner/s if HIV status unknown • Patient in labour and her partner/s if HIV status unknown • Postpartum woman and her partner/s if HIV status unknown • Patient seeking contraception and her partner/s if HIV status unknown • Patient whose partner is HIV positive • Patient whose family member is HIV positive • Patient with symptoms of HIV/AIDs • Patient with TB if HIV status unknown • Patient with STI and partner/s if HIV status unknown • MARP1 patient or between patient 15-24 years of age. Obtain informed consent • Educate patient about HIV, modes of HIV transmission, risk factors, benefits of knowing one’s HIV status and treatment. • Offer HIV testing like any other investigation. Unless the patient says no, s/he is tested. • If consent is granted, explain the test procedure and proceed to testing immediately. Test Do rapid HIV test on finger-prick blood using Colloidal Gold®. Support Ensure patient understands test result and knows where and when to access further care. Positive Do a second rapid HIV test on finger-prick blood using Uni Gold®. Positive Positive Negative Do a third rapid HIV test on finger-prick blood using Vikia® HIV test result negative Was patient at risk of HIV infection in the past 4 weeks (new or multiple sexual partners, or unprotected sex)? Yes • Repeat HIV test after 4 weeks. • Encourage patient to follow safe sex practices. No • Patient does not have HIV. • Encourage patient to remain negative and advise when to re-test: - - If sexually active, yearly - - If pregnant: between 28 and 36 weeks • Offer referral for male circumcision to decrease risk of HIV infection. Patient has HIV. Negative Negative Indeterminate/Invalid • Advise patient to practice safe sex and return after 2 weeks for repeat test. • If results are still indeterminate, send blood specimen to laboratory for ELISA test. • Give routine HIV care at this visit 76. • Offer to help disclose status to sexual partner/s. • Encourage HIV testing for sexual partners and children. 1 MARP include commercial sex workers, long distance drivers, university students and community around and workers of Mega projects. HIV
Adult 76 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 TB symptoms 71. TB Every visit If any one of: cough, weight loss, night sweats or fever, exclude TB 71. If none of the symptoms are present, start IPT. Start ART after TB has been excluded. STI Every visit If genital symptoms 36. Adherence Every visit Ask patient if s/he is taking medicines regularly. Check adherence with pill count (at pharmacy) and record of attendance. If adherence to IPT or CPT is poor, give adherence counseling before considering starting ART. Side effects Every visit Ask about side effects from ART 80, isoniazid preventive therapy (IPT) 78, co-trimoxazole 78 and fluconazole 78. Mental health Every visit • In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. • In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. • If ≥ 1 of: memory/co-ordination problems, disorientation, language difficulty, less able to cope with daily activities and work/social function: consider dementia 106. CVD risk At diagnosis Assess the patient’s CVD risk 84. Sexual health Every visit Ask about risky behaviour (patient or partner has new or > 1 partner, unreliable condom use or risky alcohol/drug use 103) and sexual problems 43. Family planning Every visit • Advise reliable2 contraception (IUD, injectable or sterilisation plus condoms) 110. • If planning pregnancy, advise patient to use contraception until viral load < 1000copies/mL. eMTCT If pregnant or breastfeeding If not on ART, start ART same day or as soon as possible. If pregnant, give antenatal care 114. Palliative care If deteriorating If patient deteriorating on ART and survival is predicted to be short, also give palliative care 120. Weight (BMI) Every visit • If weight loss ≥ 5% of body weight in 4 weeks 16. • If BMI < 17.5, malnutrition likely 70. BMI = weight (kg) ÷ height (m) ÷ height (m). MUAC Every visit, if pregnant/lactating or unable to stand If pregnant/breastfeeding and MUAC < 23cm or if not pregnant/breastfeeding and MUAC < 21cm, malnutrition likely 70. Stage Every visit • Check weight, mouth, skin, previous and current problems. • If stage 3 or 4 give co-trimoxazole and prioritise patient for ART. If clinical stage worsens while patient on ART, refer to hospital. Stage 1 Stage 2 Stage 3 Stage 4 • No symptoms • Persistent painless swollen glands • Recurrent sinusitis, tonsillitis, otitis media, pharyngitis • Papular pruritic eruption (PPE) • Fungal nail infections • Herpes zoster (shingles) • Recurrent mouth ulcers • Angular cheilitis • Unexplained weight loss < 10% body weight • Pulmonary TB • Oral candida • Oral hairy leukoplakia • Unexplained weight loss ≥ 10% body weight • Unexplained diarrhoea > 1 month • Unexplained fever > 1 month • Severe bacterial infections (pneumonia, meningitis) • Unexplained anaemia < 8g/dL, neutropaenia < 0.5x10/L, or chronic thrombocytopaenia < 50x10/L • Extrapulmonary TB • Weight loss ≥ 10% and diarrhoea or fever > 1 month • Pneumocystis pneumonia (PJP) • Recurrent severe bacterial pneumonia • Herpes simplex of mouth or genital area > 1 month • Oesophageal candida • Kaposi’s sarcoma, lymphoma, invasive cervical cancer • Cytomegalovirus infection • Toxoplasmosis • HIV-associated dementia, encephalopathy • Cryptococcal disease (including meningitis) • Cryptosporidium or Isospora belli diarrhoea Cervical screen (VIA) At diagnosis, then 5 yearly if normal If VIA abnormal 40. Continue to assess the patient with HIV 77. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. 2 The oral contraceptive and implant may be less effective on ART. Advise the patient on ART choosing to continue with oral contraceptive or implant to use condoms as well.
Adult 77 Review results of routine blood tests Assess When to assess Note Hepatitis At diagnosis and if changing from TDF • If HBsAg or hepatitis C antibody positive, refer to hospital. • If changing regimen: if HBsAg positive, continue tenofovir as a 4th medication (avoid stopping tenofovir) and refer to hospital. CD4 At diagnosis and 6 monthly • Start ART regardless of CD4 count. • If CD4 ≤ 350cells/mm3, also give co-trimoxazole. • If viral load test available, stop CD4 testing after 1 year on ART and 2 consecutive CD4 counts of >350cells/mm3 or viral load < 1000 copies/mL. • If viral load test not available, continue CD4 6 monthly testing. Cryptococcal antigen At diagnosis if CD4 ≤ 100cells/mm3 • If cryptococcal antigen positive and symptomatic, (headache, confusion), refer same day. • If cryptococcal antigen positive and asymptomatic or test unavailable, give fluconazole 78 for cryptococcal infection and start ART 4 weeks later. eGFR2 (if not pregnant) On TDF: before starting (if available) If eGFR < 50mL/min/1.73m3 : • Avoid tenofovir and start instead zidovudine3 . Adjust doses of other medications. • Check BP, glucose, urine dipstick and arrange kidney ultrasound. Refer to hospital. Creatinine (if pregnant) If creatinine ≥ 85μmol/L, avoid tenofovir and refer. CBC On AZT: before starting, at 4, 8 and 12 weeks • If Hb 7-7.9g/dL or neutrophil ≥ 0.75 x 109 /L or platelet > 50,000/mcL: start/continue ART. • If Hb < 7g/dL or neutrophils < 0.75 x 109 /L or platelet ≤ 50,000/mcL: if starting, avoid zidovudine, refer. If on AZT, switch medication 79. ALT On NVP: before starting, then 6 monthly • At diagnosis: - - If ALT > 200, refer same day. If ALT 100-200, review hepatitis results, medications, alcohol use. Avoid nevirapine. • On ART: - - If ALT > 200, refer same day. If ALT 100-200, continue medication and repeat ALT within 1 week. Viral load At 6 months, 12 months, then 12 monthly • If viral load > 1000 copies/mL for 1st time, give intensified adherence support and repeat viral load after 3 months. • If viral load > 1000 copies/mL for 2nd time, patient has virological failure: refer to hospital. Advise and treat the patient with HIV 78. 1 If not pregnant, check eGFR. If pregnant, check creatinine instead. 2 Calculate eGFR = [(140 - age) x weight (kg)]/[72x creatinine (mg/dL)]. If patient is a woman, multiply by 0.85. 3 If previously on zidovudine, refer to hospital. Continue to assess the patient with HIV Do blood tests at diagnosis, before starting ART and regularly on ART: sending blood samples to respectively assigned referral hospital At diagnosis Starting/changing ART regimen 4 weekss 8 weeks 12 weeks 6 months 1 Year Yearly 6 monthly • CD4 • If available: - - Cryptococcal antigen - - HBsAg and Hepatitis C antibody tests • Starting AZT: CBC • Starting NVP: ALT • Starting TDF: eGFR or creatinine1 • Changing from TDF: HBsAg AZT: CBC AZT: CBC AZT: CBC • Viral load • CD4 • Viral load • CD4 Viral load • CD4: If viral load test available, stop after 1 year on ART and 2 consecutive CD4 counts of >350cells/mm3 or viral load < 1000 copies/mL • NVP: ALT AZT – zidovudine CBC – complete blood count Hb – haemoglobin
Adult 78 Advise the patient with HIV • Offer to help disclose status 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 abstinence, being faithful to one partner and 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 prevent resistance. • Explain the benefits of starting ART early, regardless of CD4 or stage but especially if CD4 ≤ 350, stage 3 or 4, pregnant or breastfeeding. If patient chooses not to start ART, advise to attend regularly for routine HIV care and to return immediately if s/he becomes unwell. • Give increased adherence support to the patient with poor adherence/attendance or viral load > 1000copies/mL: - - Educate patient and family on the importance of adherence and dangers of resistance. - - Plan with patient how to take treatment. Consider adherence aids (pillboxes, diaries). - - Refer for support: adherence counsellor, support group, treatment buddy, health extension worker. Treat the patient with HIV • Give prophylaxis: isoniazid preventive therapy (IPT), co-trimoxazole and fluconazole as needed (see below). • Give ART regardless of CD4 or stage 79. • If already on ART and no problems, continue treatment. • If already on ART and contraindication to current ART or intolerable side effect, change ART 79. When to give What to give Side effects When to stop Isoniazid preventive therapy (IPT) • No TB symptoms • If also starting ART, start IPT once tolerating ART. • Avoid if TB symptoms, on TB treatment, peripheral neuropathy, liver disease, alcohol abuse. • Isoniazid 300mg daily • Pyridoxine 25mg daily • Peripheral neuropathy 50 • Rash 53 • Hepatitis - - If jaundice: refer same day. - - If nausea, vomiting, abdominal pain: check ALT and review result within 24 hours 80. Stop IPT after 6 months. Co-trimoxazole • CD4 ≤ 350cells/mm3 • Stage 3 or 4 Co-trimoxazole 960mg PO daily • Nausea/vomiting 33 • Rash 53 • Fatigue, dizziness (if Hb ≤ 7g/dL, refer to hospital) • Easy bruising, bleeding from gums: stop medication and refer same day. • Hepatitis - - If jaundice: refer same day. - - If nausea, vomiting, abdominal pain: check ALT and review result within 24 hours 80. Stop co-trimoxazole after 1 year on ART and 2 consecutive CD4 counts of >350cells/mm3 or viral load < 1000 copies/mL Fluconazole • Cryptococcal antigen positive or • Cryptococcal antigen unavailable with CD4 ≤ 100cells/mm3 • If pregnant, breastfeeding or known liver disease, avoid fluconazole and refer same day. • If symptomatic (headache, confusion), refer same day. • If asymptomatic, give fluconazole 800mg PO daily for 2 weeks, then 400mg daily for 2 months, then 200mg daily to complete at least 1 year. • Nausea/vomiting 33 • Hepatitis - - If jaundice: refer same day. - - If nausea, vomiting, abdominal pain: check ALT and review result within 24 hours 80. Stop after at least 1 year on ART and fluconazole if 2 consecutive CD4s ≥ 100cells/mm3 or viral load < 1000copies/mL. Review the patient with HIV • If starting ART: review 2 weeks after starting ART, then monthly. • Once on ART for ≥ 1 year, 2 consecutive viral loads < 1000 copies/mL, not pregnant or breastfeeding, is adherent and well, review 6 monthly. If unwell or problems with adherence, see more often. • If declines ART: see patient 2 weekly and give repeated counseling; Otherwise advise patient to return if unwell or s/he decides to start ART.
Adult 79 Start or change ART in the patient with HIV 1. Decide which ART regimen the patient needs Currently not on ART Currently on ART and contraindication or intolerable side effect. Switch to a medication from the same section 80. Choose 1st line ART Known with kidney disease or uncontrolled hypertension? Never had ART Refer to hospital for 2nd line ART Known with active psychiatric illness? Known with active psychiatric illness? Choose same regimen as before. Choose zidovudine, lamivudine and efavirenz. Choose tenofovir, lamivudine and nevirapine. Choose zidovudine, lamivudine and nevirapine. Choose tenofovir, lamivudine and efavirenz. • Do viral load test. • Is viral load > 1000copies/mL? Previously had ART and interrupted Yes Yes Yes Yes No No No No 2. Check other medications and change if needed • If epilepsy and patient is on phenytoin, monitor closely. If available or affordable, use instead valproic acid 97. • If on oral contraceptive or implant, advise the patient to use condoms as well. • If on TB treatment and starting nevirapine, replace with efavirenz 80. 3. Order blood tests as directed 77 If blood results done accordingly are abnormal, alter regimen choice 80. Discuss if needed. 4. Decide when to start/change ART If starting ART: • If pregnant or breastfeeding: start ART after 2 weeks unless newly diagnosed TB or suspected TB (refer instead to hospital). • If TB, start ART once tolerating TB treatment: - - If CD4 ≤ 50cells/mm3 or stage 4, start ART within 2 weeks. If TB meningitis, start ART after 2-8 weeks of TB treatment. - - If CD4 > 50cells/mm3 and not stage 4, start ART between 2-8 weeks of TB treatment. • If cryptococcal antigen positive: start ART after 4 weeks of fluconazole. If cryptococcal meningitis, start ART after 4-6 weeks of fluconazole. • If none of above: start ART within 2 weeks. If changing ART: • Change as soon as blood results are available. • If contraindication or intolerable side effect: change same day and review blood results as soon as possible.
Adult 80 5. Start/change ART • Give a combination of 3 medications (1 from each of the 3 sections in the table below) according to chosen ART regimen and blood results. • Give fixed dose combination tablet if available. Medication Dose Urgent side effects (stop medication and refer same day) Self-limiting side effects (refer to hospital if persist after 6 weeks) Long-term side effects 1 Tenofovir (TDF) • 300mg PO daily • Avoid if eGFR < 50mL/min/1.73m3 Kidney failure Nausea, diarrhoea - Zidovudine (AZT) 300mg PO BID • Lactic acidosis1 • Symptomatic anaemia (pallor with respiratory rate > 30, dizziness/faintness or chest pain) • Headache • Nausea • Muscle pain • Fatigue (if Hb ≤ 7g/dL switch medication 79) Fat loss in face, limbs and buttocks; fat accumulation (central obesity, breast enlargement); switch to tenofovir or abacavir 79. Abacavir (ABC) Avoid if previous Abacavir Hypersensitivity Reaction (AHR) 300mg PO BID or 600mg PO daily Abacavir Hypersensitivity Reaction likely if ≥ 2 of: • Fever • Rash • Fatigue/body pain • Nausea/vomiting/diarrhoea/abdominal pain • Sore throat/cough/difficulty breathing • Nausea • Vomiting • Diarrhoea - 2 Lamivudine (3TC) 150mg PO BID or 300mg PO daily Uncommon Uncommon. Occasional nausea and diarrhoea Uncommon 3 Efavirenz (EFV) Avoid if active psychiatric illness • 400mg PO daily • If pregnant or TB, give 600mg PO daily • Avoid taking drug with fatty meal • Rash 53 • Jaundice/hepatitis2 • Psychosis • Rash 53 • Headache, dizziness, sleep problems, low mood - take dose at night. If on 600mg daily, consider giving 400mg PO daily. • Central obesity, breast enlargement, switch to nevirapine 79. • Dyslipidemia Nevirapine (NVP) Avoid if CD4 > 250cells/mm3 (woman) or > 400cells/mm3 (man) or ALT ≥ 100 200mg PO daily for 2 weeks, then 200mg PO BID • Rash 53 • Jaundice/hepatitis2 • Rash 53 • Nausea - 1 Lactic acidosis likely if 2 or more of: fatigue/weakness, body pain, nausea/vomiting, diarrhoea, weight loss, loss of appetite, abdominal pain, difficulty breathing (more likely if rapid lactate ≥ 2.5mmol/L). 2 If jaundice: refer same day. If nausea, vomiting, abdominal pain: check ALT and review result within 24 hours 77.
Adult 81 Asthma and COPD: diagnosis • The patient with chronic cough may have more than one disease. Also consider TB, pneumocystis pneumonia (PJP), lung cancer, bronchitis, heart failure and post-infectious cough 29. • Asthma and chronic obstructive pulmonary disease (COPD) both present with cough, wheeze, tight chest or difficulty breathing. Distinguish asthma from COPD: If unsure of diagnosis, treat as asthma 82 and refer to hospital within 1 month. Asthma likely if several of: • Onset before 20 years of age • Associated allergic rhinitis, eczema, allergic conjunctivitis, other allergies • Symptom severity changes over time with symptom-free periods in between. • Symptoms worse at night, early morning, with cold, stress or common cold • Patient or family have a history of asthma Give routine asthma care 82. COPD likely if several of: • Onset after 40 years of age • Symptoms are persistent and worsen slowly over time • Cough with sputum starts long before difficulty breathing • History of heavy tobacco smoking or indoor smoke exposure • Previous diagnosis of TB • Poor response to inhaled salbutamol Give routine COPD care 83. 1 Adapted from: Zar HJ, Green C, Mann MD, Weinberg EG. A novel method for constructing an alternative spacer for patients with asthma. SAMJ. 1999 January; 89(1): 40-42. 2 If 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. While breathing in, press pump once and keep breathing in slowly. Close mouth and hold breath for 10 seconds. Breathe out. Using inhalers and spacers • If patient unable to use an inhaler correctly, add a spacer to increase drug delivery to the lungs, especially if using inhaled corticosteroids. This may also reduce the risk of oral candida. • Clean the spacer before first use and every second week: remove the canister and wash spacer with soapy water. Allow it to drip dry. Avoid rinsing with water after each use. How to make a spacer from a plastic bottle1 How to use an inhaler with a spacer2 1 • Wash a 500mL plastic cold-drink bottle with soapy water. • Leave to air-dry. • Discard the lid. 2 • Wind a steel wire around the open mouth of inhaler to form a mould. • Keep some wire for a handle. • Heat the mould with a flame until it is red hot. 1 Shake inhaler and insert into spacer. 2 • Stand up and breathe out. • Then form a seal with lips around mouthpiece. 3 Apply the hot mould to the bottom end of the bottle for 10 seconds then rotate 180° and reapply until the plastic melts. 4 • Insert mouth of inhaler immediately to create a tight fit. • Apply quick-setting glue to seal the inhaler permanently to the spacer. 3 Press pump once to release one puff into spacer. 4 • Then take 4 breaths keeping spacer in mouth. • Repeat steps 3 and 4 for each puff. • Rinse mouth after using inhaled corticosteroids. CHRONIC RESPIRATORY DISEASE
Adult 82 Asthma: routine care Advise the patient with asthma • Ask about smoking. If patient smokes tobacco 102. Support patient to change 125. • Ensure patient understands medication: beta-agonist (salbutamol) relieves symptoms but does not control asthma. Inhaled corticosteroid (beclomethasone) prevents but does not relieve symptoms and it is the mainstay of asthma control. • Inhaled corticosteroids can cause oral candida: advise patient to rinse and gargle after each dose of beclomethasone. • Advise patient to avoid allergens that worsen/trigger asthma or allergic rhinitis (e.g. animals, dust, chemicals, pollen, grass). Also advise to avoid aspirin, NSAIDs (e.g. ibuprofen) and beta-blockers (e.g. metoprolol). Treat the patient with asthma • Give inhaled salbutamol 200mcg (2 puffs) as needed, up to 4 times a day. If exercise-induced asthma, give patient salbutamol 200mcg (2 puffs) to use before exercise. • If patient received prednisolone or hydrocortisone for an acute exacerbation, give prednisolone 40mg PO daily for 5 days. • If acute exacerbation or asthma is not controlled, step up treatment: - - Before adjusting treatment ensure patient is adherent and can use inhaler and spacer correctly 81. Also check patient is avoiding smoking, allergens and medications (aspirin, NSAIDs, beta-blockers). - - Give inhaled beclomethasone 200mcg BID if not already on it. If already on it, increase beclomethsone to 400mcg BID. If not available start predisolone 2.5 to 5mg daily and refer. • If still not controlled, add theophedrine 120/10mg BID. Increase theophedrine to 240/20mg BID if needed . If not controlled after 1 month, refer to hospital. • If asthma is controlled: continue medication at same dose. If controlled and no acute exacerbations for ≥ 6 months, step down treatment: - - If on theophylline, decrease dose or stop. - - If on beclomethasone, decrease total daily dose by 200mcg. If on 200mcg daily, stop beclomethasone. - - If symptoms worsen while stepping down treatment, step up again to same medication and dose as when the patient was controlled. • If acute exacerbation, only give antibiotic if fever or thick yellow/green sputum: give doxycycline 100mg PO BID for 5 days. Avoid doxycycline if pregnant. • If > 2 courses of prednisolone given in past 6 months or acute exacerbation occurs on maximum treatment, refer to hospital. • Review the patient with controlled asthma 3 monthly, the patient with asthma that is not controlled monthly, and the patient with an acute exacerbation after 1 week. • Advise patient to return before next appointment if no better or symptoms worsen. Assess the patient with asthma Assess When to assess Note Symptom control Every visit • If patient has wheeze/tight chest and is breathless at rest or while talking or respiratory rate > 30, manage acute exacerbation 30. • Any of the following indicate that the patient’s asthma is not controlled: - - Daytime cough, difficulty breathing, tight chest or wheeze > 2 times a week - - Night-time or early morning waking due to asthma symptoms - - Limitation of daily activities due to asthma symptoms - - Need to use salbutamol inhaler > 2 times a week - - frequent exacerbations > 2 in past 12 months • If none of the above then asthma is controlled. Other symptoms Every visit • Manage symptoms as on symptom pages. Ask about and manage allergic rhinitis 26 and dyspepsia 32. • Ask the patient using inhaled corticosteroids about a sore mouth. Check for oral candida 27. Medication use Every visit Check adherence and that patient can use inhaler and spacer correctly 81. If not adherent, refer for health extension worker support.
Adult 83 Chronic obstructive pulmonary disease (COPD): routine care Advise the patient with COPD • Ask about smoking. If patient smokes tobacco 102. Support patient to change 125. Stopping smoking is the mainstay of COPD care. • Encourage the patient to take a walk daily and to increase activities of daily living like gardening, housework and using stairs instead of lifts. • Help the patient to manage his/her CVD risk 85. • Inhaled corticosteroids can cause oral candida: advise patient to rinse and gargle after each dose of beclomethasone. Treat the patient with COPD • Give inhaled salbutamol 200mcg (2 puffs) when needed, up to 4 times a day. • If patient received prednisolone or hydrocortisone for acute exacerbation at this visit, give prednisolone 40mg PO daily for 5 days. • If sputum increases in amount or changes in color to yellow/green and worsening of cough or dyspnea, treat for chest infection: - - Give doxycycline 100mg PO BID for 7 days. Avoid if pregnant. - - If increased breathlessness, also give prednisolone 40mg PO daily for 5 days if not already on it. • Before referring for treatment adjustment, ensure patient is adherent and can use inhaler and spacer correctly 81 • If moderate or severe COPD and ≥ 2 exacerbations in 1 year, add inhaled beclomethasone 200mcg BID, if available. • If severe COPD, add theophedrine 120/10mg BID. Increase theophedrine to 240/20mg BID if needed. If no better after 1 month, refer to hospital. • If ≥ 2 courses of prednisolone given in 6 months, refer to hospital for review and spirometry. If stable and mild COPD review 6 monthly. If moderate/severe COPD or frequent/recent exacerbation review monthly. Assess the patient with COPD Assess When to assess Note COPD symptoms: cough and difficulty breathing Every visit • If patient has wheeze/tight chest and breathless at rest or while talking or respiratory rate > 30, manage acute exacerbation 30. • Assess disease severity: If difficulty breathing with activities of daily living (like dressing) and at rest, COPD is severe. If unable to walk at same pace as others of same age, COPD is moderate. If difficulty breathing only when walking fast/up a hill, COPD is mild. • Investigate for TB only if patient has other TB symptoms like weight loss, night sweats, blood-stained sputum 71. Other symptoms Every visit • Manage symptoms as on symptom pages. • Ask the patient using inhaled corticosteroids about a sore mouth. Check for oral candida 27. • If swelling in both legs, and unable to lie flat, consider heart failure. Refer to hospital. BMI/MUAC Every visit If pregnant/breastfeeding and MUAC < 23cm or if not pregnant/breastfeeding and BMI < 17.5 or MUAC < 21cm, malnutrition likely 70 Medication use Every visit Check adherence and that patient can use inhaler and spacer correctly 81. If not adherent, refer for health extension worker support. Depression Every visit In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. Palliative care Every visit If severe COPD, > 3 hospital admissions for COPD in 1 year or heart failure and survival is predicted to be short, also give palliative care 120. CVD risk At diagnosis, then depending on risk • Assess CVD risk 84. • If <10%, reassess after 1 year. If 10% to < 20%, reassess after 6 months.
Adult 84 Cardiovascular disease (CVD) risk: diagnosis CVD risk is the chance of having a heart attack or stroke over the next 10 years Identify if the patient has established CVD: • Patient known with any of: previous heart attack, angina pectoris or heart failure, previous stroke or TIA or peripheral vascular disease. • If patient has current/recent chest pain, especially on exertion and relieved by rest, screen for ischaemic heart disease 94. • If patient has current/recent leg pain, especially on walking and relieved by rest, screen for peripheral vascular disease 49. • If new sudden asymmetric weakness or numbness of face, arm or leg; difficulty speaking or visual disturbance: consider stroke or TIA 93. Look for CVD risk factors: • Ask about smoking: consider the patient who quit smoking in the past year a smoker for CVD risk assessment. • Ask about family history: a parent or sibling with premature CVD (man < 55 years or woman < 65 years) is a risk factor. • Calculate Body Mass Index (BMI): weight (kg) ÷ height (m) ÷ height (m). A BMI > 25 is a risk factor. • Measure waist circumference over no/light clothing, at the end of a normal breath 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 89. • Look for diabetes: check glucose 86. Calculate the patient’s CVD risk: • Plot patient’s risk on charts1 below using diabetes status, age, sex, systolic BP (SBP) and smoking status. Show the patient what his/her risk of heart attack or stroke might be over next 10 years. • Avoid using these charts to decide treatment if patient has established CVD or kidney disease. Treat as if the patient has a CVD risk > 30%. CVD risk1 : > 30% 20-30% 10-20% < 10% 1 Adapted from WHO/ISH Cardiovascular Risk Prediction Chart for WHO epidemiological sub-regions AFR E. From: Prevention of Cardiovascular Disease. Pocket Guidelines for Assessment and Management of Cardiovascular Risk. World Health Organization. Geneva, 2007. Diabetic man Diabetic woman Non-diabetic man Non-diabetic woman Non smoker Smoker Non smoker Smoker SBP (mm Hg) Non smoker Smoker Non smoker Smoker SBP (mm Hg) ≥ 70 years ≥ 180 160-179 140-159 < 140 ≥ 70 years ≥ 180 160-179 140-159 < 140 60-69 years ≥ 180 160-179 140-159 < 140 60-69 years ≥ 180 160-179 140-159 < 140 50-59 years ≥ 180 160-179 140-159 < 140 50-59 years ≥ 180 160-179 140-159 < 140 40-49 years ≥ 180 160-179 140-159 < 140 40-49 years ≥ 180 160-179 140-159 < 140 • If CVD risk factors or CVD risk ≥ 10% or established CVD, manage the CVD risk 85. • If CVD risk < 10% and no CVD risk factors, reassess CVD risk after 5 years.
Adult 85 Cardiovascular disease (CVD) risk: routine care Assess the patient with CVD risk factors or CVD risk ≥ 10% or established CVD Assess When to assess Note Symptoms Every visit Ask about chest pain 28, difficulty breathing 29, leg pain 49, or new sudden asymmetric weakness or numbness of face, arm or leg; difficulty speaking or visual disturbance 93. Modifiable risk factors Every visit Ask about smoking, diet, substance use and exercise or activities of daily living. Manage as below. BMI Every visit BMI = weight (kg) ÷ height (m) ÷ height (m). Aim for < 25. Waist circumference Every visit 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 Check BP 89. If known hypertension 90. CVD risk At diagnosis, then depending on risk If < 10% with CVD risk factors or 10-20% reassess after 1 year. If > 20%, refer to hospital for investigation if not already done. Blood glucose At diagnosis, then depending on result Check glucose 86. If known diabetes 87. Random total cholesterol (by referral to hospital) At baseline if no CVD or diabetes within 3 months of diagnosis. • If no CVD or diabetes no need to repeat cholesterol or adjust simvastatin. • If CVD or diabetes, increase simvastatin based on repeat cholesterol on relevant page. Treat the patient with CVD risk • If no diabetes, give simvastatin 20mg PO daily if patient has established CVD, cholesterol > 300mg/dL or CVD risk ≥ 30%. • If diabetes, decide if patient needs simvastatin 87. If CVD risk remains > 30% after 6 months, refer. 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. • Invite patient to address 1 lifestyle 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. Stress Assess and manage stress 65. Physical activity • Aim for at least 30 minutes of moderate exercise (e.g. brisk walking) on most days of the week. • Increase activities of daily living like gardening, housework, walking instead of taking transport, using stairs instead of lifts. • Exercise with arms if unable to use legs. Smoking • Encourage patient not to start • If patient smokes tobacco 102. Diet • Eat a variety of foods in moderation. Reduce portion sizes. • Increase fruit and vegetables. • Reduce fatty foods: eat low fat food, cut off animal fat. Use liquid oils instead of solid or semisolid oils • Avoid adding salt to food. • Avoid/use less sugar and sugary foods/drinks. Screen for substance abuse • Limit alcohol intake ≤ 2 drinks1 /day and avoid alcohol on most days of the week. • In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the- counter medications? If yes to any 103. Weight • Aim for BMI < 25, and waist circumference < 80cm (woman) and < 94cm (man). • Any weight reduction is beneficial, even if targets are not met. • Identify support to maintain lifestyle change: health care worker, friend, partner or relative to attend clinic visits, a healthy lifestyle group. • 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 124. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. CHRONIC DISEASES OF LIFESTYLE
Adult 86 Diabetes: diagnosis Decide which glucose test to do • If patient is well and able to return for screening, check fasting plasma glucose after an 8-hour overnight fast. • Only check finger prick random glucose if patient is unwell or has symptoms of diabetes (thirst, urinary frequency, weight loss) or is unable to return easily for fasting glucose. Random glucose < 140mg/dL Random glucose 140-199mg/dL < 126mg/dL • Assess and manage CVD risk 84. • Repeat fasting plasma glucose after 1 year. Diagnose diabetes • Classify diabetes: - - Type 1 diabetes more likely if: <30 years, not overweight, no family history of diabetes, presents with DKA. - - Type 2 diabetes more likely if: >30 years, overweight, hypertension or family history of diabetes • Give routine diabetes care 87. ≥ 126mg/dL 100-125mg/dL 100-125mg/dL • Patient has impaired fasting glucose. • Repeat fasting plasma glucose within one week. No ketones Check urine for ketones. Check for symptoms of diabetes: thirst, urinary frequency, weight loss Check fasting plasma glucose after an 8-hour fast. Ketones present Random glucose > 200mg/dL No No No < 100mg/dL < 100mg/dL ≥ 126mg/dL Confirm with another fasting plasma glucose within one week. • Assess and manage CVD risk 84. • Repeat fasting plasma glucose after 3 years, or if CVD or hypertension, 1 year. ≥ 126mg/dL Recheck glucose 3 yearly from 45 years. Yes Yes Yes Check if patient has risk factors: BMI ≥ 25 and one or more of: • Hypertension • Cardiovascular disease • Physical inactivity • Family history of diabetes • Previous gestational diabetes or big baby • Previous impaired glucose tolerance or impaired fasting glucose • Give normal saline 1L IV over 2 hours then 1L 4 hourly. • Refer urgently. Check if patient needs urgent attention: • Unconsciousness 13 • Chest pain 28 • Convulsions 15 • Drowsiness • Confusion • Rapid deep breathing • Nausea or vomiting • Abdominal pain • Temperature ≥ 38o C • Severe dehydration: BP < 90/60, pulse ≥ 100
Adult 87 Diabetes: routine care Assess the patient with diabetes Assess When to assess Note Symptoms Every visit • Manage symptoms as on symptom pages. • If frequent urination, thirst or hunger, check random glucose. • Ask about chest pain 28 and leg pain 49. Family planning Every visit Assess patient’s contraception needs 110. If pregnant or planning pregnancy, refer to hospital. CVD risk At diagnosis, then yearly Assess CVD risk 84. Start simvastatin if CVD risk > 20% or patient is > 40 years old 88. BP Every visit Check BP 89. If known hypertension 90. BMI At diagnosis and yearly BMI = weight (kg) ÷ height (m) ÷ height (m). Aim for BMI < 25kg/m2 . Waist circumference Every visit Aim for < 80cm in woman and < 94cm in man. Eyes for retinopathy At diagnosis, yearly and if visual problems If visual problems, cataracts or new retinopathy, refer to hospital. Feet 50 • Visual: every visit • Comprehensive: at diagnosis then yearly, more often if problems • Visual assessment: look for ulcers, calluses, redness, warmth, deformity. • Comprehensive assessment: visual assessment as above, foot pulses, reflexes, sensation in toes and feet • If ulcers 59. If severe infection or other abnormalities, refer to hospital. Random glucose Only if symptoms or adjusting glucose-lowering medication If random glucose < 70mg/dl or > 200mg/dl give urgent attention above. Urine protein At diagnosis, then yearly if not on enalapril If urine protein > 1+, start enalapril 5mg PO daily and increase to a maximum of 10mg PO BID. Refer to hospital for annual check up. eGFR (by referral to hospital) At diagnosis, then yearly If eGFR < 60mL/min/1.73m3 , refer to hospital. Random total cholesterol (by referral to hospital) • Baseline if < 40 years or if CVD risk < 20% • 3 months after starting simvastatin and then after 3 months if ≥ 190mg/dL • If baseline cholesterol > 300mg/dL, start simvastatin. • If cholesterol ≥ 190mg/dL: increase simvastatin to 40mg. If already on 40mg daily, refer to hospital. • If cholesterol < 190mg/dL, no need to repeat. Give urgent attention to the patient with diabetes and one or more of: • Chest pain 28 • Convulsing 15 • Decreased consciousness, drowsiness • Confusion or unusual behaviour • Weakness or dizziness • Shaking • Sweating • Palpitations • Rapid deep breathing • Nausea or vomiting • Abdominal pain • Thirst or hunger • Temperature ≥ 38°C • Severe d ehydration: decrease urine output, BP < 90/60, pulse ≥ 100 Check random fingerprick glucose: Glucose < 70mg/dL with/without symptoms • Give oral glucose 20g. If unable to take orally, give instead glucose 40% 50mL IV over 2-3 minutes. Repeat if glucose still < 70mg/dL after 15 minutes. Maintain with glucose 10% solution1 . • Give the patient food as soon as s/he can eat safely. • Identify cause and educate about meals and doses 88. • If incomplete recovery, refer same day. • Discuss referral if on gliclazide or insulin. Glucose > 200mg/dL with symptoms No ketones in urine Give routine diabetes care below. • Give normal saline 1L IV over 2 hours then 1L 4 hourly. • Give regular insulin 10IU IM single dose. • Refer urgently. Ketones in urine Glucose > 200mg/dL without symptoms Check urine for ketones. 1 Add 10 vials of glucose 40% in 1L dextrose in normal saline solution at 30 drops per minute.
Adult 88 Advise the patient with diabetes • Help the patient to manage his/her CVD risk 85. • Explain importance of adherence and to eat regular meals. If newly diagnosed, poor adherence or attendance, refer local diabetes association branches. • Ensure patient can recognise and manage hypoglycaemia (shaking, sweating, palpitations, weakness, hunger): - - Drink sugar water, sugary soft drink or eat a candy or biscuit. Always carry something sweet. If convulsions, confusion/coma, rub sugar inside mouth. - - Identify and manage the cause: increased exercise, missed meals, inappropriate dosing of glucose-lowering medications, alcohol use, illnesses like infections. • Encourage the patient to eat a healthy, balanced, low-fat diet including lots of vegetables. Eat fewer sweet foods. • Educate the patient to care for his/her feet to prevent ulcers and amputation: avoid walking barefoot or without socks, wash feet in lukewarm water and dry well especially between the toes, avoid cutting calluses or corns, use care when cutting nails. Look at feet every day and see health care worker if any problem or injury. • Educate the patient using insulin: - - Explain injection technique and recommended sites: abdomen, thighs, upper arms. - - Advise patient to store insulin in fridge or a cool dark place. - - Ensure patient can recognise hypoglycaemia and hyperglycaemia. - - Arrange for on sharps disposal at home or clinic. Treat the patient with diabetes • Give simvastatin if ≥ 40 years, CVD risk > 20%, established CVD or cholesterol > 300mg/dL. Start simvastatin1 20mg PO daily. If repeat cholesterol > 190mg/dL increase to 40mg PO daily. If already on 40mg daily, refer to hospital. • Start aspirin 75-150mg PO daily if patient has established CVD or CVD risk >30%. Avoid if known peptic ulcer, dyspepsia, kidney or liver disease. • Give enalapril 5mg PO daily if diabetic kidney disease confirmed with urine albumin even if no hypertension. Increase gradually to 20mg PO daily if systolic BP remains > 100. Avoid in angioedema, stop if severe cough with use. • If type 1 diabetes, start or continue insulin: - - Start with NPH insulin at 0.2-0.4U/kg in two divided doses (2/3 morning, 1/3 evening). - - Increase by 2 units every 3 days until morning fasting blood glucose is 90-130mg/dL. - - If > 30IU needed, episodes of hypoglycemia at night or random glucose >180mg/dL repeatedly after 3 months, refer. • If type 2 diabetes, give glucose-lowering medication in a stepwise fashion below. Ensure patient is adherent before increasing treatment. • If patient using insulin: - - Advise home blood glucose monitoring if available and patient is able to operate glucometer. - - Once stable, patient to check fasting blood glucose on waking once a week. - - If unavailable, monitor fasting blood glucose at health centre (or if not possible random). Step Medication Start dose Maximum dose Note 1 Metformin (take with or after meals) 500mg PO daily 1g BID • Increase by 500mg/day every week if random glucose ≥ 180mg/dL or fasting glucose ≥ 130mg/dL and patient adherent. • Avoid in kidney or liver disease, or heart failure. • If on maximum dose, move to step 2. 2 Add glibenclamide (take with food) 2.5mg PO daily 20mg daily • Continue metformin. • If random glucose ≥ 180mg/dL and patient is adherent, increase every week by 2.5mg/day. • If total daily dose > 5mg then give in 2 divided doses. • Avoid in severe kidney or liver disease. • If on maximum dose, move to step 3. 3 Add basal insulin (NPH insulin) 0.1 units/kg/dose subcutaneously • Take at bedtime. • Continue metformin. Decrease glibenclamide gradually until stopped. • Increase by 2 units every 3 days until morning fasting glucose is between 90 and 130mg/dL. • If > 30IU needed, episodes of hypoglycaemia at night or fasting glucose ≥ 130mg/dL repeatedly after 3 months, refer. Review the patient with diabetes 6 monthly once stable.
Adult 89 Hypertension: diagnosis Check blood pressure (BP) • Seat patient with back against chair and arm supported at heart level for 5 minutes. • Use a larger cuff if mid-upper arm circumference is > 34cm. • Record systolic BP (SBP) and diastolic BP (DBP): SBP is the first appearance of sound, DBP is the disappearance of sound. • Check two readings 5 minutes apart. Use the lowest reading to determine the patient’s BP. • If patient is pregnant, interpret reading 112. Give urgent attention to the patient with BP ≥ 180/110 and one or more of: • Visual disturbances • Dizziness • Weakness or numbness • Confusion • Headache • Chest pain 28 • Difficulty breathing worse on lying flat or with leg swelling 91 • BP > 200/120 Management: • Give nifedipine 20mg PO. • Refer urgently. BP < 140/90 Approach to the patient not needing urgent attention BP ≥ 140/90 Repeat BP check on 2 more occasions. Avoid diagnosing hypertension based on one reading alone. Assess CVD risk 84. BP < 140/90 on repeat checks BP < 120/80 BP 120/80-139/89 Patient’s BP is a CVD risk factor. • Manage CVD risk 85. • Recheck BP after 1 year. Recheck BP after 5 years. BP confirmed on 3 occasions ≥ 140/90 Diagnose hypertension • Give routine hypertension care 90. • If < 40 years, refer to exclude secondary hypertension.
Adult 90 Hypertension: routine care Assess When to assess Note Symptoms Every visit Manage symptoms on symptom pages. Ask about symptoms of heart failure 91, ischaemic heart disease 94 or stroke/TIA 93. BP • Check 2 readings at every visit. • For correct method 89. • If BP < 140/90 (< 150/90 if ≥ 60 years), BP is controlled: continue current treatment and review 6 monthly. • If BP ≥ 140/90 (≥ 150/90 if ≥ 60 years), BP is not controlled: decide treatment below. If ≥ 180/110: also check if needs urgent attention 89. CVD risk At diagnosis, then depending on risk • Assess CVD risk 84. • If < 10% with CVD risk factors reassess after 1 year. If 10-20% reassess after 6 months. If > 20% refer to hospital. Eyes for retinopathy At diagnosis, then yearly and if visual problems If new retinopathy, visual problems or cataracts, refer. Glucose At diagnosis, then yearly Check glucose 86. If known diabetes 87. eGFR1 (by referral to hospital) At diagnosis, then yearly If eGFR < 60mL/min/1.73m3 , refer to hospital. Urine dipstick At diagnosis, then yearly If blood or protein on dipstick, refer to hospital and repeat dipstick at next visit. If glucose on dipstick, screen for diabetes 86. Random total cholesterol (by referral to hospital) At baseline if no CVD or diabetes within 3 months of diagnosis. • If no CVD or diabetes no need to repeat cholesterol or adjust simvastatin. • If CVD or diabetes, increase simvastatin based on repeat cholesterol on relevant page. Advise the patient with hypertension • Help patient to manage his/her CVD risk 85. Emphasise salt restriction ≤ 1 teaspoon/day, weight reduction and smoking cessation. If patient smokes tobacco 102. • Advise patient to avoid NSAIDs (e.g. ibuprofen) and combined oral contraceptive 110. If pregnant or planning pregnancy, refer to hospital. • Explain importance of adherence and that patient will need lifelong hypertension care to prevent stroke, heart disease and kidney disease. If newly diagnosed, refer for health extension worker support. Treat the patient with hypertension • If no diabetes, give simvastatin 20mg PO daily if patient has established CVD, cholesterol > 300mg/dL or CVD risk ≥ 30%. If diabetes, decide if patient needs simvastatin 87. • Give aspirin 75-150mg PO daily if patient has CVD. Avoid if peptic ulcer, dyspepsia, kidney or liver disease. • If BP is not controlled, decide treatment for hypertension using algorithm and table below: Not yet on hypertension medication Review in 1 month. Already on hypertension medication BP ≥ 160/100 Start treatment with 2 medications. Not adherent • Check patient using medication correctly. • Discuss any side effects. • Refer for health extension worker support. • Review in 1 month. Adherent • Increase current medication or if at maximum dose, add new medication. • Review in 2 weeks. No: Start 1 medication only after trying CVD risk management 85 alone for 3-6 months. Yes: Start treatment with 1 medication. BP 140-159/90-99 Any of: CVD, diabetes, CVD risk ≥ 20%, retinopathy or kidney disease? Medication Decide which medication to use Start dose Maximum dose Side effects Hydrochlorothiazide First-line therapy. Avoid in gout, severe liver/kidney disease. Refer if impaired glucose tolerance, diabetes or raised cholesterol. 12.5mg PO daily in morning 50mg daily or in 2 divided doses Impaired glucose tolerance, gout attack, gastrointestinal disturbances Enalapril Use first if diabetes with proteinuria or kidney disease. Avoid if previous angioedema. Add to hydrochlorothiazide if patient needs > 1 medication. 5mg PO daily or in 2 divided doses 40mg daily in 2 divided doses Cough (common), dizziness, angioedema (swelling tongue, lips, face, difficulty breathing: stop enalapril immediately 24). Amlodipine Use if peripheral vascular disease. Refer if patient has heart failure. 2.5mg PO daily 10mg daily Dizziness, flushing, headache, fatigue Atenolol Use if ischaemic heart disease. Avoid in uncontrolled heart failure, asthma, COPD. 50mg PO daily 100mg daily Tight chest, fatigue, slow pulse, headache, cold hands/feet, impotence 1 Calculate eGFR = [(140 - age) x weight (kg)]/[72x creatinine (mg/dL)]. If patient is a woman, multiply by 0.85.
Adult 91 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 for specialist assessment. Advise the patient with heart failure • Advise patient to adhere to treatment even if asymptomatic. • Help the patient to manage his/her CVD risk 85. Emphasize salt restriction to < 1 teaspoon/day and advise regular exercise within limits of symptoms. • Advise patient to restrict fluid intake to 1.5L/day (6 cups) and if possible to monitor weight daily. If s/he gains ≥ 2kg in 2 days, advise to return to clinic. Assess the patient with heart failure Assess When to assess Note Symptoms Every visit Manage symptoms as on symptom pages. If cough or difficulty breathing 29. Refer same day if temperature ≥ 38°C, fever/chills or fainting/blackouts. Family planning Every visit Discuss contraception needs 110. If pregnant or planning pregnancy, refer for specialist care. Substance use/abuse Every visit In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Depression Every visit In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. Weight Every visit Assess changes in fluid balance by comparing with weight when patient least symptomatic. BP and pulse Every visit Check BP 89. If known hypertension 90. If new irregular pulse, refer same day. eGFR2 and potassium At diagnosis, 6 monthly Also check 1-2 weeks after starting/increasing dose of spironolactone/enalapril. If abnormal, refer. If potassium > 5mmol/L, stop spironolactone. Other blood tests At diagnosis Check Hb, glucose (also yearly 86 to interpret results). If abnormal, refer. Test for HIV 75. Treat the patient with heart failure Aim to have patient on steps 1, 2 and 3. Add step 4 if patient has ongoing symptoms on steps 1-3. If uncontrolled on steps 1-4, refer to hospital. Step Medication Dose Note 1 Give furosemide Start: 20-40mg PO daily. Use lowest dose to prevent leg swelling. Use if moderate-severe heart failure or eGFR < 60mL/min/1.73m2 . Expect response within 2-3 days. or hydrochlorothiazide 25-50mg PO daily Use if mild heart failure and eGFR ≥ 60mL/min/1.73m2 . Avoid in gout, liver disease. 2 Add enalapril Start 2.5mg PO BID. Maximum: 20mg BID. • Increase gradually. Continue maximum tolerated dose. • Side effects: cough (common, if troublesome refer), dizziness, angioedema (stop enalapril immediately). 3 Add carvedilol Start 3.125mg PO BID. Maximum: 25mg BID. • Start once on enalapril and no oedema. Double dose 2 weekly. Continue maximum tolerated dose. • Avoid in asthma/COPD, peripheral vascular disease or if pulse < 60. 4 Add spironolactone Start 25mg PO daily. Maximum: 50mg daily Avoid if eGFR < 60mL/min/1.73m2 or potassium > 5mmol/L. Stop potassium supplements. Give urgent attention to the patient with heart failure and one or more of: • Chest pain 28 • Rapid worsening of symptoms • Respiratory rate > 30 at rest • BP < 90/60 • New wheeze • Frothy sputum Management: • Sit patient up and if oxygen saturation < 90% or oxygen saturation machine not available, give face mask oxygen. • If systolic BP > 90: give furosemide 40mg slowly IV. If no response after 30 minutes, give 80mg IV; if still no better after 20 minutes, give a further 40mg IV. If IV furosemide unavailable, give PO. • If systolic BP > 90: give sublingual isosorbide dinitrate 5mg even if there is no chest pain. Repeat 4 hourly. • Refer urgently. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. 2 Calculate eGFR = [(140 - age) x weight (kg)]/[72x creatinine (mg/dL)]. If patient is a woman, multiply by 0.85.
Adult 92 • The patient with previous rheumatic fever has had one or more episodes of fever, joint swelling/pain, rash, strange movements and carditis following a sore throat. • Sometimes the carditis can lead to rheumatic heart disease which is damage to the heart valves. Ensure that diagnosis of rheumatic fever and rheumatic heart disease is confirmed at hospital. Advise the patient with rheumatic heart disease/previous rheumatic fever • Explain the cause of rheumatic heart disease: a sore throat infection caused rheumatic fever which damaged the heart valves. • This may cause heart failure. Advise patient to return if symptoms of heart failure develop: difficulty breathing (especially on lying down), fatigue, cough, leg swelling). • Having benzathine penicillin every month will prevent recurrences of rheumatic fever and protect the heart valves. Advise the patient that this must be continued lifelong if heart valve damage, or if no heart valve damage for at least 10 years or up to the age of 25 years. • Educate patient on warfarin that it thins the blood to prevent clots on damaged or mechanical heart valves and protects against stroke. Advise to return urgently if abnormal bleeding occurs: gum/ nose bleeds, easy bruising, heavy menstruation. • Advise patient the patient with rheumatic heart disease to brush teeth regularly and to get antibiotic prophylaxis before dental procedures. Treat the patient with rheumatic heart disease/previous rheumatic fever • Give prophylaxis to protect heart valves and prevent recurrence of rheumatic fever: - - Give benzathine penicillin 1.2MU deep IM every 4 weeks. Observe for 15 minutes after injection for anaphylaxis: If sudden face/tongue swelling with difficulty breathing, collapse, anaphylaxis likely 29. - - If penicillin allergic give instead erythromycin 500mg PO BID continuously. - - Continue for life if rheumatic heart disease. If patient had rheumatic fever, the decision to stop will be made at hospital. • Give warfarin if patient has atrial fibrillation or mechanical heart valve. Start at 2.5mg PO daily and increase to maximum 10mg PO daily based on INR. Target INR is 2.0-3.0. • Give antibiotic prophylaxis 1 hour before dental procedure if rheumatic heart disease and one or more of mechanical valve or previous infective endocarditis: single dose amoxicillin 1g PO. If penicillin allergy, give single dose clarithromycin 500mg PO instead, if unavailable, refer. Advise patient to attend monthly for benzathine penicillin and routine care and refer for hospital review annually if stable. Rheumatic heart disease/previous rheumatic fever: routine care Assess the patient with rheumatic heart disease/previous Assess When to assess Note Symptoms Every visit • If cough/difficulty breathing or leg swelling, heart failure likely 91. • If fever with new joint pain or swelling, rheumatic fever recurrence likely, refer. If fever in patient with known rheumatic heart disease, refer to exclude infective endocarditis. • If weakness or numbness of face, arm or leg, especially on one side, visual disturbance, difficulty speaking or walking, refer. • If patient on warfarin has easy bleeding: gum/nose bleeds, easy bruising, heavy menstruation refer same day for INR. Adherence Every visit Check that patient is receiving monthly prophylaxis and if on warfarin, is taking it reliably. Weight At diagnosis, every visit Assess changes in fluid balance by comparing with weight when patient least symptomatic. BP and pulse At diagnosis, every visit Check BP 89. If known hypertension 90. If new irregular pulse, refer hospital same day. Pallor At diagnosis, every visit If pale, check Hb. If < 11g/dL, refer hospital. Family planning Every visit Discuss contraception needs 110. If pregnant or planning pregnancy, refer hospital. Heart failure Every visit • If cough/difficulty breathing or leg swelling, heart failure likely 91. • If known heart failure also give routine heart failure care 91. Depression Every visit In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. INR If on warfarin Ensure patient on warfarin checks INR on regular basis.
Adult 93 Stroke: diagnosis and routine care Sudden onset of one or more of the following suggests a stroke or a transient ischaemic attack (TIA): • Weakness or numbness of the face, arm or leg, especially on one side of the body • Blurred or decreased vision in one/both eyes or double vision • Difficulty speaking or understanding • Difficulty walking, dizziness, loss of balance or co-ordination If patient has one or more of: hypertension , diabetes, heart disease, on warfarin, > 60 years and has no history of head trauma, stroke likely. If not, refer to hospital to confirm the diagnosis of stroke. Advise the patient with stroke/TIA • Advise the patient to seek medical attention immediately should symptoms recur. Quick treatment of a minor stroke/TIA can reduce the risk of major stroke. • Help patient to manage his/her CVD risk 85. • If patient is < 55 years (man) or < 65 years (woman), advise the first degree relatives to have CVD risk assessment 84. • Avoid combined oral contraceptive. Advise other method such as IUD, injectable, progestogen-only pill or subdermal implant 110. Assess the patient with stroke/TIA Assess When to assess Note Symptoms Every visit • Manage symptoms as on symptom pages. • Ask about symptoms of another stroke/TIA. Also ask about chest pain 94 or leg pain 96. Depression Every visit In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. Rehabilitation needs Every visit Refer to physiotherapy for mobility. BP Every visit • Check BP 89. If new hypertension, avoid starting treatment until > 48 hours after a stroke. • If known hypertension 90. Glucose At diagnosis, then yearly Check glucose 86. If known diabetes 87. Random total cholesterol (by referral to hospital) 3 months after starting simvastatin and then after 3 months if ≥ 190mg/dL • If cholesterol ≥ 190mg/dL: increase simvastatin to 40mg. If already on 40mg daily, refer to hospital. • If cholesterol < 190mg/dL, no need to repeat. HIV At diagnosis or if status unknown Test for HIV 75. Give urgent attention to the patient with a stroke/TIA: • If oxygen saturation < 95% or oxygen saturation machine not available, give face mask oxygen. • If glucose < 70mg/dL or unable to measure, give 25mL glucose 40% IV over 1-3 minutes. Repeat if glucose still < 70mg/dL after 15 minutes. • Keep patient nil by mouth until swallowing is formally assessed. • Give normal saline 1L IV 4-6 hourly. If glucose ≥ 70mg/dL, avoid fluids containing glucose/dextrose as raised blood glucose may worsen a stroke. • If BP ≥ 220/120, give single dose of nifedipine 20mg PO. • Refer urgently. Treat the patient with an ischaemic stroke/TIA • Give aspirin 75-150mg PO daily for life. Avoid if haemorrhagic stroke, peptic ulcer, dyspepsia, kidney or liver disease. If heart valve disease or atrial fibrillation, refer for warfarin instead. • Start simvastatin 20mg PO daily. If repeat cholesterol > 190mg/dL increase to 40mg daily. If already on 40mg, refer to hospital.
Adult 94 Ischaemic heart disease (IHD): initial assessment Is patient known with ischaemic heart disease (or angina1 )? No Chest pain different to above Assess for other causes of chest pain 28. Stable angina likely • Refer to hospital to confirm diagnosis. • Give routine ischaemic heart disease care 95. Patient has stable angina. Give routine ischaemic heart disease care 95. Is chest pain/discomfort: • Occurs at rest or with minimal effort or • Not relieved by rest or • Lasts ≥ 20 minutes No Yes No Is current or previous chest pain/discomfort any of: • Feels like pressure, heaviness or tightness in centre or left side of chest • Spreads to jaw, neck, arm/s • May be associated with nausea, vomiting, pallor, sweating or shortness of breath Is chest pain/discomfort any of: • Occurs at rest or with minimal effort or • Not relieved by rest or • Lasts ≥ 20 minutes or • Worse/lasts longer than usual or • Occurs more often than usual Yes Yes No Yes Acute coronary syndrome (heart attack or unstable angina) likely • If oxygen saturation < 90% or oxygen saturation machine not available, or respiratory rate ≥ 30, give face mask oxygen. • Give single dose aspirin 300mg chewed. • Establish IV access. • If BP < 90/60, give normal saline 250mL IV. Avoid if breathless. • Refer to hospital urgently. 1 Chest pain caused by ischaemic heart disease.
Adult 95 Ischaemic heart disease (IHD): routine care Advise the patient with ischaemic heart disease • Help the patient to manage his/her CVD risk 85. • Patient can resume normal daily and sexual activity 6 weeks after heart attack if symptom free. • Emphasize the importance of lifelong adherence to medication. • Advise patient to avoid NSAIDs (e.g. ibuprofen, diclofenac, indomethacin), as they may precipitate chest pain or a heart attack or heart failure. • If patient is < 55 years (man) or < 65 years (woman), advise first degree relatives to have CVD risk assessment 84. If atenolol and amlodipine contra-indicated/not tolerated or chest pain/discomfort persists on full treatment, refer to hospital. Assess the patient with ischaemic heart disease Assess When to assess Note Symptoms Every visit • Do initial assessment if not already done 94. • Ask about leg pain 49 and symptoms of stroke/TIA 93. Modifiable risk factors Every visit • Ask about smoking, diet, khat and alcohol use and exercise or activities of daily living 85. Depression Every visit In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. BP Every visit Check BP 89. If known hypertension 90. Blood glucose At diagnosis, then yearly Check glucose 86. If known diabetes 87. Random total cholesterol (by referral to hospital) 3 months after starting simvastatin and then after 3 months if ≥ 190mg/dL • If cholesterol ≥ 190mg/dL: increase simvastatin to 40mg. If already on 40mg daily, refer to hospital. • If cholesterol < 190mg/dL, no need to repeat. Treat the patient with ischaemic heart disease • Give aspirin 75-150mg PO daily for life. Avoid if peptic ulcer, dyspepsia, severe kidney or liver desease. • Start simvastatin 20mg PO daily. If repeat cholesterol > 190mg/dL increase to 40mg daily. If already on 40mg, refer to hospital. • Give atenolol (immediate release) 50mg PO daily even if no chest pain/discomfort. Avoid in asthma/COPD uncontrolled heart failure, pulse < 50, systolic BP < 100. • If patient also has hypertension, diabetes or chronic kidney disease, give enalapril 5mg PO daily and increase slowly to 20mg daily. Avoid in angioedema. • If patient has new onset or worsening angina, refer to hospital. If patient known with stable angina continue with treatment as prescribed at hospital: Medication Dose Maximum dose Note Atenolol (immediate release) 50mg PO daily 100mg PO daily Avoid atenolol in asthma/COPD, uncontrolled heart failure, pulse < 50, systolic BP < 100 or side effects (headache, cold hands/feet, impotence, tight chest, fatigue) are intolerable. Use amlodipine instead. Amlodipine 5mg PO in the morning 10mg daily Avoid in heart failure, refer to hospital if unsure.
Adult 96 Peripheral vascular disease (PVD): diagnosis and routine care • 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 to hospital for assessment. Advise the patient with peripheral vascular disease • Help the patient to manage his/her CVD risk 85. • Advise the patient to keep legs warm and position legs below heart level (especially at night), and to avoid decongestant medications that may constrict blood vessels. • If patient smokes tobacco 102. Support patient to change 125. • 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 patient is < 55 years (man) or < 65 years (woman), advise the first degree relatives (parents, siblings, children) to have CVD risk assessment 84. Treat the patient with peripheral vascular disease • Advise active brisk exercise for 30 minutes at least 3 times a week (preferably daily). Advise patient to pause and rest whenever claudication develops. • Start simvastatin 20mg PO daily. If repeat cholesterol > 190mg/dL increase to 40mg daily. If already on 40mg, refer to hospital. • Give aspirin 150mg PO daily for life. Avoid if peptic ulcer, dyspepsia, kidney or liver disease. • Refer to hospital at diagnosis (start medications if available 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 6 monthly. Give urgent attention to the patient with peripheral vascular disease and one or more 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 • Chest pain28 Management: • Ruptured abdominal aortic aneurysm likely: avoid giving IV fluids even if BP < 90/60 (raising blood pressure may worsen the rupture). • 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 94 and symptoms of stroke/TIA 93. • Document the walking distance before onset of claudication. BP Every visit • Check BP. If ≥140/90 89. • If known hypertension 90. Legs and feet Every visit Check for pain, pulses, sensation, deformity and skin problems on both legs & feet. For foot screen and foot care education and care 47. Abdomen Every visit If a pulsatile mass felt, refer for assessment for possible abdominal aortic aneurysm. Glucose At diagnosis, then yearly Check glucose 86. If known diabetes 87. Random total cholesterol (by referral to hospital) 3 months after starting simvastatin and then after 3 months if ≥ 190mg/dL • If cholesterol ≥ 190mg/dL: increase simvastatin to 40mg. If already on 40mg daily, refer to hospital. • If cholesterol < 190mg/dL, no need to repeat.
Adult 97 Epilepsy: routine care • If the patient is convulsing 15 to control the convulsion. If the patient is not known with epilepsy and has had a convulsion 15 to assess and manage further. • Epilepsy is a chronic seizure disorder diagnosed in a patient who has had at least 2 definite convulsions with no identifiable cause or with one convulsion following meningitis, stroke or head trauma. Advise the patient with epilepsy • Educate patient about epilepsy (cause and prognosis), the medications (including about side effects) ,need for adherence to treatment and to record occurrence and frequency of convulsions. • Advise patient to avoid lack of sleep, asubstance use/abuse, dehydration and flashing lights. • Advise patient on avoiding dangers like heights, fires, swimming alone, cycling on busy roads, operating machinery. Avoid driving until free of convulsions for 1 year. • Advise patient there are many medications that interfere with anti-convulsant treatment (see below) and to discuss with health worker when starting any new medication. • Advise patient to use reliable contraception (like IUD , Injectables and condom) and to seek advice if planning a pregnancy. Assess the patient with epilepsy Assess When to assess Note Symptoms Every visit Manage symptoms as on symptom pages. Frequency of convulsions Every visit Ask patient about frequency of convulsions since last visit. Assess if convulsions prevent patient from leading a normal lifestyle. Adherence Every visit Assess past clinic attendance and pill counts. Side effects Every visit Side effects (see below) may explain poor adherence. Weigh up side effects with control of convulsions or consider changing medication. Other medication At diagnosis, if convulsion occur Check if patient is on other medication like TB treatment, ART or contraceptive. See below for interactions and consider referring the patient. Substance use or abuse At diagnosis, every visit In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Family planning Every visit (for reproductive age women) • Refer same week if patient is pregnant or planning to be, for epilepsy and antenatal care. • Assess family planning needs: avoid oral contraceptives and implants on carbamazepine or phenytoin 110. Treat the patient with epilepsy • Initiate with single medication and review every 2 weeks until no convulsions. • If still convulsing on treatment, increase dose as below if patient is adherent, there is no substance use/abuse and no interactions with other medications. • If still convulsing after 1 month on maximum dose or side effects intolerable, start new medication and increase dose without discontinuation of the first medication to avoid recurrence of convulsions. • After the second medication is increased to optimal dose, the first is gradually tapered and discontinued. Medication Dose Note Phenytoin Start 150mg PO daily. If needed, increase by 50mg weekly to 300mg daily. Maximum dose: 600mg daily. Avoid in pregnancy. Side effects: facial hair , drowsiness, large gums. Toxicity: balance problem, double vision, slurred speech. Drug interactions: anti-TB, ART, furosemide, fluoxetine, fluconazole, theophylline, oral contraceptives and implants. Phenobarbitone Start 30mg PO BID; maximum dose of 180mg per day Side Effects: Sedation, ataxia, sexual dysfunction, depression. Liver failure. Drug interactions: similar to phenytoin, see above. Carbamazepine Start dose 100mg PO BID; and a maximum dose of 1200mg daily in 2 or 3 divided doses Side effects: skin rash, blurred or double vision, ataxia, nausea. Drug interactions: isoniazid, warfarin, fluoxetine, cimetidine, theophylline, amitriptyline, oral contraceptives, Implants and antiretrovirals. Valproic acid Start 600mg PO daily in 2 divided doses. Increase daily dose by 200mg every 3 days to maintenance dose of 1-2 g daily in divided doses. Maximum dose: 2.5g daily. Avoid if liver problem, pregnant or a woman of childbearing age unless on reliable contraception. Use as first choice in patient on ART. Side effects: drowsiness, dizziness, weight gain, temporary hair loss. Drug interactions: zidovudine, aspirin. • If convulsion free, follow up 3 monthly. If convulsions uncontrolled with two medications, refer. • Consider stopping treatment if no convulsion for 2 years. Refer patient to a hospital, for gradual tapering and discontinuation of antiepileptic medications. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. EPILEPSY
Adult 98 Admit the mentally ill patient Approach to the mentally ill patient in need of hospital admission: • Before sedating the patient (if needed) fully inform patient in his/her own language about reasons for treatment and consider his/her choice if he/she opts for PO medication. • Assess if the patient can give informed consent: the patient understands that s/he is ill, is needing treatment and can communicate his/her choice to receive treatment: Assess the mentally ill patient first on appropriate symptom or chronic condition pages. Does patient agree to admission? Yes Yes Manage as an outpatient. • Refer to hospital. • Record everything clearly in patient notes and referral letter. • A close relative or a carer must accompany the patient to hospital. • Request police assistance if the patient is too dangerous to be transferred in a staffed vehicle or is likely to abscond. No No No Yes Does patient ≥ 1 of the following? • Severe mental illness or suicidal or • Needs treatment in a hospital or • Danger of harm to self, others, own reputation, financial interest or property or • Severe self neglect and poor social support
Adult 99 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 or • Loss of interest or pleasure in activities that are usually pleasurable Depression likely, treat 100. Yes Check for anaemia If pallor, check Hb. If < 11g/dL, refer to hospital. Check for thyroid disease Check TSH. If abnormal, refer to hospital. Screen for substance abuse In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Check for medication side effects Review medication: prednisolone, efavirenz, metoprolol, metoclopramide, theophylline and contraceptives can cause depression. If on any of these, refer to hospital. Yes: does the patient have difficulty carrying out ordinary work, domestic or social activities? Yes 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 • Loss of interest or pleasure in activities that are usually enjoyable • Fatigue or loss of energy • Disturbed sleep, sleeping too much/too little • Change in appetite or weight • Feeling guilty or worthless • Reduced concentration, indecisiveness ,forgetfulness • Agitated/restless or talking/moving more slowly than usual • Ideas, plans or acts of self-harm or suicide One or more of above Yes Refer to hospital. Provide support 65. None of above: does the patient have any psychotic symptoms2 ? No: has patient previously had a diagnosis of bipolar disorder or symptoms of mania: 3 or more of the following, that have lasted at least 1 week and interfered with ordinary work, domestic or social activities? • Elevated mood and/or irritability • Decreased desire to sleep • Inappropriate social behaviour • Easily distracted • Increased activity, feeling of increased energy, talkative, rapid speech • Impulsive/reckless behaviour like excess spending, thoughtless decisions, sexual indiscretion • Inflated self esteem No: has there been a major loss or bereavement within last 6 months? Yes: does patient have ideas of suicide or self-harm, feelings of worthlessness or is s/he talking or moving unusually slowly? Yes Bipolar disorder likely • Refer to a mental health professional. • If aggressive/ disruptive 63. Continue to assess and manage the stressed or distressed patient 65. No No No No No Yes Yes No: has patient had depression in the past? 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. 2 Psychotic 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). MENTAL HEALTH
Adult 100 Depression and/or anxiety: routine care Assess the patient with depression and/or 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, 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 suicide. If patient has suicidal thoughts or plans 62. Mania Every visit If abnormally happy, energetic, talkative, irritable or reckless: manage the aggression and disruption 63 and 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 likely. • If anxiety is induced by a particular situation/object, phobia likely. If patient avoids social situations because of phobia, social phobia likely. • If repeated sudden fear with physical symptoms and no obvious cause, panic likely. • If patient had a bad experience causing nightmares, flashbacks, avoidance of people/situations, jumpiness or feeling detached, post-traumatic stress likely. 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 106. Substance use/abuse Every visit In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Side effects Every visit Ask about side effects of antidepressant medication 101. Stressors Every visit Help identify the domestic, social and work factors contributing to depression or anxiety. If patient is being abused 66. If recently bereaved 65. Family planning Every visit • Discuss patient’s contraception needs 110. • If pregnant or breastfeeding, refer to hospital to evaluate risks: the risk to baby from untreated depression may outweigh any risk from antidepressants. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. Advise the patient with depression and/or anxiety • Explain that depression is a very common illness and 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 the 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. Advise not to stop treatment abruptly. • Help the patient to choose strategies to get help and cope: Get enough sleep If patient has difficulty sleeping 67. Access support Encourage patient to connect with friends, family, spiritual leaders and community groups like Edir, Mahber, Senbete. Get active Regular exercise may help. Do a relaxing breathing exercise each day. Spend time with supportive friends or family. Find a creative or fun activity to do. Encourage patient to take time to relax:
Adult 101 Review 2 weekly, even if not on antidepressants, until symptoms improve, then monthly. If no better after 8 weeks, refer. Plan when to stop antidepressant Has patient has previous episode/s of depression? Reduce dose gradually over at least 4 weeks. If withdrawal (irritability, dizziness, difficulty sleeping, headache, nausea, fatigue) develops, reduce even more slowly. Does patient have any of: onset in adolescence, severe depression, suicide attempt, sudden onset of symptoms, family history of bipolar disorder? Does patient have generalised anxiety, panic, phobia or post-traumatic stress? Consider long term treatment for at least 3 years. If ≥ 3 episodes, advise lifelong treatment. Consider stopping antidepressant when patient has had no/minimal symptoms and has been able to carry out routine daily activities for > 9 months. Consider stopping antidepressant when patient has had no/minimal symptoms and has been able to carry out routine daily activities for > 1 year. No No No Yes Yes Yes 1 Patient has felt nervous, anxious or panicky or been unable to stop worrying or thinking too much over the past month. Treat the patient with depression and/or anxiety • Give anti-depressants to the patient with any of: depression, generalised anxiety, social phobia, post traumatic stress and panic. Respect the patient’s decision if s/he declines antidepressants. • If patient has phobia, also advise gradual desensitization: - - Start with relaxing breathing exercise. - - When calm, imagine the feared thing at some distance away. Continue breathing exercise. When ready, imagine the thing coming slightly closer. Continue breathing exercise. - - Repeat the above and stop if severe anxiety. When calm, repeat, with the thing at a distance that did not cause anxiety. Advise patient to repeat gradual desensitisation daily. • If generalised anxiety disorder or features of anxiety1 when starting antidepressant, consider diazepam 2-5mg PO daily as needed, for up to 10 days. Avoid if patient is known to use substances. • Start antidepressant and increase dose as needed according to response. Plan to continue antidepressant for at least 9 months: Medication Dose Note Side effects Fluoxetine • Start 20mg PO alternate days for 1 week then increase to 20mg daily in the morning. • If partial or no response after 4 weeks, increase by 20mg every 2 weeks, up to 60mg/day. • Refer to specialist if patient has epilepsy, liver or kidney disease. • Monitor blood glucose more often in diabetes. Changes in appetite and weight, headache, restlessness, difficulty sleeping, nausea, diarrhoea, sexual problems Amitriptyline Start 25mg PO at night. Increase by 25mg every 5 days, up to 150mg/day (or 100mg/day if > 65 years). • Use if fluoxetine contraindicated. • If suicidal thoughts, avoid, or if fluoxetine not an option, supply only a few doses at a time and ensure close supervision by carer (can be fatal in overdose). • Avoid if heart disease, urinary retention, glaucoma, epilepsy. Dry mouth, constipation, difficulty urinating, blurred vision, sedation
Adult 102 Tobacco smoking Advise the patient who smokes tobacco • Ask if patient is willing to discuss tobacco smoking. For tips on how to communicate effectively 124. • 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. • Educate patient that nicotine is a very addictive substance and stopping can be difficult, resulting in withdrawal symptoms (see below). Nicotine replacement may help reduce these symptoms. • Advise that most smokers make several attempts to stop before they are successful. If patient is not ready to stop in the next month: • Discuss risks to patient (worsening asthma, infertility, heart attack, stroke, COPD, cancer) to spouse (lung cancer, heart disease) and to children (low birth weight, asthma, respiratory infections). • Help the patient identify benefits of stopping tobacco smoking like saving money, improved health, taste, sense of smell and appearance and being a positive role model for children. • Help the patient identify barriers to stopping tobacco smoking and possible solutions. • Ask if patient is ready to stop smoking tobacco in the next month. If not ready to stop, encourage patient to return. If patient is ready to stop in the next month or recently stopped: • Help the patient plan: set date to stop within 2 weeks, seek support from family and friends, avoid/manage situations associated with smoking and remove cigarettes, matches, and ashtrays. • Help manage cravings: set a time limit before giving in, advise to delay as long as possible, take a deep breath and blow out slowly (repeat 10 times). • Educate about nicotine withdrawal symptoms: increased appetite, mood changes, difficulty sleeping/concentrating, irritability, anxiety, restlessness. These should improve after 2 weeks. Assess the patient who smokes tobacco Assess When to assess Note Symptoms Every visit • Ask about symptoms that might suggest cancer: cough/difficulty breathing 29, urinary symptoms 44 or weight loss 16. • Ask about chest pain 28, leg pain 49, new sudden onset of any of: asymmetric weakness of face, arm or leg; numbness, difficulty speaking or visual disturbance 23. • Manage other symptoms as on symptom pages. Use Every visit • Ask about number of cigarettes/day, activities associated with smoking and previous attempts at stopping. • If recently stopped, ask about challenges and give advice below. Stressors Every visit Help identify the domestic, social and work factors contributing to smoking tobacco. Assess and manage stress 65. COPD At diagnosis If difficulty breathing when walking fast/up a hill, consider COPD 81. If known COPD 83 CVD risk At diagnosis Assess and manage CVD risk 84
Adult 103 Alcohol/drug use Assess the patient with unhealthy alcohol use or any drug use Assess Note Symptoms • If recently reduced/stopped use and is restless, agitated, difficulty sleeping, confused, anxious, hallucinating, sweating, tremors, headache or nausea/vomiting, treat for likely withdrawal 64. • If aggressive/violent or disruptive behaviour 63. • If patient has suicidal thoughts or plans 62. Hazardous/ harmful use • Use is harmful if it has caused physical (like injuries, liver disease, stomach ulcer), mental (like depression self harm or harm to others), social (relationship, legal or financial) harm or risky sexual behaviour. • The following is considered hazardous/harmful alcohol/drug use and increases the risk of dependence: - - If drinks ≥ 4 drinks1 /day (if man) or ≥ 2 drinks1 /day (if woman), hazardous drinking likely. - - If drinks ≥ 6 drinks1 /day (if man) or ≥ 4 drinks1 /day (if woman), harmful drinking likely. - - Any use of khat or illicit drugs (e.g. cannabis), misuse of prescription drugs, harmful/hazardous drug use likely. 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 the domestic, social and work factors contributing to alcohol/drug use. Ask about reasons for his/her substance use. If patient is being abused 66. Depression In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. Dementia If chronic alcohol/drug use and at least 6 months ≥ 1 of: memory problems, disorientation, language difficulty, less able to cope with daily activities and work/social function: consider dementia 106. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela Assess the patient who uses any drugs or drinks alcohol in way that that puts him/her at risk of harm/dependence. This may be binge drinking or daily drinking. If patient smokes tobacco 102. Advise the patient with unhealthy alcohol use or any drug use • Assess and manage stress 65. • 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. Refer patient to social worker, psychologist or counsellor. • Discuss risks/harms that using alcohol/drugs may cause. Support and encourage patient to decide for him/herself to stop or cut down. Support the patient to make a change 125. Harmful/hazardous alcohol use without dependence • If pregnant, harmful drinking, previous dependence or contraindication (like liver damage, mental illness), advise to stop alcohol completely. Avoid drinking places and keeping alcohol at home. • If none of above and patient chooses to continue alcohol, advise low-risk use: ≤ 2 drinks1 /day and avoid alcohol at least 2 days/week. Harmful/hazardous drug use without dependence • Advise to stop using illegal or misusing prescription drugs completely. • The patient with harmful/hazardous drug use without dependence can safely cut down on his/her own: encourage the patient to set goals for reducing use and a ‘quit date’. • If patient chooses to continue, advise to reduce harm: avoid injections or use sterile injection technique, test regularly for HIV and hepatitis. Alcohol/drug dependence • Advise that alcohol/drugs need to be stopped slowly. If stopped suddenly, withdrawal effects can be harmful. • If patient wishes to stop, refer to a hospital for detoxification. Ensure patient is motivated to adhere. If harmful/hazardous use, review in 1 month then as needed.
Adult 104 Psychosis: diagnosis and routine care 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. Consider psychosis in the patient who has difficulty carrying out ordinary work, domestic or social activities and any of the following: • Delusions: unusual/bizarre beliefs not shared by society. • 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 psychosis Assess When to assess Note Symptoms Every visit • Assess symptoms of psychosis above. If symptoms of psychosis and: - - Aggressive/violent 63. - - Varying levels of consciousness over hours/days or temperature ≥ 38°C, delirium likely 64. - - Patient has interrupted treatment: address reasons like side effects, substance abuse and consider intramuscular treatment if patient still struggles with adherence 104. - - Good adherence to optimal doses of treatment, refer. • Manage other symptoms as on symptom pages. Self-harm Every visit If patient has suicidal thoughts or plans 62. 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 66. Substance use/abuse Every visit In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Family planning Every visit Discuss patient’s contraception needs 110. If patient is pregnant, planning pregnancy or breastfeeding, refer to specialist. Medication Every visit • Ask about treatment side effects 105. • Ask about adherence. If non-adherent, restart medication at same dose, explore reasons for stopping treatment and refer for health extension worker support. • Refer to hospital if patient is on medication that might cause acute psychosis, like prednisolone, efavirenz, moxifloxacin and terizidone. Weight (BMI ) Every visit BMI = weight (kg) ÷ height (m) ÷ height (m). • If gaining weight or BMI > 25, assess and manage CVD risk 84 and discuss with specialist about possible alternative psychosis treatment. • If unintentionally losing weight or BMI <17.5 16. Discuss with patient and carer about the importance of eating regular healthy meals. Glucose • At diagnosis, then yearly • Also 4 monthly if gaining weight Check glucose 86. HIV At diagnosis or if status unknown Test for HIV 75. If HIV positive, avoid efavirenz, refer to hospital. Syphilis At diagnosis If positive, refer. Advise the patient with psychosis and the patient’s carer • Educate carer and patient: the patient with chronic psychosis often lacks insight into illness and may be hostile towards carers. S/he may have difficulty functioning, especially in high stress settings. • 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 substance use/abuse and encourage regular sleep routine. • Advise the patient to continue social/educational/occupational activities if possible. Refer to local NGOs or community organisations to help find educational or employment opportunities. • Emphasize importance of treatment adherence and to return immediately if symptoms of psychosis return/worsen. • Refer patient and carer to support group if available. If not, consider starting one at the health facility.
Adult 105 Treat the patient with psychosis • Give medication as in the 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. • If unsure or more than typical effective dose needed, discuss with specialist. Medication Starting dose Typical effective dose Note Haloperidol 1mg PO BID 2-10mg/day Increase by 1mg/dose until psychosis symptoms resolve. If > 60 years, start at a lower dose and increase more slowly. Trifluoperazine 5mg PO daily 15-20mg/day - Chlorpromazine 100mg PO daily in a single or divided dose 100-300mg/day in a single or divided dose • Increase every 2 weeks if needed. Give as a single dose at night once symptoms controlled. • Advise patient to avoid the sun. Fluphenazine decanoate 12.5mg deep IM injection every 2-4 weeks 25mg every 2-4 weeks Expect full response to take 2 months. • Review the patient with psychosis 8 weekly once stable. Advise patient to return immediately if symptoms of psychosis. • If restarting treatment after patient has interrupted treatment, review after 2 weeks, sooner if symptoms worsen. • If first episode psychosis, ensure patient receives 12 months of treatment after symptoms have resolved, then stop treatment. • Review the patient monthly for 6 months after stopping to check for recurrence of psychosis. • If 2 or more episodes, refer for specialist review. Look for and manage psychosis treatment side effects Urinary retention Stop treatment and refer same day. Blurred vision Refer same day. Painful muscle spasms (acute dystonic reaction) Usually within 2 days of starting medication. Give benzhexol 2-5mg PO TID if needed. Refer same day. Breast enlargement, nipple discharge Discuss with specialist whether to change medication. 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 patient to stand up slowly. Dry mouth/eyes Usually self-limiting. Constipation Usually self-limiting. Advise high fibre diet and adequate fluid intake. Extra-pyramidal side effects Abnormal involuntary movements Reduce dose. If no better, stop treatment and refer. Slow movements, tremor or rigidity May occur after weeks or months on treatment, refer. Muscle restlessness Stop treatment and refer same day.
Adult 106 Dementia: diagnosis and routine care 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 refer. • If suicidal thoughts or plans 62. • If sudden deterioration in behaviour 64. • If hallucinations (seeing or hearing things), delusions (unusual/bizarre beliefs), agitation or wandering, refer to hospital. • Manage other symptoms as on symptom pages. Side effects If on treatment If abnormal movements or muscle restlessness, stop treatment and refer same day. If painful muscle spasms, manage below. Vision/hearing problems Every visit Refer to hospital for testing and proper devices. Nutritional status Every visit Ask about food and fluid intake. BMI = weight (kg) ÷ height (m) ÷ height (m). If pregnant/breastfeeding and MUAC < 23cm or if not pregnant/breastfeeding and BMI < 17.5 or MUAC < 21cm 70. CVD risk At diagnosis, then depending on risk • Assess CVD risk 84. • If CVD risk < 10% with CVD risk factors or 10-20%, reassess after 1 year; if > 20% reassess after 6 months. Palliative care Every visit If any of: bed-ridden, unable to walk and dress alone, incontinence, unable to talk meaningfully or do activities of daily living, also give palliative care 120. HIV At diagnosis or if status unknown Test for HIV 75. If HIV positive, give routine care 76. If new HIV diagnosis with dementia, refer to hospital. Syphilis At diagnosis If positive, refer. • Consider dementia in the patient who has the following for at least 6 months and 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 church or mosque 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. • Refer to hospital to confirm the diagnosis of dementia and identify treatable causes of dementia. Advise the patient with dementia and his/her care giver • Discuss what can be done to support the patient, carer/s and family. Identify local resources, social worker, counsellor. • Advise the carer/s to: - - Give regular orientation information (day, date, weather, time, names) - - Stimulate memories and give current information with newspaper, radio, TV, photos. - - Use simple short sentences. - - Maintain a routine. - - Remove clutter and potential hazards at home. - - Maintain physical activity and plan recreational activities. Treat the patient with dementia • HIV-associated dementia often responds well to ART 76. • If psychotic symptoms, night-time disturbance, wandering or persistent aggression or anxiety, give haloperidol 0.5mg PO BID. If patient has parkinson’s disease, refer. Review the patient with dementia every 6 months.
Adult 107 Chronic arthritis: diagnosis and routine care • If patient has episodes of joint pain and swelling that completely resolve in between, consider gout 108. • The patient with chronic arthritis has had continuous joint pain for at least 6 weeks. Distinguish mechanical osteoarthritis from inflammatory rheumatoid arthritis: Osteoarthritis likely if: • Affects joints only. • Weight-bearing joints and possibly hands and feet • Joints may be swollen but not warm. • Stiffness on waking lasts less than 30 minutes. • Pain is worse with activity and gets better with rest. Inflammatory arthritis likely if: • May be systemic: weight loss, fatigue, poor appetite, muscle wasting. • Hands and feet are mainly involved. • Joints are swollen and warm. • Stiffness on waking lasts more than 30 minutes. • Pain and stiffness get better with activity. If inflammatory arthritis likely or uncertain of diagnosis, refer. Advise the patient with chronic arthritis • If BMI > 25 advise to reduce weight to decrease stress on weight-bearing joints like knees and feet. Help the patient to manage his/her CVD risk 85. • Encourage the patient to be as active as possible, but to rest with acute flare-ups. • Refer patient and care giver for education about chronic arthritis. • Advise the patient with rheumatoid arthritis that it must be treated early with disease modifying anti-rheumatic medication to control symptoms, preserve function, and minimise further damage. • 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 • Refer the patient with inflammatory arthritis for treatment. • If rheumatoid arthritis or difficulty with activities of daily living, refer to physiotherapist. • Give paracetamol 1g PO QID as needed or give ibuprofen1 400mg PO QID with food only as needed for up to 1 month. Assess the patient with chronic arthritis Assess When to assess Note Symptoms Every visit Manage symptoms as on symptom pages. 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. Sleep Every visit If patient has difficulty sleeping 67. Depression Every visit In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. 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. Assess CVD risk 84. ESR/Rheumatoid factor (RF) If inflammatory arthritis likely or unsure If ESR raised or RF positive, refer as inflammatory arthritis is more likely. HIV At diagnosis Test for HIV 75. Review monthly until symptoms controlled, then 3-6 monthly. If poor response to treatment, refer. 1 Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. MUSCULOSKELETAL DISORDERS
Adult 108 Gout: diagnosis and routine care • 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. Advise the patient with gout • Help the patient to manage his/her CVD risk 85. • Give dietary advice: - - Reduce alcohol (especially beer), sweetened drinks 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 remind her/his health worker about gout before starting any new medication. Treat the patient with gout Treat the patient with an acute gout attack: • Give ibuprofen 800mg PO TID with food until better, then 400mg PO TID until 1 day after symptoms completely resolved (usually 5-7 days). If pain no better/worsens, refer. • If peptic ulcer, asthma, hypertension, heart failure or kidney disease, give instead prednisolone 40mg PO daily, decrease by 10mg every 3rd day until stopped. If unsure, refer to specialist. • If patient is already using allopurinol, avoid stopping it during an acute attack. Treat the patient with chronic tophaceous gout: • Patient needs allopurinol if: > 3 attacks per year, chronic tophaceous gout, kidney stones/kidney disease caused by gout. • Wait at least 3 weeks after an acute gout attack before starting allopurinol. • Give allopurinol 100mg PO daily. Use smallest dose to keep urate < 6mg/dL: increase monthly by 100mg, maintenance usually 300mg daily; maximum 800mg in divided doses. If no response to treatment or uncertain of diagnosis, refer. Assess the patient with gout Assess When to assess Note Symptoms Every visit Manage symptoms as on symptom pages. Substance use/abuse Every visit In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Medication Every visit • Hydrochlorothiazide, furosemide, ethambutol, pyrazinamide and aspirin may induce a gout attack. Refer to hospital to review medication. • Continue aspirin given for CVD risk. Joints Every visit • Recognise the acute gout attack: sudden onset of 1-3 hot, extremely painful, red, swollen joints (often big toe or knee). • Recognise chronic tophaceous gout: deposits appear as painless yellow hard irregular lumps around the joints (picture). CVD risk At diagnosis, then depending on risk • Assess CVD risk 84. If < 10% with CVD risk factors or 10-20% reassess after 1 year, if > 20% reassess after 6 months. • If BMI < 18.5 or patient < 40 years, refer within 1 month to exclude possible cancer cause for gout. eGFR2 (by referral to hospital) At diagnosis, then 6 monthly If eGFR < 60mL/minute/1.73m2 , refer. Urate • At diagnosis • On allopurinol • Wait at least 2 weeks after an acute gout attack before checking urate level. • If on allopurinol, repeat monthly and adjust allopurinol dose until urate level < 6mg/dL, then repeat 6 monthly. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. 2 Calculate eGFR = [(140 - age) x weight (kg)]/[72x creatinine (mg/dL)]. If patient is a woman, multiply by 0.85. © Stellenbosch University
Adult 109 Fibromyalgia: diagnosis and routine care • 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 16. - - 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 46. - - Check ESR, Hb, TSH and test for HIV 75. • Consider another diagnosis and refer if joint problem, HIV positive, blood results abnormal or uncertain of diagnosis. • Refer to hospital for confirmation of diagnosis. 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 treatments may help (patients will have good days and bad days), fibromyalgia does not get worse over time and 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 67. Treat the patient with fibromyalgia • If no better with education and exercise, give amitriptyline 12.5mg PO at bedtime. Increase by 5mg every 2 weeks until improvement (maximum dose 75mg). • If no improvement after 3 months of advice, exercise and medication, refer for medical and psychiatric evaluation at hospital. A supportive relationship with the same health practitioner can contain frequent visits for multiple problems. Review patient 6 monthly once stable. Assess the patient with fibromyalgia 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. • Avoid dismissing all symptoms as fibromyalgia: exclude treatable and serious illness. If unsure, refer. Sleep Every visit If patient has difficulty sleeping 67. Stressors Every visit Help identify psychosocial stressors that may exacerbate symptoms. Assess and manage stress 65. Depression Every visit In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. Chronic arthritis Every visit If patient also has chronic arthritis, give routine care 107. Press tender points with the pressure that would blanch a fingernail. Compare with a control site on forehead.
Adult 110 Contraception Give emergency contraception if patient had unprotected sex in past 5 days and does not want pregnancy: • If within 72 hours of unprotected sex, give as soon as possible: single dose levonorgestrel 1.5mg PO. - - If patient taking ART (or post-exposure prophylaxis), rifampicin or phenytoin, offer copper intrauterine device instead or increase single dose levonorgestrel to 3mg. - - If patient vomits < 2 hours after taking levonorgestrel, repeat the dose or offer copper intrauterine device instead. - - Offer to start contraceptive at same visit (if intrauterine device not chosen). Use condoms or abstain for next 7 days and check pregnancy test in 3 weeks. • If within 5 days of unprotected sex or patient chooses, insert emergency copper intrauterine device instead. • Consider need for HIV and hepatitis B post-exposure prophylaxis 69. 1 If after day 7 of cycle and patient has had unprotected sex since last period, advise patient to abstain or use condoms until next period. Start contraception when period starts. If period delayed, do pregnancy test. 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 36. If sexual problems 43. • If > 40 years, ask about menopausal symptoms: hot flushes, night sweats, vaginal dryness, mood changes, difficulty sleeping and sexual problems 119. If menopausal, decide how long to continue contraceptive 119. • Manage other symptoms as on symptom pages. Adherence Every visit • If already on contraceptive, ask about concerns and satisfaction with method. • If patient has missed injections or pills, manage 111. Side effects Every visit If already on contraceptive, ask about side effects of method 111. Safe sex Every visit Ask about risky sexual behaviour: patient or regular partner has new or multiple partner/s, uses condoms unreliably or has risky alcohol/drug use 103 Other medication Every visit If on ART, TB or epilepsy treatment, check method is suitable 111. If not suitable, choose/change to IUD or injectable. Vaginal bleeding Every visit If abnormal vaginal bleeding: if already on contraceptive, first exclude pregnancy, then see method to manage 111. If not yet on contraceptive 42. Weight (BMI) First visit, then yearly BMI = weight (kg) ÷ height (m) ÷ height (m). If BMI > 25 assess and manage CVD risk 84. BP First visit, every visit on pill or injectable • Check BP 89. • If known 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 yearly Check for lumps in breasts 31 and axillae 18. Pregnancy Every visit • Before starting contraception, exclude pregnancy1 . If pregnant 112. • If pregnancy suspected (significant nausea/breast tenderness or if patient using IUD/combined oral contraceptive misses period), check pregnancy test. If pregnant 112. HIV Every visit Test for HIV 75. Cervical screen (VIA) When needed • If HIV negative and asymptomatic: screen 5 yearly from age 30-49. • If HIV positive and asymptomatic: screen at HIV diagnosis (regardless of age) then 5 yearly. • If abnormal 40. Advise the patient starting and using contraception • Educate patient to use contraceptive reliably. Advise to discuss concerns/problems with method and find an alternative, rather than just stopping it and risking unwanted pregnancy. • 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 combined oral contraceptive pill and ≥ 72 hours diarrhoea/vomiting, advise to use condoms or abstain (continue for 7 days once resolved). • Demonstrate and give male/female condoms. Recommend dual contraception: one method of contraception plus condoms to protect from STIs and HIV. • Encourage patient to have 1 partner at a time and if HIV negative to test for HIV between partners. Advise partner/s to be tested for HIV. • Educate about the availability of emergency contraception (see above) and abortion 113 to prevent unwanted pregnancy.
Adult 111 Treat the patient starting and using contraception If already using contraceptive and patient satisfied with method, check method is still suitable. If starting or changing contraceptive, help patient to choose method: Method Help patient to choose method Instructions for use Side effects Intrauterine device (IUD) • Copper IUD (Cu-IUD) • Effective for 10 - 12 years. • Fertility returns immediately on removal. • Avoid if current STI, unexplained vaginal bleeding, abnormal cervix/uterus. • If inserted after day 12 of cycle, exclude pregnancy first. • Can be inserted within 48 hours of delivery. • Must be inserted/removed by trained staff. • Heavy or painful periods: reassure usually improve within 3-6 months. To assess and manage 42. If excessive bleeding occurs after insertion or if tired and Hb < 11g/dL, refer. • Irritation of partner’s penis during sex: cut IUD strings shorter. Subdermal implant • Implanon: Etonogestrel (one-rod: 3 years) • Lasts for 3 years. • Fertility returns immediately on removal. • Avoid if unexplained vaginal bleeding, previous breast cancer or active liver disease. • Use with caution1 if BMI > 28 or on ART, rifampicin or phenytoin. • Plastic rod just under skin of upper arm. • If inserted after day 5 of cycle, use condoms or abstain for 7 days. • Must be inserted/removed by trained staff. • Amenorrhoea: reassure that this is common. • Abnormal bleeding: common. To assess and manage 42. • Acne: change to combined oral contraceptive or non-hormonal method. • Headaches: if severe, change to non-hormonal method. • Weight gain (less with progesterone-only pill) • Moodiness: reassure that this should resolve. In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any, consider changing method and 99. Progestogen injection • Medroxyprogesterone acetate (DMPA) IM 150mg every 3 months • 3 monthly injection • Fertility can be delayed for up to 1 year after last injection. • Avoid if diabetic complications. • If started after day 5 of cycle, use condoms or abstain for 7 days. • No need to adjust dosing interval for ART, TB or epilepsy treatment. Progestogen-only pill (POP) • Levonorgestrel 30mcg PO (especially if postpartum or breastfeeding) • Must be motivated to take pill reliably every day. • Fertility returns once pill is stopped. • Avoid both if active liver disease or on rifampicin or phenytoin. • Use both with caution2 if on ART. • Also avoid COC if smoker ≥ 35 years, migraines and ≥ 35 years or visual disturbances, postpartum3 , BP ≥ 140/90, hypertension, CVD risk > 10%, current or previous deep vein thrombosis/pulmonary embolus, previous stroke, ischaemic heart disease or diabetic complications. • Must be taken every day at the same time (no more than 3 hours late). • If started after day 5 of cycle, use condoms or abstain for 2 days. Combined oral contraceptive (COC) • Ethinylestradiol/ levonorgestrel 30/150mcg PO • Must be taken every day at the same time. • If started after day 5 of cycle, use condoms or abstain for 7 days. • If ≥ 72 hours diarrhoea/vomiting, advise to use condoms or abstain (continue for 7 days once resolved). • Abnormal bleeding: common in first 3 months. To assess and manage 42. • Breast tenderness, nausea: reassure usually resolve within 3 months. • Headaches: if migraines and ≥ 35 years or visual disturbances, change to non-hormonal method. • Moodiness: reassure that this should resolve.In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any, consider changing method and 99. Sterilisation • Tubal ligation/vasectomy • Permanent contraception • Surgical procedure • Refer for assessment. • Written informed consent is needed. Wound pain, infection or bleeding: refer. Follow up the patient on combined oral contraceptive pill after 3 months, then yearly. Follow up patient with IUD 6 weeks after insertion to check strings. Manage the patient who has missed injections or pills Late injection • If ≤ 2 weeks late for the DMPA: give the injection. • If > 2 weeks late for the DMPA: - - Exclude pregnancy. If pregnant 112. - - If not pregnant: give injection and use condoms or abstain for 7 days. If unprotected sex in past 5 days, also offer emergency contraception 110. Missed progestogen-only pill (> 3 hours late) • Take pill as soon as remembered, continue pack and use condoms or abstain for 2 days. • If unprotected sex in past 5 days, also offer emergency contraception 110. Missed combined oral contraceptive (> 24 hours late) • 1 or 2 active pills missed: take 1 pill immediately and take next pill at usual time. • ≥ 3 active pills missed: take 1 pill immediately and take next pill at usual time. Use condoms or abstain for 7 days: - - If 2 or more pills missed in last 7 active pills of pack: omit inactive pills and start next active pill. - - If 2 or more pills missed in first 7 active pills of pack and patient has had unprotected sex in past 5 days: also offer emergency contraception 110. 1 The subdermal implant may be less effective on ART, rifampicin and phenytoin. Advise patient to use condoms as well. 2 The oral contraceptive may be less effective on ART. Advise patient to use condoms as well. 3 Avoid COC for 6 weeks after delivery and for 6 months if breastfeeding. WOMEN'S HEALTH
Adult 112 The pregnant patient Give urgent attention to the pregnant patient with one or more of: • Convulsing or just had a convulsion • BP ≥ 140/90 and persistent headache/blurred vision/abdominal pain: treat as severe pre-eclampsia • BP ≥ 160/110 and ≥ 1+ proteinuria: treat as severe pre-eclampsia • BP ≥ 160/110 without proteinuria: treat as severe hypertension • Temperature ≥ 38°C and headache, weakness, back pain, abdominal pain • Difficulty breathing • Swollen painful calf • Vaginal bleeding • Decreased/absent fetal movements 114 • Painful contractions < 37 weeks: preterm labour likely • Sudden gush of clear or pale fluid from vagina with no contractions: premature rupture of membranes (PROM) likely Management: • If difficulty breathing, give face mask oxygen and refer urgently. • If BP < 90/60, give normal saline 1L IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • If temperature ≥ 38°C, give ceftriaxone1 1g IM/IV or ampicillin1 2g IV/IM and gentamicin 80mg IM and refer urgently. Preterm labour Premature rupture of membranes (PROM) • If < 24 weeks: refer. • If 24-34 weeks: - - Give dexamethasone 6mg IM, record time given in referral letter. - - Give nifedipine 30mg PO, then 10mg 4 hourly until transferred. - - Check BP every 30 minutes. If BP < 90/60, give IV fluids as above. • If > 34 weeks: allow labour to continue. • Refer urgently. • Confirm amniotic fluid with sterile speculum: examination. • Avoid digital vaginal examination. • If chorioamnionitis4 : - - Give ceftriaxone1 1g IV/IM or ampicillin1 2g IV/IM and gentamicin 80mg IM. - - Refer urgently to hospital. • If no chorioamnionitis4 : - - If ≥ 37 weeks: if not in active labour 8 hours after PROM, give ampicillin1 1g IV/IM and refer urgently. - - If < 37 weeks: give erythromycin 250mg 6 hourly. If 24-34 weeks, also give dexamethasone 6mg IM, record time given in referral letter. Refer same day. Vaginal bleeding Early pregnancy < 24 weeks3 Cervical os open/dilated or products of conception in cervical os/vagina? Late pregnancy ≥ 24 weeks3 • Avoid digital vaginal examination. • Give IV fluids as above. • Refer urgently. No Threatened or complete miscarriage likely Refer same day to exclude ectopic pregnancy. Yes Incomplete or inevitable miscarriage likely • If ≥ 12 weeks, refer same day. • If < 12 weeks, do MVA. • If pain, give ibuprofen 400mg PO TID. • If bleeding heavy (pad soaked in < 5 minutes): - - Give IV fluids as above. - - Give single dose misoprostol 800mcg intravaginally. - - Refer same day If temperature ≥ 38°C, pulse ≥ 100 or smelly vaginal discharge, give ceftriaxone1 1g IM/IV or ampicillin1 2g IV/IM and gentamicin 80mg IM. • If BP ≥ 160/110, give hydralazine 5mg IV over 4 minutes. Also give 200mL normal saline IV. If BP still ≥ 150/100, repeat hydralazine 5mg every 30 minutes to a total maximum of 20mg. • Arrange urgent referral after giving the first doses of medications. Severe hypertension Convulsing or just had a convulsion • Give magnesium sulphate 4g in 200mL normal saline IV over 20 minutes. Also give 5g IM mixed with 1mL of lidocaine 2% in each buttock, and then 5g IM 4 hourly. • Continue 1L normal saline IV 12 hourly. • Insert urethral catheter and record urine output every 4 hours. • Stop magnesium sulphate if urine output < 100mL in 4 hours or respiratory rate < 162 or knee reflexes disappear. • If convulsion recurs or does not respond, refer urgently to hospital. • If < 20 weeks 15. • If between 20 weeks and 1 week postpartum, treat for eclampsia: - - Lie patient in left lateral position. - - Avoid placing anything in mouth. - - Give 100% face mask oxygen. - - Give magnesium sulphate: Severe pre- eclampsia If Rh-negative, give anti-D immunoglobulin 250mcg IM. Give routine antenatal care to the pregnant patient not needing urgent attention 113. 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid and refer. 2 If respiratory rate < 16, give calcium gluconate 10% 1g IV slowly over 10 minutes. 3 If gestation not known, manage as late pregnancy if uterus palpable above umbilicus. 4 Temperature ≥ 38°C, maternal pulse ≥ 100, fetal heart rate ≥ 160, painful abdomen or smelly amniotic fluid.
Adult 113 Does the patient want the pregnancy? Approach to the newly diagnosed pregnant patient not needing urgent attention. Identify the pregnant patient who needs referral level antenatal care • Current medical problems: diabetes, heart/kidney disease, asthma, epilepsy, on TB treatment, substance use/abuse, hypertension, HIV stage 3 or 4. • Current pregnancy problems: rhesus negative with antibodies, multiple pregnancy, < 18 years old, vaginal bleeding or pelvic mass • Previous pregnancy problems: stillbirth or neonatal loss, ≥ 3 consecutive miscarriages, birth weight < 2500g or > 4500g, admission for hypertension or pre-eclampsia, congenital abnormality • Previous reproductive tract surgery (including caesarean section) If not needing referral level antenatal care, give routine antenatal care in health centre 114. • Discuss the options around continuing with pregnancy, choosing adoption or abortion. Refer to social worker. • Determine gestational age by dates and on examination. If unable to determine gestational age, arrange ultrasound. No or unsure Yes No Yes Patient decides to continue with pregnancy. • Abortion is not an option. • Discuss possibility of adoption. • Give routine antenatal care. • < 12 weeks: do MVA or provide medical abortion. • ≥ 12 weeks: refer to hospital for TOP. • Discuss future contraception 110. Patient requests abortion Any one of < 18 years old, pregnant following incest or rape, severe mental illness or congenital malformation?
Adult 114 Routine antenatal care 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. 2 BMI = weight (kg) ÷ height (m) ÷ height (m). 3 High risk of gestational diabetes if any of: previous gestational diabetes, glucose in urine, family history of diabetes, BMI > 30 or previous large baby > 4.5kg. 4 Oral glucose tolerance test: take fasting blood glucose specimen after overnight fast. Give oral glucose 75g in 250mL water to drink within 5 minutes. Take blood glucose specimen 1 hour and 2 hours later. Assess the pregnant patient at first visit and then at 16, 24–26, 32, 36-38 weeks. Assess When to assess Note Symptoms Every visit Manage symptoms as on symptom pages. Check if patient needs urgent attention 112. Estimated delivery date Every visit Plot on antenatal card. If patient ≥ 41 weeks, confirm EDD and refer for fetal evaluation and possible induction of labour. Fetal movements Every visit from 20 weeks If decreased or absent fetal movements, assess fetal heart rate (FHR): if FHR > 160 or < 110 or absent, refer to hospital. TB Every visit If cough > 2 weeks, weight loss, night sweats or fever, exclude TB 71. Mental health Every visit • In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. • If taking ≥ 14 units of alcohol/week or misusing illicit or prescription drugs, refer for secondary hospital antenatal care. Weight Every visit Expect weight gain of 1-2kg at each visit. If < 1kg gain over 2 visits, refer to hospital. BMI2 First visit • BMI < 18.5: exclude TB 71 and give routine malnutrition care 70. • BMI > 30: refer to hospital for CVD risk assessment and management. Mid upper arm circumference First visit MUAC < 23cm: exclude TB 71, HIV 75 and give routine malnutrition care 70. Abdominal examination Every visit • If mass other than uterus in abdomen or pelvis, refer for assessment. • Plot symphysis-fundal height (SFH) on, antenatal card: measurement in centimeters is roughly gestational age in weeks. If SFH is not within 3cm from expected gestational age, refer to hospital. • If breech or non-cephalic presentation at 37 weeks, refer to hospital. Vaginal discharge Every visit • If abnormal discharge, treat for STI 36. • If sudden gush of clear or pale fluid with no contractions: premature rupture of membranes likely 112. If small amounts of clear/pale fluid, refer. Avoid digital examination. BP (BP is normal if < 140/90) Every visit If BP ≥ 140/90, repeat after 1 hour lying on left side. If 2nd BP normal, repeat after 2 days. If 2nd BP still raised, check urine dipstick for protein: • No proteinuria: start methyldopa 250mg PO TID and refer to hospital. • If BP ≥ 140/90 and ≥ 1+ proteinuria, refer to hospital. If BP ≥ 140/90 and symptoms or BP ≥ 160/110, manage as severe pre-eclampsia 112. Arrange ultrasound First visit Book ultrasound before 24 weeks. Urine dipstick: test clean, midstream urine Every visit • If dipstick normal with dysuria (burning urine) or if leucocytes or nitrites present, treat for complicated urinary tract infection 44. • If proteinuria, check BP: - - BP ≥ 160/110, manage as severe pre-eclampsia 112. - - BP < 140/90 and ≥ 2+ proteinuria, refer to hospital to exclude kidney disease. If BP < 140/90 and < 2+ proteinuria, reassess at next antenatal visit. • If glucose in the urine, check random blood sugar 86. Diabetes screen • 26 weeks • If high risk3 : also at first visit • At 26 weeks, do oral glucose tolerance test4 : if fasting glucose ≥ 120mg/dl or following a 75gm oral glucose lose, 1-hour > 180mg/dl or 2-hour ≥ 140mg/dl, refer to hospital. • If high risk at first visit, check blood glucose 86. If diabetes, refer to hospital. Haemoglobin (Hb) First visit or if patient pale • If Hb < 8g/dL at < 34 weeks or Hb < 10g/dL at > 34 weeks or pallor with respiratory rate > 30, dizziness/faintness or chest pain, refer to hospital same day. • If Hb 8-10g/dL at the first visit , treat 115 and repeat Hb monthly until Hb > 10g/dL. Rh status First visit • If Rh-positive, continue routine care. • If Rh-negative, give anti-D immunoglobulin 250mcg IM at 28 weeks and immediately after delivery. Also give if miscarriage, ectopic or abdominal trauma. Continue to assess the pregnant patient 115.
Adult 115 Advise the pregnant patient • Advise to stop smoking, drinking alcohol, using drugs and/or misusing medications. Support patient to change 125. Advise patient not to take medications unless prescribed by clinician. • Advise patient to avoid potentially harmful foods: unpasteurised milk, soft cheeses, raw or undercooked meat, poultry, raw eggs and shellfish. Advise to cut down on caffeine. • Advise patient to reduce indoor pollution (rural setting) and avoid smoking (urban setting). • Discuss safe sex. Advise patient to have only 1 partner at a time. Discuss contraception following delivery 110. • Ensure patient knows the danger signs of a pregnancy 112. • Give patient advice to avoid mosquito-transmitted diseases: - - Avoid travel to malaria areas. - - If in malaria area: Use insect repellent and cover exposed skin with long-sleeved shirt/pants and hat. Stay and sleep in screened or air-conditioned room if possible. Sleep under insecticide dipped net. • Regardless of HIV status, encourage exclusive breastfeeding for 6 months: only breast milk (no formula, water, cereal) and if HIV-exposed, nevirapine and co-trimoxazole prophylaxis. • Refer for support if mental health risk: previous depression/anxiety or family history, < 20 years, unwanted pregnancy, poor social/family support, no/unsupportive partner, violence at home, difficult life event in last year or undisclosed HIV. Treat the pregnant patient • Give iron/folic acid 60mg/400mcg PO daily. Avoid tea/coffee 2 hours after taking tablet. If Hb < 10g/dL, give iron/folic acid 60mg/400mcg PO TID for 3 months and reassess. • Check if tetanus immunisations are up to date (3 doses of tetanus in the past): - - If up to date, give 1 dose of tetanus vaccine at 27-36 weeks gestation. - - If not up to date/unknown, give 3 doses of tetanus vaccine: at first visit , then after 1 month and then after 6 months. • Be cautious of the risk of pre-eclampsia if first pregnancy, hypertension, diabetes, kidney disease, twin pregnancy, BMI > 30, previous pre-eclampsia or family history, < 18 years or > 35 years, > 10 years since last pregnancy. • Prevent malaria in a malaria area: if not on co-trimoxazole, give chloroquine 300mg weekly from 14 weeks. • Treat the HIV positive patient: - - If stage 3 or 4 or CD4 ≤ 350cells/mm3 , give co-trimoxazole 160/800mg PO daily. - - If on ART, continue. If on efavirenz, no need to change regimen. - - If not on ART, start ART within 2 weeks 80. Continue to assess the pregnant patient Syphilis First visit, 32 week If positive 41. HIV First visit and at 36 weeks if negative • Test for HIV 75. If patient refuses, offer test at each visit, even in early labour. • If HIV positive give routine care 76 and start ART same week 115. HIV viral load At first visit if HIV positive; On ART: 6 months, 12 months, then yearly • If viral load > 1000copies/mL for 1st time, give increased adherence support 78 and repeat viral load after 3 months. • If viral load > 1000copies/mL for 2nd time, patient has virological failure: refer to hospital. Give postnatal care to mother and baby 116. Treat the HIV positive patient in labour • If HIV positive on ART, continue ART throughout delivery and breastfeeding. • If newly diagnosed HIV positive or known HIV positive and not on ART, start ART 80. • Ensure mother gets routine HIV care after delivery 76. Treat the HIV-exposed baby immediately after birth • Give the baby born to an HIV positive mother a dose of nevirapine syrup (10mg/mL) as soon as possible after birth 118.
Adult 116 Routine postnatal care Give urgent attention to the postnatal patient with one or more of: • Heavy bleeding (soaks pad in < 5 minutes): postpartum haemorrhage likely • Convulsing or just had a convulsion up to 1 week postpartum 112. • BP ≥ 140/90 and persistent headache/blurred vision/abdominal pain: treat as severe pre-eclampsia 112. • Feeling unwell and temperature > 38°C • BP < 90/60 • Pulse ≥ 100 • Tear extending to anus or rectum • Pallor with respiratory rate > 30, dizziness/faintness or chest pain • Pallor with Hb < 7g/dL Management: • If BP < 90/60 or bleeding with pulse ≥ 100, give normal saline 1L IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • If postpartum haemorrhage likely: - - Look for and repair any perineal tears. - - Massage uterus and empty bladder (with catheter if needed). - - Give oxytocin 10IU IM, then 30IU in 1L normal saline at 40 drops/minute IV. - - Ensure placenta is delivered. If controlled cord traction fails, try manual delivery and give ampicillin1 2g IV/IM. - - If uterus still soft after this, give ergometrine2 0.2mg IM/IV or misoprostol 400mcg sublingual and continue massaging uterus. - - If still bleeding heavily, apply bimanual3 or external aortic compression4 or non-pneumatic anti-shock garments (if available) during referral. • If feeling unwell and temperature > 38°C: give ceftriaxone1 1g IM/IV or amoxicillin1 1g PO with metronidazole 1g PO. • Refer urgently. Assess the mother and her baby within 24 hours, 2-3 days, 1 week and 6 weeks following delivery Assess When to assess Note Symptoms Every visit • Manage mother’s symptoms as on symptom pages. Manage baby’s symptoms with IMCI guide. • Ask about urinary incontinence (leaking or dribbling urine). If still present at 6 weeks, treat for flow problem 44. Depression Every visit If patient not interacting with baby and 2 or more of: a difficult life event in the last year, unhappy about pregnancy, absent or unsupportive partner, previous depression or anxiety, violence at home 99. Substance use/abuse Every visit In the past year, has patient: 1) drunk ≥ 4 drinks5 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Family planning Every visit Assess patient’s contraception needs 110. Baby feeding Every visit • If breastfeeding: check for breast problems 31. Check that baby latches well and is not mixed feeding. • If formula feeding: ensure correct mixing of formula and water and that it is affordable, feasible, acceptable, safe and sustainable. Baby Every visit Assess and manage the baby according to the IMNCI guide. Ensure baby received immunisations at birth and ensure baby is immunised at 6 week visit. Abdomen and perineum Every visit • If perineal or abdominal wound: check healing. • If painful abdomen, smelly discharge or poorly contracted uterus: check temperature and refer. BP Every visit Check BP. If BP ≥ 140/90, recheck after 1 hour rest. If BP still ≥ 140/90 and ≤ 1 week postpartum, refer urgently. Continue to assess the mother and her baby 117. 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid and refer. 2 Avoid if eclampsia, pre-eclampsia or known hypertension. 3 Bimanual compression: insert clenched fist into vagina, back of hand directed posteriorly, knuckles in anterior fornix. Place other hand on abdomen behind uterus and squeeze uterus firmly between hands. 4 External aortic compression: press down with fist just above umbilicus until femoral pulse not felt. 5 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
Adult 117 Assess When to assess Note HIV test in mother • If not done • At 6 weeks • If breastfeeding: 3 monthly • Test for HIV 75. If HIV positive, give routine care 76. If not on ART, start ART 79. • If mother tests HIV positive, do HIV PCR on baby same day and start post-exposure prophylaxis in baby while waiting for PCR result 118. HIV test in HIV-exposed baby • 6 weeks • 9 months if previous test negative • 18 months if previous test negative • Decide which HIV test to do: - - If < 9 months, do PCR. If positive, start ART and confirm result with 2nd PCR. - - If 9 - 17 months, do rapid test. If positive, do PCR. If PCR positive, start ART and confirm result with 2nd PCR. - - If ≥ 18 months 75. • If mother diagnosed with HIV while breastfeeding or baby unwell, do HIV test same day. Haemoglobin (Hb) If pale If Hb < 7g/dL, refer same day. If Hb 7-11g/dL, treat as below. Syphilis If not done Test mother for syphilis: if positive, treat mother and baby 41. Cervical screen (VIA) At 6 weeks if needed • If HIV negative: screen every 5 years if patient between 30-49 years. • If HIV positive: screen at HIV diagnosis (regardless of age) then 5 yearly. • If abnormal 40. Treat the HIV-exposed baby Give eMTCT regimen 118. Advise the mother • Encourage mother to become active soon after delivery, rest frequently and eat well. If mother has little support at home, arrange support. • Advise mother to keep perineum clean and to change pads 4-6 hourly. • Advise to return urgently if heavy bleeding, smelly vaginal discharge, red/smelly/oozing wound, fever, dizziness, severe headache, blurred vision, severe abdominal pain, severe calf pain or baby unwell. • Give feeding advice: - - Encourage exclusive breastfeeding for 6 months: baby gets only breast milk (no formula, water, cereal) and if HIV-exposed, nevirapine and co-trimoxazole prophylaxis. - - Refer to an infant feeding support group. - - If patient chooses to formula feed, ensure it is affordable, feasible, acceptable, safe and sustainable. Check formula is correctly prepared. Discourage mixed feeding before age 6 months. - - From 4-6 months, introduce food while continuing with feeding choice. - - If mother HIV positive, continue breastfeeding until 1 year if mother on ART and until at least 2 years if baby diagnosed HIV positive. - - If mother HIV negative: continue to breastfeed until at least 2 years. Explain importance of regular HIV testing while breastfeeding. • If mother HIV positive: ensure mother knows how to give nevirapine syrup correctly. • Advise that mother and baby sleep under an insecticide dipped bed net if in a malaria area. • Advise mother to reduce indoor pollution (rural setting) and avoid smoking (urban setting). Treat the mother • Continue iron/folic acid 60mg/400mcg PO daily for 6 weeks post partum. If Hb 7-11g/dL, give iron/folic acid 60mg/400mcg PO TID for 3 months and reassess Hb. • Check antenatal Rh-status: if Rh-negative, confirm anti-D immunoglobulin was given at delivery. If not given within 72 hrs of delivery, give anti-D immunoglobulin 250mcg IM. • Check tetanus immunisation is up to date: 5 doses in a lifetime. If not up to date: give 1 dose of tetanus vaccine. Repeat at 4 weeks, then 6, 18 and 30 months after first dose. • If painful perineal or abdominal wound, give paracetamol 1g PO QID as needed for up to 5 days. • If HIV positive and not on ART, start ART 79. If mother is already on ART, continue.
Adult 118 Elimination of mother-to-child transmission (eMTCT) of HIV Approach to the HIV-exposed baby (mother is known with HIV1 ) Start post-exposure prophylaxis as soon as possible within 6 hours of birth: Mother on ART Low risk of HIV transmission Give nevirapine PO daily for 6 weeks (see table). High risk of HIV transmission Refer to hospital. Treat the HIV-exposed baby • Give eMTCT: nevirapine. Dose according to weight and age (see table). If ≤ 35 weeks gestation, discuss dose. • Start co-trimoxazole at 6 weeks of age. Dose according to weight (see table). Stop if HIV negative 6 weeks after last breastfeed. Nevirapine syrup (10mg/mL) Birth weight (born > 35 weeks) Age Dose < 2.0kg Birth up to 6 weeks 0.2mL/kg daily 2.0-2.49kg Birth up to 6 weeks 1mL daily ≥ 2.5kg Birth up to 6 weeks 1.5mL daily - 6 weeks to 12 weeks 2mL daily Co-trimoxazole syrup (40/200mg/5mL) Weight Dose 3.0-5.9kg 2.5mL daily 6.0-13.9kg 5mL daily Mother not on ART Start ART in mother same day 79. 1 If mother’s HIV status is unknown and mother not available, do rapid HIV test on baby. If positive, send HIV PCR test and refer to hospital. If negative, there is no need for eMTCT. No No Yes Yes Did mother initially test HIV negative and then became HIV positive during this pregnancy? Was there poor adherence to ART or mother in stage 3 or 4?
Adult 119 Menopause Treat the menopausal patient • Give calcium 500-1000mg daily. • If menopausal symptoms interfere with daily function and no history of abnormal vaginal bleeding, cancer of uterus/breast, previous DVT or pulmonary embolism, recent heart attack, uncontrolled hypertension or liver disease, refer to hospital for initiation and routine follow up of hormone therapy. • Exclude pregnancy before diagnosing menopause. If pregnant 112. • Menopause is no menstruation for at least 12 months in a row in a woman above 40 years of age. Most women have menopausal symptoms and irregular periods during perimenopause. • If woman is < 40 years, refer to hospital. 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 67 and sexual problems 43. • If night sweats, ask about other TB symptoms: if cough ≥ 2 weeks, weight loss or fever, exclude TB 71. • Manage other symptoms as on symptom pages. Depression Every visit In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. Thyroid function At diagnosis If weight change, pulse ≥ 100, tremor, weakness/tiredness, dry skin, constipation or intolerance to cold or heat, refer to hospital. Vaginal bleeding Every visit If bleeding between periods, after sex or after being period-free for 1 year, refer to hospital. CVD risk At diagnosis, then depending on risk • Assess CVD risk 84. • If < 10% reassess after 1 year. If 10% to < 20%, reassess after 6 months. Osteoporosis risk At diagnosis Refer for possible treatment if high osteoporosis risk: < 60 years with loss of > 3cm in height and fractures of hip/wrist/spine; previous non-traumatic fractures; corticosteroid treatment > 3 months; onset of menopause < 45 years; BMI < 18.5; > 2 alcoholic drinks/day; smoker. Family planning At diagnosis • If on combined oestrogen/progestogen pill or progestogen injection, change to non-hormonal method or progestogen only pill or subdermal implant when ≥ 50 years. • If on non-hormonal method, continue for 2 years after last period if < 50 years and for 1 year after last period if ≥ 50 years. • If on progestogen only pill or subdermal implant, continue until 55 years, or if still menstruating, until 1 year after last period. Breast check At diagnosis If any lumps found in breasts or axillae, refer same week to hospital. Cervical screen When needed If HIV negative, screen every 5 years if patient between 30-49 years. If HIV positive, screen at HIV diagnosis (regardless of age) then 5 yearly. If abnormal 40. Advise the menopausal patient • To cope with the hot flushes, advise patient to dress in layers and to decrease alcohol, avoid spicy foods, hot drinks and warm environments. • Advise increased weight bearing exercise, such as walking. • If patient smokes tobacco 102. Support patient to change 125. • Help patient to manage CVD risk if present 85. • If patient is having mood changes or not coping as well as in the past, refer to counsellor or support group. • Educate the patient about the risks, contraindications and benefits of hormone therapy and that it can be used to treat menopausal symptoms for up to 5 years. Long term use can increase risk of breast cancer, deep vein thrombosis (DVT) and cardiovascular disease.
Adult 120 Life-limiting illness: routine palliative care A patient can be given curative and palliative care at the same time. A doctor should confirm the patient with a life-limiting illness's need for palliative care: • If patient terminally sick and survival is predicted to be short then s/he needs palliative care 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 failure, cancer, dementia, HIV, TB. Advise the patient needing palliative care and his/her carer • Explain about the condition and prognosis. Explaining what is happening relieves fear and anxiety. Support the patient to give as much self care as possible. • Discuss the plan for caring for the patient. Advise whom to contact when pain or other symptoms get severe. • 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. • Refer patient and carer to available palliative carer, support group, counsellor, spiritual counsellor. Deal with bereavement issues 65. • Prevent bedsores if bedridden: 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). • Prevent contractures if bedridden: at least twice a day, gently bend and straighten joints as far as they go. Avoid causing pain. Massage muscles. • Prevent mouth disease: brush teeth and tongue regularly using toothpaste or dilute bicarbonate of soda if available. Rinse mouth with ½ teaspoon of salt in 1 cup of water after eating and at night. • The patient’s appetite will diminish 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. • Emphasize the importance of taking pain medication regularly (not as needed) and if using codeine/morphine to use a laxative daily to prevent constipation. Assess the patient needing palliative care Assess Note Symptoms • Manage on symptom pages: fever, constipation, nausea/vomiting, difficulty swallowing, difficulty breathing/cough, sore mouth, weight loss, incontinence, vaginal discharge. • If patient concerned about appetite loss, reassure that this is normal at the end of life. Consider trying a short course of prednisolone 121. Pain • 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, refer. • Assess the severity of the patient’s pain to help the patient to decide which pain medications s/he needs to start or increase : • Ask the patient to point on the pain scale whether his/her pain is mild, moderate or severe. no pain mild pain moderate pain severe pain worst possible pain 0 1 2 3 4 5 6 7 8 9 10 • Ask patient to describe the pain: muscles spasms, bone pain; if burning or electric like sensations, nerve pain likely; if cramping, colicky pain in abdomen, organ pain likely. Sleep If patient has difficulty sleeping 67. Depression In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. Side effects Manage side effects on symptom pages. Nausea, confusion and sleepiness on morphine usually resolve after a few days. Chronic care • Assess how much patient and family understands 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. Carer Ask how the carer is coping and what support s/he needs. Assess for stress or distress 65. Mouth Check oral hygiene and look for dry mouth, ulcers and oral candida 27. Bed sores If patient is bedridden, check common areas for damaged skin (change of colour) and bedsores (see picture). If patient has bedsore 59. Smelly wound/discharge If patient has a malignant wound or discharge not responding to treatment that is smelly and causing embarrassment, treat with metronidazole solution to reduce smell 121.
Adult 121 • If pain persists/increases, increase dose to maximum and then move to next step. If pain decreases, step down. • Review 2 days after starting or changing medication. If side effects intolerable after decreasing dose, refer. Review the patient needing palliative care and his/her carer regularly. Treat the patient needing palliative care • If smelly wound or discharge not responding to treatment, give metronidazole to control infection and smell: dissolve 5g in 2L normal saline and wash/douche daily. • If poor appetite is distressing the patient at the end of life, give prednisolone 5mg PO daily in the morning to stimulate appetite. Increase up to 15mg if needed. • Treat pain. Aim to have patient pain free at rest and as alert as possible. If the patient has any pain, start pain medication. Does patient have mild, moderate or severe pain? If unsure start at lower step and increase pain medication if needed. Also check if patient needs adjuvant pain medication: does s/he have nerve pain, organ cramps, bone pain or muscle spasms? Is anxiety making pain worse? Mild pain Start pain medication at step 1. Use paracetamol in step 1 and add amitriptyline. Nerve pain Add diazepam. Muscle spasms Use ibuprofen or diclofenac in step 1. Bone pain Add hyoscine. Organ cramps Add diazepam. Anxiety Moderate pain Start pain medication at step 2. Severe pain Start pain medication at step 3. Step Pain medication Start dose Maximum dose Note Step 1 Use one of: Paracetamol 1g PO QID 4g daily NSAIDS are very good for visceral and somatic pain. Start this if mild pain and also use in step 2 or 3 and in neuropathic pain with amitriptyline. Diclofenac 50mg BID or PO TID 150g daily Give with/after food. Avoid if peptic ulcer, dyspepsia, bleeding problem, kidney or liver disease, asthma. Ibuprofen 400mg PO QID 2.4g daily Give with/after food. Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. Step 2 Add one of: Codeine 30mg PO 4 hourly 240mg daily If no diarrhoea , give bisacodyl 5-15mg PO daily to prevent constipation. Tramadol 50mg-100mg PO QID 400mg daily • If no diarrhoea, give bisacodyl 5-15mg PO daily to prevent constipation. • Avoid in epilepsy Step 3 Stop step 2 and add: Morphine oral syrup 2.5mg-5mg PO 4 hourly None. If respiratory rate < 12, skip 1 dose, then halve dose. • If no diarrhoea, give bisacodyl 5-15mg PO daily to prevent constipation. • If pain persists after first 24 hours, increase dose by 1.5-2 times. • If patient has severe nausea, give metoclopramide 10mg PO TID for 1 week only • Dizziness should clear in few days. Advise to avoid driving, heavy machinery. If persists > 1 week, lower dose. Add adjuvant pain medication to any step if needed. Amitriptyline 25-75mg PO 75mg/daily Use at night. Advise it may cause dizziness and sedation and to avoid driving and using heavy machinery. Diazepam 5mg PO TID 15mg/daily Explain about dizziness which will clear in few days but avoid driving, heavy machinery Hyoscine 10-40mg PO TID 120mg /daily - PALLIATIVE CARE
Adult 122 Protect yourself from occupational infection Give urgent attention to the health worker who has had a sharps injury or splash to eye, mouth, nose or broken skin with exposure to one or more of: • Blood • Blood-stained fluid/tissue • Pleural/pericardial/peritoneal/amniotic/synovial/cerebrospinal fluid • Vaginal secretions • Semen • Breast milk 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 or normal saline. • If health worker has had contact with viral haemorrhagic fever1 suspect, discuss with specialist2 . • Assess need for HIV and hepatitis B post-exposure prophylaxis 68. Adopt measures to diminish your risk of occupational infection Protect yourself Adopt standard precautions with every patient: • Wash hands with soap/water or use alcohol-based cleaner before and after contact with patients or body fluids. • Do not recap or bend needles • Safely pass sharp instruments • Dispose of sharps correctly in sharps bins. Wear personal protective equipment: • Wear gloves when handling blood, body fluids, secretions or non-intact skin. • Wear face mask if in contact with respiratory virus suspects • Wear N95 respirator if caring for MDR TB patient. • Wear face mask with a visor or glasses if at risk of splashes. • Wear personal protective equipment if in contact with viral haemorrhagic fever1 suspects. Get vaccinated: • Get vaccinated against hepatitis B and yearly against influenza. Know your HIV status: • Test for HIV 75. ART and IPT can decrease the risk of TB. • If HIV positive, you are entitled to work in an area of the facility where exposure to TB is limited. Protect your facility Clean the facility: • Clean frequently touched surfaces (door handles, telephones, keyboards) daily with soap and water. • Disinfect surfaces contaminated with blood/secretions with 70% alcohol or chlorine-based disinfectant. Ensure adequate ventilation: • Leave windows and doors open when possible and use fans to increase air exchange. Organise waiting areas: • Prevent overcrowding in waiting areas. • Fast track influenza and presumed TB patients. Manage sharps and other infectious wastes safely: • Ensure sharps bins are easily accessible and regularly replaced. • Segregate and dispose wastes properly Manage infection control in the facility: • Appoint an infection control officer for the facility to coordinate and monitor infection control policies. Reduce TB risk Identify the presumed TB patient promptly: • The patient with cough ≥ 2 weeks is a presumed TB patient. • Separate presumed TB patient from others in the facility. • Educate about cough hygiene and give face mask/tissues to cover mouth/nose to protect others. Diagnose TB rapidly: • Fast track TB workup and start treatment as soon as diagnosed. Protect yourself from TB: • Wear an N95 respirator (not a face mask) if in contact with an infectious MDR TB patient. Reduce risk of respiratory viruses (including influenza) • Wash hands with soap and water. • Wear a face mask over mouth and nose during procedures on patient. • Encourage patient to cover mouth/ nose with a tissue when coughing/sneezing, to dispose of used tissues correctly and to wash hands regularly with soap/water. • Advise patient to avoid close contact with others. 1 Suspect viral haemorrhagic fever in patient who lived in or travelled to an endemic area or had contact with confirmed viral haemorrhagic fever in past 21 days and has fever and ≥ 1 of: bloody diarrhoea, bleeding from gums, bleeding into skin, eyes. 2 Report to the head of the health centre who will contact the Public Emergency Management unit within the Public health institute. Manage possible occupational exposure promptly
Adult 123 Protect yourself from occupational stress Give urgent attention to the health worker with occupational stress and one or more of: • Alcohol or drug intoxication at work • Aggressive or violent behaviour at work • Inappropriate behaviour at work • Suicidal thoughts or behaviour 62 Management: • Arrange assessment same day with mental health practitioner. 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. Identify occupational stress in yourself and your colleagues: Possible alcohol or drug problem • In the past year, have you or your colleague: drunk ≥ 4 drinks1 /session, used khat or illegal drugs, or misused prescription or over-the-counter medications? • Smells of alcohol Change in mood • Indifferent, tense, irritable or angry • In the past month, have you or colleague: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? Recent distressing event • Diagnosis of chronic condition • Bereavement • Needlestick injury • Traumatic event Poor attendance at work • Frequent absenteeism Marked decline in work performance • Reduced concentration • Fatigue Adopt measures to diminish your risk of occupational stress Protect yourself Look after your health: • Get enough sleep. • Exercise, eat sensibly, minimise alcohol and don’t smoke 85. • Get screened for chronic conditions. Look after your chronic condition if you have one: • Adhere to your treatment and your appointments. • Don’t diagnose and treat yourself. • If you can, confide in a trusted colleague/manager. Manage stress: • Delegate tasks as appropriate, develop coping strategies. • Talk to someone (friend, psychologist, mentor). • Do a relaxing breathing exercise each day. • Find a creative or fun activity to do. • Spend time with supportive friends or family. Have healthy work habits: • Manage your time sensibly. • Take scheduled breaks. • Remind yourself of your purpose as a clinician. • Be sure you are clear about your role and responsibilities. Protect your team Decide on an approved way of behaving at work: • Communicate effectively with your patients and colleagues 124. • Treat colleagues and patients with respect. • Support each other. Consider setting up a staff support group. • Instead of complaining, rather focus on finding solutions to problems. Cope with stressful events: • Develop procedures to deal with events like complaints, harassment/bullying, accidents/mistakes, violence or death of patient or staff member. Look at how to make the job less stressful: • Examine the team’s workload to see if it can be better streamlined. • Identify what needs to be changed to make the job easier and frustrations fewer: equipment, drug supply, training, space, décor in work environment. • Discuss each team member’s role. Ensure each one has say in how s/he does his/her work. • Support each other to develop skills to better perform your role. Celebrate: • Acknowledge the achievements of individuals and the team. • Organise or participate in staff social events. If you or your colleagues have any of the above you may have substance abuse, stress, depression/anxiety or burnout. Ensure that you seek help. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
Adult 124 Communicate 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 • Give all your attention • Recognise non-verbal behaviour • Be honest, open and warm • Avoid distractions e.g. phones The patient might feel: • ‘I can trust this person’ • ‘I feel respected and valued’ • ‘I feel hopeful’ • ‘I feel heard’ Don’t • Talk too much • Rush the consultation • Give unwanted advice • Interrupt The patient might feel: • ‘I am not being listened to’ • ‘I feel disempowered’ • ‘I am not valued’ • ‘I cannot trust this person’ Discuss Discussing a problem and its solution can help the overwhelmed patient to develop a manageable plan. Do • Use open ended questions • Offer information • Encourage patient to find solutions • Respect the patient’s right to choose The patient might feel: • ‘I choose what I want to deal with’ • ‘I can help myself’’ • ‘I feel supported in my choice’ • ‘I can cope with my problems’ Don’t • Force your ideas onto the patient • Be a ’fix-it’specialist • Let the patient take on too many problems at once The patient might feel: • ‘I am not respected’ • ‘I am unable to make my own decisions’ • ‘I am expected to change too fast’ Empathise Empathy is the ability to imagine and share the patient’s situation and feelings. Do • Listen for, and identify his/her feelings e.g. ‘you sound very upset’ • Allow the patient to express emotion • Be supportive The patient might feel: • ‘I can get through this’ • ‘I can deal with my situation’ • ‘My health worker understands me’ • ‘I feel supported’ Don’t • Judge, criticise or blame the patient • Disagree or argue • Be uncomfortable with high levels of emotions and burden of the problems The patient might feel: • ‘I am being judged’ • ‘I am too much to deal with’ • ‘I can’t cope’ • ‘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 • Get the patient to summarise • Agree on a plan • Offer to write a list of his/her options • Offer a follow-up appointment The patient might feel: • ‘I can make changes in my life’ • ‘I have something to work on’ • ‘I feel supported’ • ‘I can come back when I need to’ Don’t • Direct the decisions • Be abrupt • Force a decision The patient might feel: • My health worker disapproves of my decisions’ • ‘I feel resentful’ • ‘I feel misunderstood’
Adult 125 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 or 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 and not lower. 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: • Assist the patient to set a realistic change goal. • Explore the factors that may help the patient to change or may make it difficult. • Help the patient plan how s/he will fit the change into the routine of the day. Encourage patient to use strategies s/he used successfully in the past. If the patient is not ready to change: • Respect the patient's decision. • Invite patient to identify the pros and cons of change. • Acknowledge patient’s concerns about change. • 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, health extension worker). • 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.
Child 126 Child contents Long-term health conditions A Abdominal symptoms 143 B Breathing difficulty, child 140 Burns 133 C Cardiac arrest 128 Cardiopulmonary resuscitation (CPR) 128 Coma 131 Confusion 131 Convulsions 130 Cough 140 Cough, recurrent 142 D Dehydrated child 129 Diarrhoea 144 E Ear symptoms 138 Emergency child 127 F Fever 134 H Headache 135 Head injury 127 Hearing problems 138 I Injured child 132 L Leg symptoms 146 Limp 146 Lymphadenopathy 136 M Mouth symptoms 139 P Pallor 137 R Rash, generalised 147 Rash, localised 148 Respiratory arrest 128 Resuscitation, child 128 S Seizures 130 Shock 129 T Throat symptoms 139 U Unconscious child 131 Underweight 150 Urinary symptoms 145 W Walking problems 146 Wheeze 141 Wheeze, recurrent 142 Symptoms Malnutrition 153 Epilepsy 154 Quick reference chart 155
Child 127 The emergency child Give urgent attention to the emergency child Does child respond to voice or physical stimulation? Assess and manage airway, breathing, circulation and level of consciousness: No Feel for pulse for maximum of 10 seconds: feel carotid pulse. No pulse felt or no signs of life. Pulse felt Call for help and start CPR 128. Yes Child breathing well Pulse rate < 60 Child gasping or not breathing • Check airway clear and give 1 breath with bag valve mask attached to oxygen every 4 seconds. • Recheck pulse every 2 minutes. Pulse rate ≥ 60 Airway • If noisy breathing, position in ‘sniffing position’. If injured, keep neck stable, use instead jaw-thrust1 only. • Check for foreign body in mouth: if easy-to-reach, remove. Suction secretions. • If unresponsive, insert an oropharyngeal airway2 . Breathing • If difficulty breathing or oxygen saturation ≤ 92%, give facemask oxygen 140. • If respiratory rate decreased, or blue lips/tongue, assist each breath with bag valve mask attached to oxygen (at least every 4 seconds). Circulation • Establish IV access: try 3 times for < 90 seconds each, if unsuccessful and trained to do so, insert external jugular or intra-osseous line3 . • If ≥ 2 of: 1) cold hands/feet, 2) weak/fast pulse, 3) capillary refill3 > 3 seconds, 4) decreased level of consciousness 5) decreased urine output: shock likely 129. • If actively bleeding or enlarging/ pulsating swelling, elevate and apply direct pressure. If unsuccessful, compress the nearest large artery. Glucose/level of consciousness • Check fingerprick glucose: - - If glucose if < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose4 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose4 bolus. • Determine AVPU: - - A: alert - - V: responds to voice - - P: responds to pain - - U: unresponsive • If decreased level of consciousness 131. Check breathing: Manage further according to disability and symptoms and refer urgently: • If injured: - - If head injury, neck/spine tenderness, decreased level of consciousness or weak/numb limb, immobilise head with tape and sandbags/bags of IV fluid on either side of head. Use spine board if needing to move patient. - - Identify all injuries: undress child fully and assess front and back using log-roll to turn. Then cover and keep warm. Manage injuries 132. • If pupils unequal or respond poorly to light, tilt bed to raise head by 30 degrees. If injured, avoid bending spine: keep body straight with head/neck in midline. • Manage further according to symptoms: if covulsing 130, if just had convulsion 130, if unconscious 131, if burn 133. • Keep child warm. 3 If trained, insert an intraosseous line: Clean with antiseptic, locate site on medial surface of tibia, 2 finger breadths below tibial tuberosity, stabilize thigh/knee, insert 15-18 gauge intraosseous needle 90o angle to bone with bevel towards foot. Advance with twisting motion, stop when sudden decrease in resistance (needle should be fixed in bone). Remove stylet (if present) and confirm position by aspirating 1mL of blood/marrow with 5mL syringe. Flush with 5mL IV fluid. Apply dressing and secure. Monitor for calf swelling. 1 Lift chin forward with fingers under bony tips of jaw. 2 Size oropharyngeal airway: flat rim at middle of mouth (front incisors), laid on side of face, tip at angle of jaw. If child resists, coughs or gags, likely too alert to tolerate airway. 3 Capillary refill time: hold hand/foot higher than level of heart. Press soft pad of finger/toe until it turns pale, then release pressure and take note of time taken for colour to return. 4 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline). CHILD
Child 128 Cardio-pulmonary resuscitation (CPR) of the child Decide when to stop CPR: Return of pulse ≥ 60 127. No return of pulse after 20 minutes • If hypothermia, near drowning or poisoning, continue prolonged CPR and transfer urgently. • If no pulse and fixed dilated pupils after 20 minutes of effective CPR, stop CPR and pronounce dead. • Arrange bereavement counselling for family. In the unresponsive child with no pulse or pulse < 60, start chest compressions: • Note start time. • Give cycles of 15 compressions and 2 breaths with bag valve mask attached to oxygen at a flow rate of 10-15L/min. If only one rescuer, give 30 compressions and 2 breaths. Ensure correct CPR technique: - - For chest compressions: • Find correct hand position: palpate xiphoid process and place hands directly above this area on the sternum. Place one hand on top of the other and push down onto the chest, making sure to keep your shoulders directly over your hands and elbows locked. • Push hard (≥ ⅓ of depth of chest) and fast (100/minute). • Allow full chest recoil (chest to return to normal shape in between compressions). • Minimise interruptions in compressions. - - For breaths: • Check airway clear and head and neck in the‘sniffing position’. If injured, keep neck stable, use instead jaw thrust1 • Give adrenaline 1:10 000, which is 1mL adrenaline (1:1000) diluted in 9mL normal saline, 0.1mL/kg IV/IO every 3 minutes (for quick reference, use the table below): Dose IV/IO adrenaline (1:10 000) according to age 1:10 000 concentration: dilute 1mL adrenaline (1:1000) diluted in 9mL normal saline. Age Volume 5-7 years 2mL 7-11 years 3mL 11-15 years 5mL • If glucose if < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose2 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose2 bolus. • Treat for likely shock 129. • Warm child. • Check for pulse after every 2 minutes of CPR. 1 Lift chin forward with fingers under bony tips of jaw. 2 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline). Use heel of hand/s.
Child 129 Assess and manage child’s fluid needs 1 Capillary refill time (CRT): hold hand/foot higher than level of heart. Press soft pad of finger/toe until it turns pale, then release pressure and note time taken for colour to return. 2 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline). 3 Pinch skin on abdomen between 2 fingers. Release. Skin usually snaps rapidly back to its normal position. A slow skin pinch takes longer. 4 Severe acute malnutrition: BMI below -3 line or very low MUAC (< 13cm in a child 5-9 years old or < 16cm in a child 10-14 years old). Yes: shock likely • Establish IV access: try 3 times for < 90 seconds each, if unsuccessful, insert external jugular or intra-osseous (IO) line. If IV access not possible, refer urgently with ORS 20mL/kg/hour NGT or orally if NGT not possible. • Is there ≥ 1 of: 1) severe acute malnutrition4 2) difficulty breathing 3) suspected meningitis? No • Give normal saline 20mL/kg bolus IV/IO rapidly. • Then assess response: feel hands, check pulse and CRT. Good response: hands warmer, CRT faster, pulse slower and stronger Yes Stop IV fluids, give oxygen 2L/minute via nasal prongs, and refer urgently to hospital. Refer urgently. While awaiting transfer: • If not already done, check finger prick glucose: if < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose2 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose2 bolus. • If not due to watery diarrhoea or trauma, or if child has severe acute malnutrition4 , give ceftriaxone 100mg/kg (up to 2g) IV/IM. • Reassess fluid status hourly and keep warm: cover with blanket. Good response: hands warmer, CRT faster, pulse slower and stronger Give 2nd bolus: normal saline 20mL/kg bolus IV/IO and urgently refer to hospital. Continue with normal saline 30mL/kg over 30 minutes, then give 70mL/kg for 2½ hours. No longer shocked. No longer shocked. Give 2nd bolus: DNS 15mL/kg IV/IO over 1 hour and urgently refer to hospital. Continue ORS 10mL/kg/hour orally (or NGT if vomiting). Poor response: hands still cold or pulse weak or not felt, CRT > 3 seconds Poor response: hands still cold or pulse weak or not felt, CRT > 3 seconds Still shocked Are eyelids puffy, leg swelling worse, is pulse rate up by 25 beats/minute or respiratory rate up by 5 breaths/minute? Still shocked Is pulse rate up by 25 beats/ minute or respiratory rate up by 5 breaths/minute or eyelids puffy? Yes • Give DNS 10mL/kg IV/IO over 20 minutes. • Then assess response: feel hands, check pulse and CRT. No • If lethargic, check finger prick glucose if < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose2 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose2 bolus. • Is there ≥ 2 of: 1) sunken eyes, 2) drinking poorly, 3) lethargic, 4) very slow skin pinch3 (≥ 2 seconds) 5) decreased urine output? Yes Moderate dehydration (5%) likely Is there ≥ 1 of: 1) severe acute malnutrition4 , 2) difficulty breathing, 3) suspected meningitis? • Record weight. • If child vomits, wait 10 minutes, then continue more slowly. • If refusing to drink, give via NGT. • Give more ORS if child wants it. • Check fingerprick glucose and manage as above, if necessary. Reassess after 4 hours: • If still dehydrated or weight not up, refer to hospital. • If no longer dehydrated and child has diarrhoea 144. • Address other symptoms on symptom page. No Is there ≥ 2 of: 1) sunken eyes, 2) thirsty/drinks eagerly, 3) restless/irritable, 4) slow skin pinch3 ? No Child not dehydrated No Give ORS 20mL/kg/ hour orally, using small frequent sips, for 4 hours. Yes Give ORS 10mL/kg/ hour orally using small frequent sips, for 4 hours. Return to relevant symptom page to assess and manage symptom/s. Yes Severe dehydration (10%) likely Is there ≥ 1 of: 1) severe acute malnutrition4 , 2) difficulty breathing, 3) suspected meningitis? No No No Give normal saline 30mL/kg IV over 30 minutes, then give 70mL/kg for 2½ hours. Yes Give ReSoMal 5mL/kg orally/NGT every 30 minutes for the first 2 hours. Then 5-10mL/kg/ hour orally/ NGT for the next 4 hours. Assess the child’s fluid needs: Is there ≥ 2 of 1) cold hands/feet, 2) weak/fast pulse, 3) capillary refill time (CRT)1 > 3 seconds, 4) decreased level of consciousness 5) decreased urine output?
Child 130 Seizures/convulsions Give urgent attention to the child who is unconscious and convulsing: Give medication to stop the convulsion whilst giving supportive treatment. Then treat possible causes. Stop the convulsion that has lasted > 5 minutes • Give rectal1 diazepam 0.1mL/kg PR or if IV line already inserted, give diazepam 0.05mL/kg IV slowly (see table below). • Expect a response within 5 minutes. Monitor breathing: if decreased respiratory rate, breathing stops or gasping, ventilate with bag-valve mask (1 breath every 3-5 seconds) 127. • If child still convulsing after 5-10 minutes, give a 2nd dose of diazepam. If child still convulsing 5-10 minutes after this, give a 3rd dose of diazepam. Weight/age Rectal1 diazepam (10mg/2mL) 0.1mL/kg IV diazepam (10mg/2mL) 0.05ml/kg 18-25kg (5-8 years) 1.5mL 0.9mL ≥ 25kg (≥ 8 years) 2mL 1mL • If child still convulsing or repeated convulsions without regaining consciousness despite diazepam: give phenytoin 20mg/kg PO via nasogastric tube (NGT) or phenobarbitone 20mg/kg (up to 1g) PO via NGT. • Refer to hospital urgently. Give supportive treatment and treat possible causes • Open airway: clear mouth, stabilise neck if trauma patient and suction secretions. • If not trauma patient, place in recovery position2 . Avoid placing anything in mouth. • Give facemask oxygen 5 L/minute. • Check fingerprick glucose: if < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose3 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose3 bolus. • If meningitis4 likely, give ceftriaxone 100mg/kg (up to 2g) IV. • If malaria is suspected/confirmed5 : give artesunate 3mg/kg IM or artemether 3.2mg/kg IM. 1 Rectal administration: draw up correct dose, remove needle and connect to an NGT that has been cut to a length of 5cm (length of baby finger). Insert into rectum, inject diazepam solution and hold buttocks together. 2 Recovery position: turn onto left side, place left hand under cheek with neck slightly extended and bend the right leg to stabilise position (see picture above). 3 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline). 4 Meningitis likely if: temperature ≥ 38°C, neck stiffness, headache and/or vomiting. 5 Test for malaria with parasite slide microscopy or if unavailable, rapid diagnostic test. 6 Dehydration: ≥ 2 of: 1) sunken eyes, 2) thirsty/drinks eagerly, 3) restless/irritable, 4) slow skin pinch. 7 Family history of epilepsy refers to a parent or sibling with childhood onset epilepsy. Has child had ≥ 2 convulsions in the last year on 2 different days? Refer patient same day if one or more of: • Temperature ≥ 38°C • Convulsion > 15 minutes • Unresponsive to voice > 1 hour after convulsion • > 1 convulsion in 24 hours • Convulsion occurs only on one side • Neck stiffness/ meningism • Weakness of arm/leg/face, even if resolved • Dehydration6 • Suscpted/confirmed malaria5 • Ingestion of medication/potentially harmful substance • Previous birth trauma, head injury, meningitis • Family history of epilepsy7 • HIV positive • Head injury within past week • Close TB contact Approach to the child who is not convulsing now: • If child known with epilepsy, give routine epilepsy care 154. • If not know with epilepsy: confirm that child indeed had a convulsion: jerking movements, loss of consciousness, eyes open during convulsion, incontinence, post-convulsion drowsiness and confusion. If not, refer to hospital. Yes Refer to hospital. No • If talking/understanding problems, refer to hospital. • If otherwise well, review in 3 months for further convulsions, new symptoms or delayed milestones. Advise the caretaker on what to do if child has a convulsion at home • Place child in safe place (on floor or bed) away from objects that may cause injury. • Lie child on left side in recovery position2 . Avoid placing anything in his/her mouth. Wipe away secretions. • Time convulsion: get help if convulstion continues for more than 3 minutes or child does not wake up properly between convulsions. • Encourage caretaker/s to have a plan ready if medical attention needed urgently: know where nearest clinic is, have reliable transport plan.
Child 131 Decreased level of consciousness 1 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline). 2 Test for malaria with parasite slide microscopy or if unavailable, rapid diagnostic test. 3 Capillary refill time: hold hand/foot higher than level of heart. Press soft pad of finger/toe until it turns pale, then release pressure and note time taken for colour to return. Give urgent attention to the child with a decreased level of consciousness • If not already done, assess and manage airway, breathing and circulation 127. • If no history of trauma, place child in recovery position: turn left side, place left hand under cheek with neck slightly extended and bend the right leg to stabilise position. • Ask about possible causes and manage symptoms: trauma or injury 132, ulsing or just had a convulsion 130, burns 133. • If known allergy with exposure to allergen, manage as anaphylaxis below. • If poisoning likely, refer to hospital urgently. • Check fingerprick glucose, temperature, pupils and skin: Glucose • If glucose < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose1 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose1 bolus. • If glucose ≥ 200mg/ dL, DKA likely. Assess fluids needs 129. ≤ 35.5° C • Clothe including head and cover with warmed blankets. Place near heater. • Give ceftriaxone 100mg/kg (up to 2g) IV/IM. Treat for likely infection: • Give ceftriaxone 100mg/kg (up to 2g) IV/IM. • If malaria is suspected/ confirmed2 : give artesunate 3mg/kg IM or artemether 3.2mg/kg IM. ≥ 38°C Purple/red rash that does not disappear with pressure. Meningococcal disease likely • Establish IV/IO. • If ≥ 2 of: 1) cold hands/ feet, 2) weak/fast pulse, 3) capillary refill time3 > 3 seconds, 4) decreased level of consciousness 5) decreased urine output: shock likely 129. • Give ceftriaxone 100mg/ kg (up to 2g) IV/IM. Both pupils dilated or pinpoint Poisoning likely • If pinpoint pupils, excessive drooling/ sweating, coughing up or choking on secretions, slow pulse, organo-phosphate poisoning likely: give atropine 0.05mg/ kg IV. If no response, double the dose every 3 minutes until improving. Tilt bed to raise head by 30 degrees. If injured, avoid bending spine: keep body straight with head and neck in midline. Sudden rash There may be swelling of face/tongue or wheezing. Anaphylaxis likely • Lie child flat and give 100% facemask oxygen at 5L/minute. • Give adrenaline (1mg/mL, 1:1000) 0.3mL IM into mid- outer thigh. If no better, repeat every 5 minutes. Give normal saline 20mL/kg IV bolus. Also give diphenhydramine 1mg/kg IM/IV (up to 50mg). Unequal or respond poorly to light Temperature Pupils Skin rash • Consider child abuse if any of: history inconsistent with examination, delay in presentation, skull fracture, old and new scars on body, unusual or patterned wounds, burns, wounds around ano- genital region, refer to hospital. • If child aggressive or violent: ensure safety, assess child with help of other staff, use security personnel if needed. Discuss with hospital doctor before sedating. • Refer urgently with advanced life support ambulance. While waiting for transport: - - Check pulse, respiratory rate, oxygen saturation (if available) and capillary refill time3 every 15 minutes. - - If pulse/respiratory rate abnormal, oxygen saturation drop ≤ 92%, or capillary refill time3 > 3 seconds, reassess airway, breathing and circulation 127. Assess the AVPU scale. The child with a decreased level of consciousness is not alert and does not responds voice, s/he only responds to pain or is unresponsive.
Child 132 The injured child Give urgent attention to the injured child with any of: • Decreased level of consciousness • Difficulty breathing: abnormal respiratory rate, grunting, nasal flaring or chest indrawing • Distended abdomen • Bleeding despite direct pressure • Pulsatile or growing swelling • Burns 133 • Weak/numb limb • Multiple injuries • Poor perfusion below injury: cold, pale, numb, no pulse • Weak/numb limb • Stab or gunshot wound • Severe mechanism: high speed collision, car accident, fall from height Also give urgent attention to the child with a head injury and any of: • Lethargy or decreased level of consciousness • History of loss of consciousness • Strange behaviour or memory loss since injury • Suspected skull fracture • Vomiting ≥ 2 episodes • Severe headache • Pupils unequal or respond poorly to light • Blurry/double vision • Blood or clear fluid leaking from ear/nose • Bruising around eyes or behind ears • Blood behind eardrum • Drug or alcohol intoxication Management: • Assess and manage airway, breathing, circulation 127. Establish IV access and assess and manage fluid needs 129. • If actively bleeding or enlarging/pulsating swelling, apply direct pressure while arranging urgent ambulance transfer to hospital. • If severe head injury, neck/spine tenderness, decreased level of consciousness or weak/numb limb, immobilise head with tape and sandbags/bags of IV fluid. Use spine board if moving child. • If pupils unequal/respond poorly to light, keep body straight, raise head by 30 degrees (do not bend spine) and keep head in midline. • Identify all injuries: undress child fully and assess front and back using log-roll to turn. Then cover and keep warm. • While awaiting transport, monitor every 15 minutes: pulse, respiratory rate, oxygen saturation (if available). If deteriorates, reassess and manage airway, breathing and circulation 127. • Refer urgently to hospital. Approach to the injured child not needing urgent attention Consider child abuse, if any of: clear history of abuse, history inconsistent with exam, delayed presentation, skull fracture, old and new scars, burns, unusual or patterned wounds, grasp marks on arms/chest/face, bruises on trunk, different colour bruises, wounds around anus/genital region. Wound • Apply direct pressure to stop bleeding. • If open wound, give tetanus toxoid 0.5mL IM if none in past 5 years. If unavailable, check for tetanus antitoxin (TAT) hypersensitivity1 : if no hypersensitivity, give single dose TAT 3000U SC. • Remove foreign material, loose/dead skin. Irrigate with normal saline or if dirty, dilute povidone iodine solution. • If sutures needed: suture and apply non-adherent dressing for 24 hours. Plan to remove sutures after 5 days (face), 4 days (neck), 10 days (leg) or 7 days (rest of body). • Avoid suturing if wound > 12 hours old (or > 24 hours on head/neck), infected, remaining foreign material or deep puncture, instead: - - Pack wound with saline-soaked gauze and - - Give cloxacillin2 25mg/kg QID PO plus metronidazole 7.5mg/kg (up to 400mg) TID PO for 7-10 days. - - Review in 2 days. If no infection, suture now if still needed, unless deep puncture (irrigate and dress every 2 days instead). • Advise to return if skin red, warm, painful: infection likely. • If unable to close wound easily, cosmetic concerns or child needs sedation to suture, refer to hospital. Head injury • Advise caretaker to observe child carefully for 24 hours and limit activity for at least 48 hours. • Advise to return immediately if any of: blurred vision, vomiting, headache despite paracetamol, difficult to wake, balance problem. Painful limb • Give single dose paracetamol 15mg/kg (up to 1g) PO. • Apply firm, supportive bandage, refer to hospital. 1 Inject 0.1mL TAT SC and 0.1mL normal saline at separate site as control: if wheal with redness develops around TAT site, child has TAT hypersensitivity. Refer to hospital. 2 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give instead erythromycin 12.5mg/kg (up to 500mg) QID PO for 7-10 days.
Child 133 Burns Calculate percentage total body surface area (%TBSA) burnt using below figure. Approach to the child with burn/s not needing urgent attention: • Cool burnt area < 3 hours old with cold tap water for 30 minutes. Give paracetamol 15mg/kg (up to 1g) QID PO as needed for up to 5 days. • Clean with water or normal saline, apply thin film of silver sulfadiazine 1% or fusidic acid 2% cream and cover with vaseline gauze dressing. • Give tetanus toxoid 0.5mL IM if none in past 5 years. If unavailable, check for tetanus antitoxin (TAT) hypersensitivity3 : if no hypersensitivity, give single dose TAT 3000U SC. • If cigarette burn, glove and stocking type burn or history given inconsistent with burn, consider child abuse, refer to hospital. • Review daily the child with burn/s not needing urgent attention: - - Dress wound daily with vaseline® gauze dressing. If pain/anxiety with dressing changes, give paracetamol 15mg/kg (up to 1g) PO 1 hour before changing dressing. - - Refer if infection likely (skin red, warm, painful), rash develops, pain despite medication or burn not healing. Decide on maintenance fluid2 rate Weight 24 hour fluid need 10-20kg 1000mL + (50mL for every kg body weight over 10kg) e.g.: if 14kg: 1000mL + (50 x 4) = 1200mL/24 hours ≥ 20kg 1500mL + (20mL for every kg body weight over 20kg) Up to 2000mL in girls and 2500mL in boys e.g.: if 23kg: 1500mL + (20 x 3) = 1560mL/24 hours Give urgent attention to the child with burn/s and any of: • Electric/chemical burn • Full-thickness burn (white/black, painless, leathery, dry) • Partial thickness burn (pink/red, blisters, painful, wet) > 10% TBSA • Likely inhalation burn (burns to face/neck, hoarse, stridor or black sputum) • Circumferential burn of chest/limbs • Temperature ≥38°C • Sudden skin swelling with redness, pain or warmth • Burn of face, hand, foot, genitals, joint • ≥ 2 of: 1) cold hands/ feet, 2) weak/fast pulse, 3) capillary refill time1 > 3 seconds, 4) decreased level of consciousness: shock likely Management: • Remove burnt/hot and tight clothing. Cool burn with water or wet towel for 30 minutes unless ≥ 20% TBSA burn. Avoid hypothermia. • If burn > 10% TBSA, inhalational burn, oxygen saturation ≤ 92%, drowsy/confused, give face mask oxygen 5L/minute. • Give IV fluid: - - If shock likely, assess and manage child's fluid needs 129. If TBSA ≥ 20%, give normal saline 20mL/kg IV bolus. - - If > 10% TBSA: give normal saline IV 4mL x weight(kg) x %TBSA over first 24 hours. Give half this volume in first 8 hours from time of burn. If delay in transfer > 8 hours from time of burn: give the second half of the fluid volume over the next 16 hours. - - In addition, begin maintenance fluids2 according to table below. • Give paracetamol 20mg/kg (up to 1g) and then 15mg/kg 4 hourly PO. If severe pain, give morphine sulphate 0.4mg/kg PO 4 hourly as needed. Monitor breathing, if respiratory rate decreases or oxygen saturation < 92%, give face mask oxygen 5L/minute. • Clean burn with water or normal saline, remove loose/dead skin and apply thin film of silver sulfadiazine 1% or fusidic acid 2% cream. - - If hospital transfer within 12 hours, no need to apply dressing. Wrap child in clean dry sheets and keep warm. - - If delayed > 12 hours, apply vaseline® gauze and cover with dry gauze. - - If full thickness/>10%TBSA burn, cover with vaseline® gauze occlusive dressing and cover with plastic wrap (cling film). • Give tetanus toxoid 0.5mL IM if none in past 5 years. If unavailable, check for tetanus antitoxin (TAT) hypersensitivity3 : if no hypersensitivity, give single dose TAT 3000U SC. • Reassess airway, breathing and circulation hourly 127. • If other injuries, manage 132. • Check fingerprick glucose: if < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose4 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose4 bolus. • Refer urgently. How to calculate %TBSA of burn Front Back 4.5% 4.5% 7% 8% 8% 18% 4.5% 4.5% 7% 8% 8% 18% Child's open hand (area of palm) represents is 1% TBSA. Do not include simple erythema (redness) in calculation. 1 Capillary refill time: hold hand/foot higher than level of heart. Press soft pad of finger/toe until it turns pale, then release pressure and note time taken for colour to return. 2 To make 1000mL: mix 500mL 5% DW + 500mL DNS + 5 vials of 40% glucose (or mix 500mL 5% DW + 500mL NS + 9 vials of 40% glucose). 3 Inject 0.1mL TAT SC and 0.1mL normal saline at separate site as control: if wheal with redness develops around TAT site, child has TAT hypersensitivity. Refer to hospital. 4 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline).
Child 134 Fever Approach to the child with fever (temperature ≥ 38°C now or in the past 3 days) not needing urgent attention • If lumps/swellings in neck, axilla or groin 136, ear pain 138, sore throat 139, cough 140], abdominal pain/swelling 143, diarrhoea 144, urinary symptoms 145, limping/difficulty moving limb 146. • Give paracetamol 15mg/kg QID PO as needed for up to 5 days. Do a peripheral blood film examination or a malaria rapid diagnostic test Plasmodium vivax Give chloroquine: 16.6mg/kg (up to 1g) PO initially, then 8.3mg/kg (up to 500mg) at 6, 24 and 48 hours (total of 4 doses) and primaquine 0.25mg/kg daily PO for 14 days. • Give artemether/lumefantrine 20/120mg BID PO for 3 days according to weight: - - 15-24kg: 2 tablets; - - 25-34kg: 3 tablets; - - ≥ 35kg: 4 tablets - - Also give single dose primaquine 0.25mg/kg PO. Advise patient to return if no better. Plasmodium falciparum Both Plasmodium falciparum and Plasmodium vivax • Report. Delouse, shave hair and change clothes. • First insert IV line, then give procaine penicillin5 200 000-400 000IU IM. Monitor for reaction every 15 minutes for next 2 hours, then every 30 minutes for next 4 hours: if drop in BP, increased pulse rate, collapse, give 20mL/kg normal saline bolus. • Repeat peripheral blood film after 12 hours: - - If negative: give tetracycline 250mg TID PO for 3 days or erythromycin 10mg/kg TID PO for 3 days. - - If positive: repeat procaine penicillin5 and monitoring as above, every 12 hours until blood film negative. • Advise family members to wash well, reduce crowding and wash clothes. • If no overnight facilities, refer to hospital. • If none of above, advise cold compresses and review after 2 days. • If cause uncertain, refer. Positive for malaria Manage according to type of parasite/s seen: Positive for Borrelia (relapsing fever) If intermittent fever with any of: headache, lives in overcrowded setting, poor personal hygiene or body lice, typhus fever likely: • Give doxycycline for 7-10 days according to weight: - - < 45Kg: 2.2mg/kg (up to 200mg) BID PO - - ≥ 45kg: 100mg BID PO • Or give chloramphenicol 25mg/kg QID PO for 7 days. If persistent fever with any of: diarrhoea followed by constipation or poor food hygiene, typhoid fever likely: give ciprofloxacin 25mg/kg BID PO for 10-14 days or amoxicillin 10mg/ kg TID PO for 14 days. If fever ≥ 2 weeks, exclude TB and test for HIV. Negative for malaria & Borrelia6 Ask about pattern of fever, personal hygiene, headache, diarrhoea/constipation and look for lice on body: Give urgent attention to the child with a fever (temperature ≥ 38°C now or in the past 3 days) and any of: • Just had convulsion 130 • Decreased level of consciousness • Headache • Neck stiffness • Purple/red rash that does not disappear with pressure • Increased respiratory rate and/or difficulty breathing 140 • Tenderness right lower abdomen, appendicitis likely • Jaundice • Little or no urine 145 • Features of rheumatic fever1 • Previous rheumatic fever or known with rheumatic heart disease Manage and refer urgently: • If decreased level of consciousness, assess and manage airway, breathing and circulation 127. • Assess and manage child’s fluid needs 129. • Check fingerprick glucose: if glucose if < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose2 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose2 bolus. • If headache, decreased level of consciousness, neck stiffness, and/or purple/red rash, meningitis likely, give ceftriaxone 100mg/kg (up to 2g) IV/IM. • If appendicitis likely, give ceftriaxone 100mg/kg (up to 2g) IV/IM. • If malaria is suspected/confirmed3 : give artesunate 3mg/kg IM or artemether 3.2mg/kg IM. • If rheumatic fever likely, give benzathine benzylpenicillin4 IM according to weight: < 20kg, 600 000 units and if ≥ 20kg, 1.2 million units and report as a reportable disease. • Give paracetamol 15mg/kg (up to 1g) PO. 1 ≥ 2 of: joint pain/swelling that moves from joint to joint, strange movements of limbs/face, lumps over joints/tendons, rash (round pink lesions with pale centre. 2 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline). 3 Do a peripheral blood film examination or a malaria rapid diagnostic test. 4 If penicillin allergy, refer to hospital for doctor decision. 5 If penicillin allergy (anaphylaxis, urticaria, angioedema), give instead single dose tetracycline 250mg PO or single dose erythromycin 10mg/ kg PO. 6 Widal and Weil felix tests not recommended, as not specific and do not show new infection.
Child 135 Headache Give urgent attention to the child with headache and any of: • Sudden severe headache • Headache/vomiting on awakening or waking from sleep • Headache getting worse and more frequent • Temperature ≥ 38°C • Decreased level of consciousness • Neck stiffness/meningism • Head tilted to one side (torticollis) • Pupils different size • Weakness of arm or leg • Vision problems (e.g. double vision) • Head trauma in last week 132 • Abnormally large head • Elevated BP1 Manage and refer urgently: • If neck stiffness/meningism or decreased level of consciousness, meningitis likely: give ceftriaxone 100mg/kg (up to 2g) IV/IM. • If malaria is suspected/confirmed1 : give artesunate 3mg/kg IM or artemether 3.2mg/kg IM. • If temperature ≥ 38°C 134. • Give paracetamol 15mg/kg (up to 1g) PO. Approach to child with headache not needing urgent attention Is headache throbbing, disabling and recurrent with nausea/vomiting or light/noise sensitivity, that resolves completely within 72 hours? Migraine likely • Give immediately and then as needed: paracetamol 15mg/kg (up to 1g) QID PO or if ≥ 20kg and able to swallow tablet, ibuprofen2 200mg TID PO with meals. Advise to return if no better after 24 hours and refer to hospital. • Advise child/caretaker with migraine: - - Recognise migraine early and rest in dark, quiet room. - - Draw up a headache calendar to identify and avoid triggers like lack of sleep, stress, prolonged screen time, hunger and some food or drink. - - Migraine may occur at start of menstrual period. Reassure. - - Give letter with advice on care if migraine occurs at school. • If ≥ 2 attacks/month or no response to treatment, refer to hospital. Sinusitis likely • Give paracetamol 15mg/kg (up to 1g) QID PO as needed for up to 5 days. • Give normal saline drops into nostrils as needed. • If no better, give oxymetazoline 0.025% 2 drops TID into each nostril for up to 5 days. • If symptoms > 10 days: give amoxicillin3 50mg/kg (up to 1g) BID PO for 10 days. • If > 1 episode, test for HIV. • If poor response to antibiotic or > 4 episodes per year, refer to hospital. • If swelling around sinus/eye or tooth infection, refer same day to hospital. Consider tension headache and muscular neck pain Tightness around head or generalised pressure-like pain Tension headache likely • Give paracetamol 15mg/kg (up to 1g) QID PO as needed for up to 5 days. • Do vision test, if problem, refer to hospital. Constant aching neck pain, tender neck muscles Muscular neck pain likely • Give paracetamol 15mg/kg (up to 1g) QID PO as needed for up to 5 days. • Advise sleeping on different pillow, avoid prolonged screen time (TV, cellphones and computers) and correct posture. Yes Yes No No Pain over cheeks, thick nasal (or postnasal) discharge, recent common cold, headache worse on bending forward? If unsure or poor response to treatment refer to hospital. 1 Do a peripheral blood film examination or a malaria rapid diagnostic test. 2 Avoid if asthma, heart failure or kidney disease. 3 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give instead erythromycin 12.5mg/kg (up to 500mg) QID PO for 5 days.
Child 136 Lumps/swellings in neck, axilla or groin Give urgent attention to the child with lumps/swellings in groin: • Severe abdominal pain, vomiting or not passing stool, incarcerated/strangulated inguinal hernia likely Refer urgently. Approach to the child with lumps/swellings in neck, axilla or groin not needing urgent attention: • First exclude thyroid mass and hernia: - - Lump in neck that moves on swallowing, thyroid mass likely: refer to hospital. - - Lump in groin that bulges on crying/coughing/passing stool, inguinal hernia likely: refer to hospital. • If none of the above, a lump/swelling 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)? Localised lymphadenopathy: is lymph node hot, red and painful? Generalised lymphadenopathy • Look for likely cause: check face, skin, gums/teeth and throat. If sore throat 139. • If lymph node in groin and if sexually active, treat child and partner for lymphogranuloma venereum 36. If child abuse suspected, refer to hospital. Bacterial lymphadenitis likely • If painful neck lymphadenopathy with sore throat, tonsillitis likely 139. • Give amoxicillin 30mg/kg (up to 500mg) TID PO for 5 days. If penicillin allergy (previous anaphylaxis, urticaria or angioedema), give instead erythromycin 12.5mg/kg (up to 500mg) QID PO for 5 days. • If poor response to treatment after 2 days, change amoxicillin to cephalexin 12-25mg/kg (up to 500mg) QID for 7 days. • Review in 2 weeks: if no better, refer to hospital. Generalised lymphadenopathy If local cause found: • Treat the cause. • Advise to return in 4 weeks if no better on treatment and refer to hospital. • If lymph node > 1cm persists for > 2 weeks, refer to hospital. • Advise to return if new symptoms or lymph nodes grow. Refer to hospital. If no cause found: • If close TB contact or TB symptoms (cough or fever ≥ 2 weeks, not growing well/losing weight, tired/less playful), exclude TB. • If status unknown, test for HIV. If HIV positive, manage according to national HIV programme guidelines. • If none of the above: Localised lymphadenopathy Any of: weight loss, fever, night sweats, lymph node growing quickly, weakness, pallor1 ? Yes Yes No No 1 If child’s palm significantly less pink than your own.
Child 137 Pallor Give urgent attention to the child with a low Hb and/or pallor and any of: • Hb < 7g/dL • Jaundice • Swollen legs • Widespread/easy bruising • Increased respiratory rate • Increased pulse rate • Palpitations or chest pain • Bone or joint pain • Lethargy or decreased level of consciousness • Purple/red rash that does not disappear with pressure Manage and refer urgently: • If increased respiratory rate, give oxygen 2L/minute via nasal prongs. • Check for malaria2 : if malaria test positive, give artesunate 3mg/kg IM or artemether 3.2mg/kg IM. This refers to the child with pale palms1 and/or conjunctiva. If possible, check Hb: if Hb < 11g/dL, child has anaemia. Approach to the child with pallor not needing urgent attention Are laboratory services available to take blood for complete blood count (CBC)? 1 If child’s palm significantly less pink than your own. 2 Test for malaria with parasite slide microscopy or if unavailable, rapid diagnostic test. 3 MCV: Mean Corpuscular Volume. The MCV helps to decide the underlying cause of anaemia and can be found on FBC result sheet. Check if MCV high, low or normal compared to the reference range for age of child. No Yes Take blood for complete blood count (CBC) and manage further according to MCV3 result: Iron deficiency anaemia likely • Deworm: give single dose albendazole 400mg PO every 6 months. • Give ferrous gluconate or ferrous lactate or ferrous sulphate according to weight TID PO with food. Check Hb monthly. Continue treatment until Hb ≥ 11g/dL: Weight (kg) Ferrous gluconate elixir (30mg iron per 5mL) Ferrous lactate drops (25mg iron per 1mL) Ferrous sulphate tablets (60mg iron per tablet) 10-25kg 5mL TID PO 0.9mL TID PO - ≥ 25kg - - 1 tablet TID PO • If girl who has started menstruation, ask about heavy bleeding and/clots. If problem 42. • If no response to treatment after 2 months, refer to hospital. MCV3 low MCV3 normal Systemic disease or long-term health condition likely • Exclude TB and HIV. • If no cause found, refer to hospital. MCV3 high Folate and/or vitamin B12 deficiency likely Start treatment and refer to hospital: give folic acid 5mg daily PO and vitamin B12 500mcg IM monthly.
Child 138 Ear symptoms/difficulty hearing Itchy ear Is ear itchy, painful, discharging or is there difficulty hearing? Discharge from ear3 Discharge ≥ 2 weeks or hole in eardrum © University of Cape Town Chronic suppurative otitis media likely • Clean ear1 . • Apply hydrogen peroxide solution 3% 5-10 drops BID topically to affected ear for 5 days. • Give amoxicillin2 50mg/kg (up to 1g) TID PO for 7-10 days. • If poor response to treatment, test for HIV and TB. • Refer to hospital if: - - No better after 4 weeks - - Large hole in drum - - Difficulty hearing • Refer to hospital same day if: - - Neck stiffness - - New pain in or behind ear - - Yellow/white deposit on eardrum, cholesteatoma likely Foreign body Wax Discharge for ≤ 2 weeks • Ear canal not red/swollen. • Able to view eardrum? Painful ear No Pain > 2 days or pain waking at night? Yes Yes Yes No • Give paracetamol 15mg/kg QID PO for 5 days as needed. • Review in 2 days if no better. No Has temperature been ≥ 38°C in last > 2 days? • Syringe ear4 with warm water. • Avoid syringing and refer to hospital if: - - Hole in eardrum - - Grommets - - Battery/ food in ear. - - Recent trauma to head or ear - - Neck stiffness Syringe ears4 with warm water unless child has grommets/ uncooperative/ has chronic suppurative otitis media. Fluid behind eardrum Otitis media with effusion likely • Keep ear dry. • Advise that this usually resolves on its own. • If communication problem, refer to hospital for hearing test. • If concerns about hearing remain after 3 months or if child clumsy/poor balance, refer to hospital. Red bulging eardrum © University of Cape Town Acute otitis media likely • Give paracetamol 15mg/kg (up to 1g) QID PO for 5 days as needed. • Give amoxicillin2 50mg/kg (up to 1g) TID PO for 7-10 days. • Clean ear1 if discharge and avoid getting ear wet. • If > 1 episode, test for HIV. • Refer to hospital same day if: - - No response to treatment or > 5 episodes per year. • Refer same day if: - - Painful swelling behind ear, mastoiditis likely - - Neck stiffness • If treated above but communication problem present, refer to hospital for hearing test. Ear canal red/swollen (pus may be present) © University of Cape Town Otitis externa likely • Clean ear1 . • Apply hydrogen peroxide solution 1.5% 5-10 drops BID topically to affected ear for 5 days. • Give paracetamol 15mg/kg (up to 1g) QID PO for 5 days as needed. • If severe pain, firm red swelling behind ear or temperature ≥ 38°C, give amoxicillin2 50mg/kg (up to 1g) TID PO for 7-10 days. • If blisters on ear, herpes zoster likely, refer to hospital. Difficulty hearing • If on drug resistant TB medication, discuss with TB health worker. • If itchy or painful ear or discharge from the ear, see left algorithm/s. • Look in ear for foreign body, wax or fluid behind eardrum. If normal looking ear, refer to hospital for hearing test. 1 Cleaning the ear (dry mopping): roll a piece of clean soft tissue into a wick. Insert wick into ear with twisting action. Remove 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. 2 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give instead erythromycin 12.5mg/kg QID PO for 7-10 days. 3 If child has grommets (small tubes in eardrum) and purulent discharge persists > 2 weeks, refer to hospital. 4 How to syringe an ear: fill a 50-200mL syringe with warm water. Ask child/caretaker to hold container under ear to catch water. Pull ear upwards and backwards to straighten ear canal. Place tip of syringe at opening (no further than 8mm into canal) and spray water upwards into canal. Check after syringing to see if wax cleared. • Stop and refer to hospital if unsuccessful after 3 attempts/ causes pain or if foreign body remains in ear. • If no better, refer to hospital for hearing test.
Child 139 Mouth and throat symptoms Give urgent attention to the child with mouth and throat symptoms with any of: • Unable to open mouth or swallow at all • Red swelling blocking airway Refer urgently. Assess the child with mouth and throat symptoms not needing urgent attention Examine mouth and throat for a red throat, white patches, blisters or ulcers. Red throat Pus or white patches on tonsils? White patches on cheeks, gums, tongue, palate, or cracks in corners of mouth. Oral thrush/candida likely • Give nystatin suspension 1mL QID PO after meals for 7 days. Keep inside mouth for as long as possible. • Give paracetamol 15mg/kg (up to 1g) QID PO as needed for up to 5 days. • If status unknown, test for HIV. If HIV positive, manage according to national HIV programme guidelines. If difficulty/painful swallowing or refusing to eat, oesophageal candida likely. Refer to hospital. Any of runny nose, cough, hoarseness, conjunctivitis or diarrhoea? Herpes simplex likely • Apply vaseline® to blisters on outside of mouth to prevent spread. • Give paracetamol 15mg/kg (up to 1g) QID PO as needed for up to 5 days. • If HIV or extensive herpes (and < 72 hours from onset), give aciclovir 20mg/kg (up to 800mg) QID PO for 7 days. • If extensive/recurrent or no better after 2 weeks, refer to hospital. • If status unknown, test for HIV. If HIV positive, manage according to national HIV programme guidelines. Groups of painful blisters on lips/mouth Painful ulcer/s with central white patch Aphthous ulcer/s likely • Give paracetamol 15mg/ kg (up to 1g) QID PO as needed for up to 5 days. • Rinse with salt water1 for 1 minute BID. • If recurrent, consider HIV. • If large (> 1cm) or not healed within 3 weeks, refer to hospital. Bacterial tonsillopharyngitis likely • Give paracetamol 15mg/kg (up to 1g) QID PO as needed for up to 5 days. • Give single dose benzathine benzylpenicillin2,3 < 30kg, give 600 000 units IM or ≥ 30kg, give 1.2 million units IM or phenoxymethylpenicillin2 250mg BID PO for 10 days. • If mild, fine red rash after antibiotic, glandular fever likely. - - Stop antibiotic. Reassure will resolve spontaneously. - - Child may return to school when better but can only resume sporting activities > 3 weeks from onset of illness. • If ≥ 5 episodes per year or persistent snoring, refer to hospital. Give bland, soft foods and advise to keep mouth and teeth clean by brushing and rinsing regularly. Viral tonsillo- pharyngitis likely • Give paracetamol 15mg/kg (up to 1g) QID PO as needed up to 5 days. • Salt water gargle1 may help. • Explain that antibiotics are not necessary. Yes Yes 1 Mix ½ teaspoon of salt in ½ cup of lukewarm water. 2 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give instead erythromycin 12.5mg/kg (up to 500mg) QID PO for 5 days. 3 For benzathine benzylpenicillin 1.2 million units injection: dissolve benzathine benzylpenicillin 1.2 million units in 3.2mL lidocaine 1% without adrenaline. No No Advise to return to immediately if any of the following develop: painful or swollen joint/s, strange movements of limbs or face, lumps over joints/tendons or rash (round lesions with pale centre) to exclude rheumatic fever 134.
Child 140 Cough and/or breathing problems The child with breathing problems may have noisy breathing, wheeze, grunting, snoring or stridor (noisy, high-pitched breathing). If child not breathing 127. Give urgent attention to the child with cough and/or breathing problems and any of: • Lower chest indrawing • Nasal flaring • Grunting • Blue lips/tongue • Oxygen saturation ≤ 92% • Stridor (noisy, high-pitched breathing) • Decreased level of consciousness/ lethargy • Recent episode of choking • Restless or irritable • Known heart problem Manage and refer urgently: • If wheeze 141. • Give oxygen 2L/minute via nasal prongs or 5L/minute via face mask. • Check finger prick glucose: - - If < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose1 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose1 bolus. - - If ≥ 200mg/dL, diabetic ketoacidosis likely. Assess fluids needs 129 and refer urgently. • Give ceftriaxone 80mg/kg (up to 1.5g) IV/IM. • If stridor (with no recent episode of choking), encourage caretaker to keep child calm. - - Give dexamethasone 0.6mg/kg IM or prednisolone 2mg/kg (up to 60mg) PO and - - Nebulise 1mL adrenaline (1:1000) in 5mL normal saline with oxygen 8L/minute, every 15 minutes until stridor disappears. Monitor closely for at least 3 hours. • If sudden difficulty breathing and generalised itchy rash or face/tongue swelling, anaphylaxis likely: give adrenaline (1mg/mL, 1:1000) 0.3mL IM into mid-outer thigh. If no better, repeat every 5 minutes. Give normal saline 20mL/kg IV bolus. Also give diphenhydramine 1mg/kg IM/IV (up to 50mg). • Refer urgently. 1 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline). 2 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give instead erythromycin 12.5mg/kg (up to 500mg) QID PO for 5 days. 3 Episodes where breathing stops > 10 seconds. 1 episode of cough (or breathing problems) < 2 weeks Is respiratory rate increased (≥ 25 breaths/minutes if 5-12 years old or ≥ 20 breaths/minute if ≥ 12 years old)? Yes Pneumonia likely • Give amoxicillin2 30mg/kg (up to 1g) TID PO for 7 days. • Give paracetamol 15mg/kg (up to 1g) QID PO as needed for 5 days. • Advise to return if condition worsens. • Review after 2 days: if respiratory rate still increased, refer to hospital. No • Exclude TB. • If recent common cold: - - If wet cough ≥ 4 weeks, chronic bronchitis likely, refer to hospital. - - If dry cough, post-infectious cough likely: should resolve by 8 weeks. • If persistent snoring with poor sleep/apnoea3 , refer to hospital. Runny/blocked nose Common cold likely • Check ears 138, throat 139. • Reassure caretaker antibiotics not needed. • Advise to drink warm liquids to relieve symptoms. Barking cough, may be hoarse Viral croup likely • Give single dose dexamethasone 0.6mg/kg PO or prednisolone 2mg/kg (up to 40mg) PO. • Advise to return immediately if worse or stridor develops. Repeated episodes or cough (or breathing problems) ≥ 2 weeks If none of above and repeated episodes of wheeze 142. If cause uncertain or not growing well, chest deformity, cough > 8 weeks cough worse despite treatment, refer to hospital. Approach to the child with cough and/or breathing problems not needing urgent attention: • Approach to the child with cough and/or breathing problems not needing urgent attention: • Reduce indoor pollution (rural setting) and avoid smoking (urban setting). • If wheeze 141. If breathless on exertion, refer same day. • If coughing attacks with “whoop”on breathing in, pertussis likely: give erythromycin 12.5mg/kg (up to 500mg) QID PO for 10 days, report as reportable disease and isolate for 2 days. • Ask about duration and number of episodes:
Child 141 Wheeze Give urgent attention to the child with wheeze and any of: • Oxygen saturation < 90% • Marked accessory muscle use1 • Significantly reduced breath sounds • Unable to talk or only able to talk in single words • Agitation or confusion Manage as severe asthma: • Sit child up and give oxygen via face mask and reservoir bag or nasal prongs and • Give salbutamol via spacer 1200mcg (12 puffs) every 20 minutes and • Give prednisolone 2mg/kg (up to 60mg) PO. If unable to take orally, give hydrocortisone 4-5mg/kg (up to 250mg) slow IV or dexamethasone 0.6mg/kg (up to 20mg) IM. • If child presents with absent air entry or no response after 3 doses of salbutamol, give adrenaline (1:1000) 0.01mL/kg (up to 0.4mL) IM/SC every 15-20 minutes. If pulse rate ≥ 180 beats/minute, avoid repeating adrenaline. • Refer urgently to hospital while continuing to give salbutamol puffs. 1 Accessory muscle use is any of: subcostal recession, intercostal recession, tracheal tug, use of neck muscles. 2 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give erythromycin 12.5mg/kg (up to 500mg) QID PO for 5 days. Approach to the child with wheeze not needing urgent attention Manage according to severity of symptoms: • Oxygen saturation 91-94% • Moderate accessory muscle use1 • Wheeze with reduced breath sounds • Able to talk only in phrases Mild asthma likely • Give salbutamol via spacer 1200mcg (12 puffs) every 20 minutes. • Assess response after 20 minutes, repeat for 3 doses if needed: Good response Wheeze improved, no accessory muscle use1 , oxygen saturation ≥ 94% and able to drink and talk Poor response after 1 hour (3 doses), reclassify. Poor response after 1 hour • Refer to hospital while continuing oxygen and salbutamol via spacer 1200mcg (12 puffs) every 20 minutes. • If child’s condition deteriorates despite treatment, consider adrenaline (1:1000) 0.01mL/kg (up to 0.4mL) IM/SC every 15-20 minutes. If pulse rate ≥ 180 beats/minute, avoid repeating adrenaline. • Discharge on salbutamol 2-6 puffs inhaled every 4-6 hours as needed. • If known asthma, also give prednisolone 1mg/kg (up to total daily dose 40mg) BID PO for 4 days. • If respiratory rate ≥ 25, also give amoxicillin2 30mg/kg TID PO for 5 days. • If not known with asthma and wheeze recurrent 142. Moderate asthma likely • Give oxygen via face mask and reservoir bag or nasal prongs and • Give salbutamol via spacer 1200mcg (12 puffs) every 20 minutes and • Give single dose prednisolone 2mg/kg (up to 60mg) PO. If unable to take orally, give single dose hydrocortisone 4-5mg/kg (up to 250mg) slow IV or dexamethasone 0.6mg/kg (up to 20mg) IM. ≥ 1 of above None of the above
Child 142 Recurrent wheeze or cough 1 Acute exacerbations infrequent and not severe (child not hospitalised) and in past 4 weeks: daytime cough, wheeze or difficulty breathing < twice a week; able to run/play without easily tiring due to asthma; salbutamol needed < twice a week; little or no night waking /coughing due to asthma. 2 Wheeze improves 15 minutes after salbutamol via spacer 600mcg (6 puffs). If no better, child is not bronchodilator responsive. Do symptoms persist for > 10 days after a common cold or are there symptoms between colds? Symptoms remain the same. Symptoms improve with trial of treatment and worsen when treatment is stopped. Refer to hospital. Asthma likely • Continue beclomethasone 200mcg BID inhaled and • Give salbutamol via spacer 100-200mcg (1-2 puffs) QID inhaled as needed. • If symptoms controlled1 reduce beclomethasone to 100mcg BID inhaled. Recurrent virus-induced wheeze likely • If wheeze is bronchodilator responsive2 give salbutamol via spacer 100-200mcg (1-2 puffs) QID inhaled when needed for 5 days. • Check ears 138, throat 139. Refer to hospital. Does child have recurrent wheeze? Yes Yes Yes ≥ 1 of above No No No Approach to the child with recurrent wheeze or cough First exclude TB. While excluding TB, ask about the following: • History of eczema/allergic rhinitis • Parents with history of eczema/allergic rhinitis/asthma • > 3 episodes wheeze per year • Wheeze episode needing hospital admission • Symptoms worse at night and in early morning • Symptoms triggered by: smoking, pets, pollen, perfume, paint, hairspray, cleaning agents, change in weather or season, exercise, emotion, laughter or stress None of above: are symptoms triggered by common colds? Give a trial of treatment for 2 months: • Give inhaled corticosteroid: beclomethasone 200mcg BID inhaled and • Give salbutamol via spacer 100-200mcg (1-2 puffs) QID inhaled as needed. • Demonstrate inhaler technique as below and encourage child/caretaker to identify and avoid triggers. • Assess response to treatment after 2 months: How to use an inhaler with a spacer • Prime spacer initially with 10 puffs of medication. When medication is finished, replace only the canister. Clean spacer monthly: remove canister and wash spacer with soapy water. Do not rinse with water. Allow to drip dry (no need to re-prime). • Demonstrate inhaler technique 2-3 times until child and/or caretaker understand. Then ask child and/or caretaker to show you how to use it. 1 • Remove cap from inhaler and spacer. • Shake inhaler for 5 seconds and insert into spacer. 2 Put spacer into mouth and close lips around it and form seal with lips around mouthpiece. If needed, make a spacer from a plastic bottle 81. 3 Press pump down once and allow 6 deep breaths before continuing. 4 Remove inhaler and spacer and wait for 30 seconds before repeat. Repeat for each puff prescribed. 5 Rinse mouth after using inhaled corticosteroids (beclomethasone).
Child 143 Abdominal symptoms Give urgent attention to the child with an abdominal symptom: • Guarding, rebound tenderness or rigidity of abdomen1 , peritonitis likely • Tender in right lower abdomen and vomiting, appendicitis likely • Cramping pain and jelly-like stool • No stool/wind for 24 hours and vomiting • Bile-stained vomiting • Tender, elevated testes • Painful groin/umbilical swelling • Rash and joint pain • Vomiting, deep sighing respiration, fatigue, acidosis likely Manage and refer urgently: • Check fingerprick glucose: - - If ≥ 200mg/dL, diabetic ketoacidosis likely. Assess fluids needs 129 and refer urgently. - - If < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose2 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose2 bolus. • Assess and manage child’s fluid needs 129. • Keep nil per os. Give maintenance fluid3 IV according to table. • If peritonitis or appendicitis likely, give ceftriaxone 80mg/kg (up to 1.5g) IV/IM. Approach to the child with abdominal symptom not needing urgent attention • If recent injury/trauma 132. If temperature ≥ 38°C or history of fever 134. Check throat: if white patches on throat 139. Check urine: if burning urine or nitrites/leucocytes/blood on dipstick 145. • If close TB contact or TB symptoms (cough or fever ≥ 2 weeks, not growing well/losing weight, tired/less playful), exclude TB. • Is there abdominal swelling? Is swelling localised or generalised? • Advise a high fibre diet (vegetables, fruit, wholemeal cereals and bran). • If no better despite diet change, refer to hospital. • Ensure 6 monthly deworming in place. If worms, give single dose albendazole 400mg PO. • Check growth (weight, height, MUAC): if growth problem 150. If pallor4 137. • Is child constipated: stools infrequent and any of: pain, impaction, involuntary leakage or voluntary withholding? • If girl and pain around time of period, dysmenorrhoea likely: - - Give ibuprofen5 400mg TID PO for 3 days. - - Reassure that is common and encourage to carry on with everyday activities. • If girl and sexually active: - - If lower abdominal pain and/or vaginal discharge, pelvic infection likely 36. - - If lower abdominal pain with amenorrhoea or vaginal bleeding 6-8 weeks after last period, ectopic pregnancy likely, refer to hospital. - - If child abuse suspected, refer to hospital. Yes Yes No No If cause unclear or not resolved, refer to hospital. Localised • If bulge on crying/ coughing/ passing stool in groin or umbilical area, hernia likely, refer to hospital. • If mass felt in abdomen, refer to hospital. Generalised • Exclude TB. • Do urine dipstick: - - ≥ 3+ protein, nephrotic syndrome likely, refer to hospital. • Assess growth (weight, height, MUAC): - - If growth problem 150. - - If growth normal, refer to hospital. 1 Guarding: abdominal muscles tense on palpation. Rebound tenderness: pain on quick release after pressing down slowly on abdomen. Rigidity: abdominal wall is hard/board-like. 2 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline). 3 To make 1000mL: mix 500mL 5% DW + 500mL DNS + 5 vials of 40% glucose (or mix 500mL 5% DW + 500mL NS + 9 vials of 40% glucose). 4 If child’s palm significantly less pink than your own. 5 Avoid if peptic ulcer, asthma or kidney disease. Decide on maintenance fluid3 rate Weight 24 hour fluid need 10-20kg 1000mL + (50mL for every kg body weight over 10kg) e.g.: if 14kg: 1000mL + (50 x 4) = 1200mL/24 hours ≥ 20kg 1500mL + (20mL for every kg body weight over 20kg) Up to 2000mL in girls and 2500mL in boys e.g.: if 23kg: 1500mL + (20 x 3) = 1560mL/24 hours
Child 144 Diarrhoea Approach to the child with diarrhoea not needing urgent attention • Confirm child has diarrhoea: ≥ 3 watery or loose stools/day. Ask about duration of diarrhoea. • Do stool microscopy for ova or parasite and inflammatory cells. • Advise child to take more fluids, eat small frequent meals when able and avoid sweet/caffeinated/fizzy drinks. • Give oral rehydration solution to prevent dehydration. Positive If diarrhoea for > 2 weeks, test for HIV. Diarrhoea for > 2 weeks Knowing child’s HIV status helps in the management. Test for HIV. • Check ears 138, check urine 145. Assess growth (weight, height, MUAC): if growth problem 150. • If close TB contact or TB symptoms (cough or fever ≥ 2 weeks, not growing well/losing weight, tired/ less playful), exclude TB. • Give single dose vitamin A 200 000IU PO. • Give zinc 20mg daily PO for 14 days. Review stool microscopy result. If diarrhoea persists despite treatment or cause is not clear, refer to hospital. Review in 2 weeks if diarrhoea still present. Negative Diarrhoea for ≤ 2 weeks HIV negative/ unknown Amoebic trophozoite and RBC/WBC seen RBC/WBC only seen Ova or parasite only seen Avoid antibiotics. Avoid antibiotics. • Give metronidazole 7.5mg/kg (up to 500mg) TID PO for 5-7 days. • If no response after 2 days, add ciprofloxacin 6-10mg/kg (up to 400mg) BID PO for 5 days. Give ciprofloxacin 6-10mg/kg (up to 400mg) BID PO for 5 days. • If amoebiasis, give metronidazole 7.5mg/kg (up to 500mg) TID PO for 5-7 days. • If giardiasis, give single dose tinidazole 50mg/kg (up to 2g) PO. • If strongyloidiasis, give albendazole 400mg BID PO for 3 days. • If other parasites, albendazole 400mg daily PO for 3 days. HIV positive • Give routine HIV care according to national HIV programme guidelines. • Lopinavir/ritonavir can cause ongoing diarrhoea. • If ART not started or ART failed, treat for possible Isospora belli and microsporidiosis with co-trimoxazole 20mg/kg BID PO for 21 days and albendazole 400mg BID PO for 14 days. First assess and manage child's fluid needs 129. Give urgent attention to the child with diarrhoea and any of: • Guarding, rebound tenderness or rigidity of abdomen1 , peritonitis likely • Unable to drink • Shock or severe dehydration • Distended abdomen • Swelling of legs/ wasting • Large volumes of rice colored watery stool: cholera likely Manage and refer urgently: • Check fingerprick glucose: if < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose2 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose2 bolus. • If temperature ≥ 38°C or likely peritonitis, give ceftriaxone 80mg/kg (up to 1.5g) IV/IM. • If cholera likely: - - Report disease and isolate child and follow standard infection prevention precautions122. Assess and manage child’s fluid needs 129 and give doxycycline 6mg/kg daily PO for 3 days. - - Discuss with the head of the facility and/or Woreda Health Office and review after 6 hours: • If no dehydration and < 3 liquid stools in past 6 hours, consider discharge. Give enough ORS for home treatment for 2 days. Advise to return if vomiting, diarrhoea worsens or drinking/eating poorly. • If still dehydrated or > 3 liquid stools in past 6 hours, continue rehydration. If poor urine output, refer to hospital. 1 Guarding: abdominal muscles tense on palpation. Rebound tenderness: pain on quick release after pressing down slowly on abdomen. Rigidity: abdominal wall is hard/board-like. 2 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline).
Child 145 Urinary symptoms The child with urinary symptoms may have pain on passing urine, urinating very often/large volumes, urgency, new incontinence, bed-wetting, bloody/brown urine, unable to pass urine or foul-smelling urine. Approach to the child with urinary symptoms not needing urgent attention • Check urine dipstick: look for blood, leucocytes and nitrites on dipstick. - - If glucose/ketones in urine, check finger prick glucose: if ≥ 200mg/dL, diabetic ketoacidosis likely. Assess fluids needs 129 and refer to hospital. - - Manage further according to results: Blood on dipstick, no leucocytes or nitrites Is there protein on urine dipstick? Leucocytes/nitrites on dipstick Urinary tract infection likely • Send urine for microscopy. • Give amoxicillin1 15mg/kg (up to 500mg) TID PO for 5 days. • Advise to wipe from front to back. • Encourage child to drink frequently. • Avoid irritant soaps and bubble baths. • If no response to treatment after 2 days, refer to hospital. • Recurrent urinary tract infections might indicate an abnormal urinary tract, if ≥ 2 urinary tract infections, refer to hospital for investigations once antibiotic complete. Refer to hospital. Schistosomiasis likely • Send urine for S. haematobium ova. • Give single dose praziquantel 40mg/kg (up to 3g) PO. • Advise to avoid contaminated water to prevent re-infection. • Review results in 3 days, repeat dipstick and refer if: - - Urine schistosomiasis test negative - - Blood not cleared - - Symptoms not resolved. • Advise to return if swelling of face or feet and refer to hospital. Has child been in a bilharzia area? Ask caretaker if aware of abuse of child. Ask child if anyone hurts or upsets him/her. If yes to either, child abuse likely, refer to hospital. No No Yes Yes No blood or leucocytes/nitrites Is bed-wetting a problem? No Yes Reassure and reassess in one week if not better. • If previously dry, ask about recent stressful events. Discuss possible solutions. If daytime incontinence, to finger prick glucose to exclude diabetes and refer. • Give advice: - - Reduce fluid intake during evening: avoid fluids 1 hour before bedtime. - - Teach child to wake with urination urge by initially waking him/her to urinate. - - Suggest a reward system like a star chart for a dry bed. - - Advise to avoid punishing child. - - Refer if above measures unhelpful. Give urgent attention to the child with urinary symptoms and any of: • Passing little amounts or unable to pass urine • Temperature ≥ 38°C/rigors/flank pain, pyelonephritis likely • Swelling of face/feet and either blood in urine or passing little amounts of urine, nephritis likely Management: • If nephritis likely and signs of fluid overload (increased pulse/respiratory rate or puffy eyes), give oxygen 2L/minute via nasal prongs and give furosemide 1mg/kg (up to 40mg) IV over 5 minutes (avoid IV fluids). Then check BP. If increased, give nifedipine 0.25mg/kg (up to 10mg) squirted into mouth. • If pyelonephritis likely, give ceftriaxone 80mg/kg (up to 1.5g) IV/IM. • Refer urgently. 1 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give erythromycin 12.5mg/kg QID PO for 7 days.
Child 146 Leg symptoms/limp/walking problems Approach to the child with leg symptom not needing urgent attention • If any of: weight loss, night sweats, weakness, fatigue, generalised rash or early morning joint stiffness lasting > 15 minutes, refer to hospital. • Identify leg problem: Problem walking Is child limping? Leg swelling Ask about duration of limp. • If swelling of 1 leg and no history of injury, refer. • If swelling of both legs, do urine dipstick: Abnormal leg shape Limp < 48hrs Limp ≥ 48hrs Sprain/strain likely • Ensure can bear weight on leg, otherwise refer to hospital. • Rest and elevate leg. • Apply pressure bandage. • If skin marks, bruises of different ages or poor growth, suspect neglect and refer to hospital. • Advise child to move leg after 2-3 days if not too painful. • Give paracetamol 15mg/kg (up to 1g) QID PO as needed up to 5 days. If pain not responding to paracetamol, give ibuprofen3 200mg TID PO with food for up to 5 days. • Review after 1 week (or sooner if symptoms worsen): if no better, refer to hospital. • If bow-legs, look for forehead prominence, bowing of arms, bony lumps along ribcage. If present, rickets likely: refer to hospital. • If shape otherwise not normal, refer to hospital. • If injury 132. • If well and leg pain only at night and active during day, growing pains likely, reassure pain will resolve. • If leg pain occurs in day and night, refer to hospital. < 3+ protein Assess growth (weight, height, MUAC). Is there a growth problem? No No Yes Refer to hospital. Heart failure likely. Refer to hospital. Yes Severe acute malnutrition likely. Manage and refer urgently 150. ≥ 3+ protein Nephrotic syndrome likely. Refer to hospital. Leg pain Give urgent attention to the child with leg symptoms with any of: • Sudden refusal to sit, stand or walk • Sudden onset weakness in leg/s • Leg pain and temperature ≥ 38°C • Limping and weight loss/lethargy • Unable to bear weight after leg injury • Any of: strange movements of limbs or face, lumps over joints/tendons or rash (round pink lesions with pale centre), rheumatic fever likely Management: • If rheumatic fever likely, give benzathine benzylpenicillin1,2 IM according to weight: < 30kg, 600 000 units and if 30kg, 1.2 million units. • Refer urgently. 1 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), refer. 2 For benzathine benzylpenicillin 1.2 million units injection: dissolve benzathine benzylpenicillin 1.2 million units in 3.2mL lidocaine 1% without adrenaline. 3 Avoid if peptic ulcer, asthma or kidney disease.
Child 147 Generalised rash Bumps become weeping blisters and crusts on face, scalp, trunk and limbs. © University of Cape Town Hyper-pigmented bumps, surrounding skin often hyper- pigmented (not on face) © University of Cape Town Chicken pox likely • Apply calamine lotion and give paracetamol 15mg/kg (up to 1g) QID PO for up to 5 days. If very itchy, give cetirizine, according to weight, until itch controlled (up to 2 weeks): 12-21kg: give 5mg daily PO, ≥ 21kg: give 10mg daily PO. • If rash extensive or child has HIV, give aciclovir 20mg/kg (up to 800mg) QID PO for 7 days. • If rash and surrounding skin red, painful and swollen with temperature ≥ 38°C, impetigo likely 148. • Refer to hospital if any of: - - Does not resolve by 10 days. - - Difficulty breathing - - Signs of meningitis (≥ 2 of: temperature ≥ 38°C, headache, decreased level of consciousness, neck stiffness) • If recurrent, test for HIV. • Highly contagious (spreads in air). - - Allow return to school once blisters crusted. - - Avoid contact with pregnant women. Papular pruritic eruption (PPE) likely • If HIV unknown, test for HIV. If HIV positive, manage according to national HIV programme guidelines. • Exclude scabies. • Apply hydrocortisone 1% cream in morning and moisturise with liquid paraffin at night until improvement. • Give cetirizine, according to weight, until itch controlled (up to 2 weeks): 12-21kg: give 5mg daily PO, ≥ 21kg: give 10mg daily PO. • Advise child/caretaker: - - Explain that PPE may be long- standing. - - May temporarily worsen on starting ART. - - Reduce exposure to insect bites. Scabies likely • Apply benzyl benzoate lotion 25% to whole body from neck to feet after hot bath and dry well. Wash off next day and repeat next night. Repeat treatment after 1 week. • Give cetirizine, according to weight, until itch controlled (up to 2 weeks): 12-21kg: give 5mg daily PO, ≥ 21kg: give 10mg daily PO. - - 12-21kg: 5mg, ≥ 21kg: 10mg • Treat all house members at same time. • Wash linen and clothes in hot water and expose bedding to direct sunlight. • Keep finger nails short and clean. • If blisters and yellow crusts appear, impetigo likely 148. If no response to treatment, refer to specialist for review. If patches of red, scaly, crusted skin in infant or dry scaly skin in older child, usually on flexor surfaces of elbows, knees and on scalp and neck, eczema likely. Urticaria likely • If recently started new medication, consider drug reaction. • Consider possible triggers1 . • Give cetirizine, according to weight, for itch (until 72 hours after resolution of wheals): 12-21kg: give 5mg daily PO, ≥ 21kg: 10mg daily PO. • If not better after 24 hours, refer to hospital within one month. • If repeated episodes, allergy likely. Refer to hospital. • Advise to return immediately if any symptoms of anaphylaxis occur. If sudden onset (few hours) of generalised itchy rash or face/tongue swelling and 1 or more of: 1) difficulty breathing, 2) fainting/ dizziness/collapse, 3) abdominal pain/vomiting, anaphylaxis likely: • Give adrenaline (1mg/mL, 1:1000) 0.3mL IM into mid- outer thigh. If no better, repeat every 5 minutes. • Give normal saline 20mL/kg IV bolus. • Also give diphenhydramine 1mg/kg IM/IV (up to 50mg). A widespread very itchy rash with burrows in web-spaces of hand and feet, axillae and genitalia. © St. Paul's Hospital Millennium Medical College Red raised wheals that appear suddenly, disappear and then reappear elsewhere. © St. Paul's Hospital Millennium Medical College 1 Possible triggers can be a viral infection, food (commonly peanuts, eggs milk, fish), medication or insect sting.
Child 148 Localised rash • If itchy rash on scalp/neck, look for nits/eggs in hair. If found, lice likely. • If dry, itchy, scaly skin, usually on flexor surfaces of elbows, knees and on scalp and neck, eczema likely. • Manage according to presenting symptom/s: Vesicles, pimples (pustules) in centre © University of Cape Town Scaling moist lesions between toes and on soles of feet ProjectManhattan/Wikimedia Commons Ring shaped patches, red, scaly edge If rash extensive, recurrent or responds poorly to treatment, refer. Athlete’s foot likely Encourage open shoes/sandals. • Apply clotrimazole 2% cream BID topically for 2 weeks. • Avoid sharing towels/clothes. • Wash skin well before applying treatment and dry well between toes. Tinea (ring worm) likely • If multiple or large lesions, test for HIV. • If HIV positive, manage according to national programme guidelines. • Apply clotrimazole 2% cream 8 hourly for 2 weeks. • Avoid sharing towels/clothes. • Wash skin well before applying treatment. • If lesions on scalp or hair loss: 1 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give instead erythromycin 12.5mg/kg (up to 500mg) QID PO for 7-10 days. Look for blisters/honey coloured crusts and flaky/greasy crusts, flaky pink raised plaques Pus-filled blisters which dry to form honey coloured crusts © St. Paul's Hospital Millennium Medical College Impetigo likely • Keep nails short. Wash and soak sores in soapy water to soften and remove crusts. Cover draining lesions with saline- soaked gauze dressing. • Apply povidone iodine 5% cream TID topically and give cephalexin1 12-25mg/kg (up to 500mg) QID PO for 7-10 days or cloxacillin1 12.5-25mg/kg (up to 500mg) QID PO for 7 days. • If rash does not resolve completely, repeat treatment. • Look for cause: if scabies 147. Also consider eczema and insect bites. • Advise caretaker that impetigo is contagious: - - Ensure regular hand-washing to prevent spread. - - May return to school 1 day after starting antibiotic. • Refer if: - - Extensive lesions - - Cellulitis or abscess - - Temperature ≥ 38°C - - No better after the above treatment • Advise to return immediately if blood in urine or limb/face/ feet swelling and refer to hospital same day. Flaky or greasy crusts with underlying red base on face, forehead, behind ears, eyebrows, eyelids and nasal creases. May be itchy. © St. Paul's Hospital Millennium Medical College Seborrhoeic dermatitis likely • Reassure caretaker that it will resolve without treatment in few weeks/months. • If extensive and HIV status unknown, test for HIV. If HIV positive, manage according to national HIV programme. • Advise caretaker to: - - Trim nails and avoid scratching. - - Wash body with aqueous cream and avoid perfumed soap. • If in > 1 area, apply hydrocortisone cream 1% BID topically until improved. • If extensive and no response to hydrocortisone cream, refer. © University of Cape Town Tinea capitus likely Look hair and scalp symptoms page 149.
Child 149 If brown hair has turned reddish or hair become sparse/brittle, assess growth (weight, height, MUAC): if problem 150. Does child have scale, itch, patches of hair loss or pimples/pustules? Itchy scaly patches or plaques • If flaky or greasy crusts with underlying red base, consider seborrhoeic dermatitis 148. • If patches of hair loss: Itchy scalp Look for lice or nits. If no lice/nits seen, exclude tinea capitus. © University of Cape Town Tinea capitus likely • Give griseofulvin 20-25mg/kg daily PO for 6-8 weeks or fluconazole 4-6mg/kg daily PO for 4 weeks. - - Use ketoconazole 2% shampoo twice a week to reduce sheddin of spores • Advise child/caretaker to avoid: - - Shaving head. - - Sharing combs and hairbrushes. Lice/nits likely • Apply malathion 1% shampoo to scalp after bath at night: Comb into hair repeatedly until whole scalp is covered: - - Dip a fine-toothed comb in vinegar and remove lice by combing entire head twice. - - Then rinse hair with lukewarm water and wash malathion out with normal shampoo. • Advise to: - - Avoid broken skin and contact with eyes. - - Wash bed linen in very hot water. - - Treat all household contacts. - - If lice/nits persist, shave hair. • Consider child abuse if lice on pubic, peri-anal areas or eyelashes /eyebrows, refer to hospital. No Yes Alopecia areata likely • Give betamethasone 0.1% gel to apply topically daily for 3 months. • If no response to treatment, refer to hospital. Patches of hair loss Is there scaling? Pimples/pustules © University of Cape Town Folliculitis likely • Keep area clean and dry. • If extensive or redness/pain/ swelling/temperature ≥ 38°C, give cloxacillin2 12.5-25mg/ kg (up to 500mg)QID PO or cephalexin2 12-25mg/kg (up to 500mg) QID PO for 5 days. • Wash hands regularly to prevent spread. Hair and scalp symptoms 1 If malathion 1% lotion unavailable: give benzyl benzoate lotion 25%. Apply benzyl benzoate to whole body from neck to feet after hot bath and dry well. Wash off next day and repeat next night. Put on cleaned washed clothes after treatment. Repeat treatment after 1 week. 2 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give instead erythromycin 12.5mg/kg QID PO for 5 days.
Child 150 The underweight child Measure child's weight and height and calculate body mass index (BMI): weight (kg) ÷ height (m) ÷ height (m), then plot BMI 151 (if girl) or 152 (if boy). Also measure MUAC1 . Does child have swelling of both feet? Approach to the underweight child with one or more of: • Visible wasting • BMI below -2 line • Low MUAC1 (< 14cm in a child 5-9 years old or < 18cm in a child 10-14 years old). No Yes Yes Give routine malnutrition care 153. Refer to hospital for inpatient care. Fails the appetite test Fails the appetite test Passes the appetite test Is outpatient care available, home circumstances reliable and caretaker willing? No: does child a BMI below -3 line or very low MUAC1 (< 13cm in a child 5-9 years old or < 16cm in a child 10–14 years old)? Yes Severe acute malnutrition (SAM) likely No Moderate acute malnutrition (MAM) likely Do appetite test (see below). No: severe acute malnutrition (SAM) without medical complications. Do appetite test (see below). Give urgent attention to the child with severe acute malnutrition (SAM) with medical complications: • If fast breathing: give oxygen 2L/min via nasal prongs. • Manage and assess child's fluid needs 129. • If glucose < 54mg/dL give 10% glucose2 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still < 54mg/dL, repeat 10% glucose2 bolus. • Feed at least 2 hourly until transfer. If refusing, give sugar water3 via NGT. • Treat infection: give ceftriaxone 80mg/kg (up to 1.5g) IV/IM. • Give vitamin A: 200 000IU PO. • Keep warm: cover with blanket. • Refer urgently. Yes: severe acute malnutrition (SAM) likely 1 Mid upper arm circumference. 2 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline). 3 Dissolve 4 teaspoons of sugar (20g) into 200mL water. Does child have any of: • Vomits everything • Unable to eat/drink • Temperature < 35.5°C or ≥ 38°C • Glucose < 54mg/dL • Hb < 10g/dL • Increased respiratory rate • Diarrhoea (> 3 watery stools/ 24 hours) • Weeping skin lesions • Lethargy or decreased level of consciousness How to do an appetite test • Give Ready-to-use-Therapeutic-Food (RUTF/F75®/10% dextrose) according to weight (see table). • Test may take up to one hour. Do not force child to eat. Offer child plenty of water to drink. • If child finishes minimum amount of feed, s/he passes the appetite test. • If child does not finish minimum amount of feed: s/he fails the appetite test. Minimum amount to be given to child Body weight (kg) RUTF Imunut® Sachet (92g) F75® 10% dextrose2 15 -30 70g 200mL 200mL ≥ 30 92g 250mL 250mL
Girl's BMI chart World Health Organization. BMI-for-age Girls 5-19 years (z-scores). 2007 5 to 19 years (z-scores) BMI (kg/m²) Age (completed months and years) -3 -2 -1 0 1 2 3 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 Months Years 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 12 14 16 18 20 22 24 26 28 30 32 34 36 12 14 16 18 20 22 24 26 28 30 32 34 36 Child 151
Boy's BMI chart World Health Organization. BMI-for-age Boys 5-19 years (z-scores). 2007 5 to 19 years (z-scores) BMI (kg/m²) Age (completed months and years) -3 -2 -1 0 1 2 3 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 Months Years 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 12 14 16 18 20 22 24 26 28 30 32 34 36 12 14 16 18 20 22 24 26 28 30 32 34 36 Child 152
Child 153 Malnutrition • Acute malnutrition likely if visible wasting, low BMI < -2 line or low MUAC1 (< 14cm in a child 5-9 years old or < 18cm in a child 10-14 years old). • Severe acute malnutrition likely if BMI < -3 line or very low MUAC1 (< 13cm in a child 5-9 years old or < 16cm in a child 10–14 years old) or if malnutrition with oedema. Advise the caretaker of child with acute malnutrition • Educate caretaker that good nutrition is vital for the normal function of the body. Refer to social worker and link with local NGOs. • Advise caretaker to give foods rich in protein3 , iron4 , vitamin A5 and C6 , dairy, vegetables and fruits. • Advise to feed child 5 times a day (3 meals with 2 nutritious snacks). Add a teaspoon of butter or vegetable oil to porridge. • Give hygiene advice: wash hands with soap and water regularly, especially when handling food/after using toilet. Wash fruit/vegetables and use boiled water if no access to clean water. • Refer for community health extension worker support and physiotherapy/occupational therapy for rehabilitation and physical and emotional stimulation. Treat the child with acute malnutrition • Check immunisations are up to date and give single dose vitamin A 200 000IU PO and albendazole 400mg PO. • If severe acute malnutrition without danger signs, also give amoxicillin7 30-40mg/kg (up to 1g) BID PO for 5 day at diagnosis. • Refer to Therapeutic Feeding Unit/Center (TFU/TFC): ensure a monthly supply of correct product and amount: enriched porridge plus energy drink plus Ready-to-use Therapeutic/Supplementary Food (RUTF/RUSF). • Review weekly until stable (gaining weight at 3 consecutive visits). Then review every 2 weeks until growing well8 . • Once child growing well8 review monthly and continue on supplements from Therapeutic Feeding Unit/Center (TFU/TFC) until weight remains on upward growth curve > 3 months. Advise caretaker to return immediately if condition worsens (unable to drink/eat, vomiting everything, fever, profuse watery diarrhoea, lethargy). 1 Mid upper arm circumference. 2 If child’s palm significantly less pink than your own. 3 Protein-rich foods: chicken, fish, cooked eggs, beans, lentils (shiro watt/thick soup), soya. 4 Iron-rich foods: liver, kidney, dark green leafy vegetables like spinach, cooked egg, beans, peas, lentils, fortified cereals. 5 Vitamin A-rich foods: vegetable oil, liver, yellow sweet potatoes, dark green leafy vegetables like spinach (imifino), mango, full cream milk. 6 Vitamin C-rich foods: oranges, melons, tomatoes. 7 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give erythromycin 12.5mg/kg (up to 500mg) QID PO for 5 days instead. 8 Growing well: MUAC ≥ 14 cm in a child 5-9 years old or ≥ 18 cm in a child 10-14 years old. Assess the child with acute malnutrition Assess When to assess Note Symptoms Every visit Manage symptoms as on symptom page. Ask specifically about diarrhoea 144. Check if urgent attention needed 150. Feeding At diagnosis Ask the following about diet: is child eating regular protein, dairy, vegetables, fruit; how often is child eating; what quantity is child eating; what fluids is child drinking and advise on correct habits depending on response. TB risk Every visit If close TB contact or TB symptoms (cough or fever ≥ 2 weeks, not growing well/losing weight, tired/less playful), exclude TB. Caretaker Every visit Check HIV status, contraceptive needs and TB symptoms. Social At diagnosis Ask who looks after child most of the time. If concerns about neglect, refer to hospital. Oedema Every visit If swelling of feet, hands or face, severe acute malnutrition (SAM) likely, refer to hospital. Weight-for-age Every visit • If weight loss > 5% [(weight lost ÷ weight at last visit) x 100] at any visit; if child has lost weight on 2 consecutive visits or if no weight gain for 3 consecutive visits, refer to hospital. • If weight-for-age (WFA) still below -2 line after 2 months of supplements from Therapeutic Feeding Unit/Center (TFU/TFC), refer to hospital. BMI Monthly If BMI still below -2 line after 2 months of supplements from Therapeutic Feeding Unit/Center (TFU/TFC), refer to hospital. MUAC1 Monthly If MUAC1 still low (< 14cm in a child 5-9 years old or < 18cm in a child 10-14 years old) after 2 months of supplements from Therapeutic Feeding Unit/Center (TFU/TFC), refer to hospital. Mouth/teeth At diagnosis If white patches in mouth (inside of cheeks/lips and on tongue), oral thrush/candida likely 139. If dental caries, refer to hospital. Hb At diagnosis Look for pallor2 and if possible check Hb: if pallor or Hb < 11g/dL, anaemia likely 137. If Hb < 7g/dL, refer to hospital. HIV At diagnosis Test for HIV. If HIV positive, manage according to national HIV programme guidelines.
Child 154 Epilepsy • If child convulsing now or is not known with epilepsy and has had a recent convulsion 130 • A doctor decides to start long-term treatment in a child with ≥ 2 convulsions and no identifiable cause. Advise the caretaker of a child with epilepsy • Explain what to do if child has a convulsion at home 130. Avoid possible triggers: lack of sleep, alcohol/drug use, dehydration and flashing lights. • Educate about epilepsy and need for adherence to be convulsion free. • Advise to keep a home record/convulsion diary to record frequency of convulsion, length of convulsion, possible triggers and changes in medication. Encourage caretaker to take a video of event. • Help caretaker to get Medic alert bracelet. Refer for support. Caretaker to inform teachers, explain what to do if child has a convulsion and what activities child should avoid. • Reduce chance of injury: supervise swimming/bathing/crossing roads (walking to school/shops), shield fireplaces/cookers, avoid contact sports (rugby), advise not to lock doors (bed/bathroom). Assess the child with epilepsy: record epilepsy diagnosis and care plan in birth record. Assess When to assess Note Long term health conditions Every visit If other long-term health conditions present, ensure they are adequately treated. Adherence and side effects Every visit Ask if child takes medication every day. If not, explore reasons for poor adherence. Ask about side effects of treatment (below). Other medication Every visit If child started TB or HIV treatment or antibiotics, refer to hospital to assess for drug interactions. Convulsion frequency Every visit Review convulsion diary. If still convulsing after 2 months and adherent to treatment (correct dose) with no obvious triggers1 or medication interactions, refer to hospital. School problems Every visit If failing grades, not coping with school work or bullying/violence at school, caretaker to arrange meeting with teacher. Family planning If sexually active girl If on valproate, ensure child on reliable contraception 110. Treat the child with epilepsy • A single medication is best. Start low dose and increase slowly every 2 weeks until convulsion free or side effects intolerable (treatment usually initiated at hospital). Medication Dose Maximum dose Indication Side effects Valproate2 • Start dose: 5mg/kg/dose 8-12 hourly • Increase to: 15-20mg/kg/dose 8-12 hourly • Maintenance dose: 20-30mg/kg/dose 8-12 hourly 40mg/kg/day in divided doses • Choose if generalised tonic/clonic seizures, absence seizures, on ART. • Avoid if liver disease. Urgent: jaundice, vomiting, abdominal pain: stop medications and refer urgently. Self-limiting: nausea, diarrhoea, constipation. Carbamazepine3 • Start dose: 2mg/kg/dose 8-12 hourly • Increase to: 5-10mg/kg/dose 8-12 hourly • Maintenance:10-20mg/kg/day in divided doses 10mg/kg/day in divided doses • Choose if focal seizures/convulsion. • Avoid in absence, myoclonic seizures or if child on ART. Urgent: skin rash, refer. Self-limiting: drowsiness, dry mouth, dizziness, ataxia, nausea, loss of appetite, constipation, abdominal pain. If drowsiness affects school performance, refer to hospital. Phenobarbitone Start and maintain: 3-5mg/kg/dose as a single dose at night. 5mg/kg/day Avoid in absence seizures. Drowsiness, behaviour problems, hyperactivity. • If convulsions worsen or persist despite maximum treatment or if loss of milestones, refer to hospital. • If convulsion free, review 6 monthly. If no convulsions for 2 years: discuss stopping treatment with doctor in hospital. Gradually decrease dose of anticonvulsant over 2 months. If convulsions recur, refer to hospital. 1 Triggers include: lack of sleep, dehydration, flashing lights, recent illness (fever), alcohol/drug use. 2 If unable to swallow tablet, give crushable formulation (100mg tablets) TID. If able to swallow, give controlled release (CR) formulation BID. 3 Give syrup formulation TID and tablet formulation BID.
Child 155 Assess level of consciousness (LOC) with the AVPU scale: Is child alert and awake? Child has normal LOC (A on AVPU scale) Yes No Child responds Child is lethargic (V on AVPU scale) If this is main presenting symptom. Child responds Child has a decreased LOC (P on AVPU scale) Child still does not respond Child is unresponsive/unconscious/comatose (U on AVPU scale) Child does not respond Check if child responds to pain by firmly rolling a pen over child’s nailbed: Try to rouse child by talking to him/her or shaking his/her arm: Assess level of consciousness with AVPU A Alert V responds to Voice P responds to Pain U Unresponsive/Unconscious Quick reference chart Estimate weight according to age 5-12 years Weight (kg) = (3 x age in years) + 7 Decide if respiratory rate is normal for age Age Respiratory rate (breaths/minute) Respiratory rate decreased if: Respiratory rate increased if: 5-12 years < 20 ≥ 25 ≥ 12 years < 15 ≥ 20 Decide if pulse rate is normal for age Age Pulse rate (beats/minute) Pulse rate decreased if: Pulse rate increased if: 5-12 years < 80 ≥ 120 ≥ 12 years < 60 ≥ 100 Decide if blood pressure is normal for age Age Blood pressure decreased if: Blood pressure increased if: DBP SBP DBP SBP 6-10 years old < 57 < 97 > 76 > 115 10-12 years old < 61 < 102 > 80 > 120 12-15 years old < 64 < 110 > 83 > 131 Decide on maintenance fluid rate Weight 24 hour fluid need < 10kg 120mL/kg 10-20kg 1000mL + (50mL for every kg body weight over 10kg) e.g.: if 14kg: 1000mL + (50 x 4) = 1200mL/24 hours ≥ 20kg 1500mL + (20mL for every kg body weight over 20kg) Up to 2000mL in girls and 2500mL in boys e.g.: if 23kg: 1500mL + (20 x 3) = 1560mL/24 hours
Adult 156 About PACK Global The Ethiopian Primary Health Care Clinical Guidelines were developed by localizing the PACK Global Adult (2017) and PACK Western Cape Child (2017) guides developed by the Knowledge Translation Unit of the University of Cape Town Lung Institute, South Africa. The Practical Approach to Care Kit (PACK) was developed, tested and refined since 1999 by the Knowledge Translation Unit (KTU) of the University of Cape Town Lung Institute Proprietary Limited in collaboration with clinicians, health managers and policy makers in South Africa, and expanded upon through research and localization throughout the world. This guide is a comprehensive tool to the commonest symptoms and conditions seen in primary care in low and middle- income countries. It integrates content on communicable diseases, non-communicable diseases, mental illness and women’s health. Each of the almost 3000 screening, diagnostic and management recommendations is informed by evidence and guidance in the BMJ’s (British Medical Journal) clinical decision support tool, Best Practice, as well as the latest World Health Organization guidelines, including the 2015 WHO Model List of Essential Medicines. The content has been carefully localised for health workers in Ethiopia and is, as of October 2017, believed to comprise best practice and comply with local guidelines and policies. The KTU’s involvement in the localisation work was supported by the United Kingdom’s National Institute of Health Research (NIHR) using Official Development Assistance (ODA) funding (NIHR Global Health Research Unit on Health System Strengthening in Sub-Saharan Africa, King's College London (16/136/54)). The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the English Department of Health. To the fullest extent permitted by law, the University of Cape Town Lung Institute (Pty) Ltd or BMJ Publishing Group Limited of Health shall not be held liable or be responsible for any aspect of healthcare administered in reliance upon, or with the aid of, this information or any other use of this information. PACK is also being implemented in South Africa, Brazil and Nigeria, and the content is revised annually in line with latest evidence and WHO guidelines. For access to the most up-to-date templates, tools, associated training materials and a mentorship programme for countries wishing to localise it for their health systems visit: www.knowledgetranslation.co.za or contact ktu@uct.ac.za
ethiopian-health-clinical-guidelines.pdf
ethiopian-health-clinical-guidelines.pdf

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ethiopian-health-clinical-guidelines.pdf

  • 1. Addis Ababa 2010 (EC) | 2017 (GC) Care of Children 5-14 years and Adults 15 years or older in Health Centers Ethiopian primary health care clinical guidelines Federal Democratic Republic of Ethiopia Ministry of Health
  • 2. Foreword The Ethiopian health care system has three tiers: primary health care, general hospital and specialized care centers. The primary health care level includes health posts, health centers and district hospitals. These health facilities are the first patient contact levels. Early case detection and appropriate treatment at the primary care level has pivotal role in better treatment outcome, disease control, and provision of quality of care. This is in line with global initiatives of achieving universal health coverage (UHC). And most importantly it can be a crucial input for the realization of Woreda transformation agenda of the HSTP (Health Sector Transformation Plan) by strengthening high performing PHCUs (Primary Health Care Units). Standardization of patient care at all health tier levels is important. To achieve this important goal, in the past years several guidelines have been developed. Some of these address specific diseases while others are general. This First Edition of the Ethiopian Primary Health Care Clinical Guidelines is a guide for the primary care of older children and adults. The adult content is a comprehensive guide to the adult presenting to primary health care facilities. The paediatric content addresses priority conditions in children aged 5-14 years presenting to primary care and is intended to complement the Integrated Management of Childhood Illness which addresses the child younger than 5 years old. The Ethiopian Primary Health Care Clinical Guidelines is an integrated symptom-based algorithmic approach to address the common presenting symptoms and priority chronic conditions in the country. The scope of what is covered in chronic conditions for adults, and long-term health conditions for older children includes: cardiovascular diseases; diabetes; chronic respiratory diseases; mental health, musculoskeletal disorders; and women’s health. The Guidelines provides basic management principles to deal with these diseases at a health center level in an integrated user-friendly way to support health workers to provide care that is evidence-informed, compliant with local guidelines, comprehensive, compassionate and respectful. The Ethiopian Primary Health Care Clinical Guidelines were developed by localizing the PACK Global Adult (2017) and PACK Western Cape Child (2017) guides developed by the Knowledge Translation Unit of the University of Cape Town Lung Institute, South Africa. Localising the Ethiopian Primary Health Care Clinical Guidelines to reflect Ethiopian policy and burden of disease required the establishment of a core technical team working full time and three intensive workshops with many clinicians. We thank the many clinicians who contributed to the development of the Ethiopian Primary Health Care Clinical Guidelines for their efforts (see Acknowledgements). The localisation process aligned the Ethiopian Primary Health Care Clinical Guidelines to Federal Ministry of Health policies, guidelines and clinical protocols. These include: Standard Treatment Guidelines for Health Center (2014), List of Medicine for Health Centers (2012), Guidelines on Clinical and Programmatic Management of Major Non Communicable Diseases (2016) , National guidelines for comprehensive HIV prevention, care and treatment (2014), Guidelines for clinical and programmatic management of TB/HIV and leprosy in Ethiopia (2016), Guidelines for the management of acute malnutrition (2016), National guidelines for the management of sexually transmitted infections using syndromic approach (2015), National malaria guidelines, National guidelines for family planning, Ethiopian paediatric hospital care (2016) and others. FMOH Ethiopia has a strong belief that the full implementation of this clinical guide in the health centers will standardize the care given at this level, will improve the quality of service and in effect will improve the health outcomes of the country. In this regards, I strongly encourage health workers in health centers to utilize this guide to the best of their capacity in the provision of health care, especially outpatient health service. And also in the same line, I encourage the health managers in the health system (especially in the Woreda Health Offices) to ensure the implementation and institutionalization of this guide and its practice in the health centers. Kebede Worku (MD, MPH) State Minister Ministry of Health
  • 3. Acknowledgements The development of this guideline was initiated by his excellency Dr Kesetebirhan Admassu, former Minister of Health, after he observed the PHC guidelines from South Africa and Botswana. Earlier draft versions of this guide were informed by these guidelines. Here by, FMOH Ethiopia acknowledges the Ministries of Health of Botswana and South Africa for sharing their guidelines and experiences. FMOH Ethiopia would like to acknowledge the following for their contributions: • Clinical Services Directorate and Health Center Reform case team – for leading the development of the guideline and for follow up to their fruition. • Disease prevention and Health Promotion Directorate, Maternal and Child Health Directorates, Health Extension and Basic Health Services Directorate and other directorates of FMOH – for contributing and improving the development of this guideline in many ways. • AA Health Bureau, Arada HC, Lideta HC and Addis Ketema HC – for conducting a pretest of few pages of the guideline and for giving constructive feedbacks. • Addis Ababa University – for availing different clinicians to contribute in the guideline. • Core Technical Team (CTT) – for working diligently and persistently till the finalization of the guideline. • KTU (Knowledge Translation Unit) of the University of Cape Town Lung Institute and BMJ (British Medical Journal) - for realizing this guideline with their generous all rounded support, which included availing all necessary resources to the Core Technical Team, allowing access to the generic PACK Adult and Child guidelines, to the online evidence database, and by orienting and mentoring the national core technical team throughout the adaptation process. • The United Kingdom’s National Institute of Health Research (NIHR) - for sponsoring the contribution of KTU and BMJ. • JSI- SEUHP (USAID Strengthening Ethiopia's Urban Health Program) - for supporting the initiative by employing senior technical assistants • USAID Transform: Primary Health Care project and ICAP - for sponsoring adaptation workshops. • Health managers, clinicians and other experts (see list below) - for working on the details and content of the guide. Managerial Leads: Daniel G/Michael Desalegn Tegabu Yibeltal Mekonnen Core Technical Team: Desalegn Tegabu (Project lead) Ermias Diro (Localization coordinator) H/mariam Segni (Content expert) Hassan Mohammed (Project lead) Solomon Emyu (Localization Coordinator) Solomon Shiferaw (M&E expert) Telahun Teka (Content expert) Wubaye Walelgne (Content expert) Yibeltal Mekonnen (Project lead) Yoseph Mamo (Content expert) KTU Team: Lauren Anderson (Training lead) Ajibola Awotiwon (Adult content editor) Ruth Cornick (Editorial lead) Tracy Eastman (Project coordinator) Lara Fairall (KTU head) Sandy Picken (Child content editor) Christy-Joy Ras (Training mentor) Pearl Spiller (Design) Izak Volgraaf (Illustrations) Camilla Wattrus (Adult content editor) Contributors: Ambachew Teferra Anteneh Kassa Aschalew Worku Ashna Bowry Ayalew Marye Charlotte Hanlon Damenu Zeleke Dereje Assefa Elnathan Kebebew Khalid Abdella Mariye Asfaw Melaku Belay Meron Yakob Meseret Zerihun Mohammed Shafi Molla Gedefaw Nicola Ayers Noor Ramji Samuel Girma Solomon Worku Tigist Bacha Yared Mamushet FMOH Ethiopia also acknowledge the sources of the photographs: the Centers for Disease Control and Prevention (CDC) Public Health Image Library, BMJ Best Practice, Stellenbosch University, the University of Cape Town, Project Manhattan/Wikimedia commons and Saint Paul Hospital Millennium Medical College. Yibeltal Mekonnen (MD) Clinical Service Directorate Acting Director
  • 4. How to use this Guide Ethiopia’s PHC clinical guide is an algorithmic guideline, prepared to be used as a quick and action oriented reference material for care givers in a health center; and primarily it targets health officers and nurses as care givers. It is divided into two main parts: first part for “adults”(15 years or older) and second part for children (5 to 14 years). Each part is divided into two sections: symptoms and chronic conditions (Routine Care). For management of the child aged younger than 5 years, please see the Integrated Management of New-borns and Childhood Illness (IMNCI) guidelines. To use this guide, • First consider the age of the patient and identify which part to use based on patient’s age. • In a patient presenting with one or more symptoms (Eg. Fever, cough, chest pain…), - - Start by identifying the patient’s main symptom. - - Use the Symptoms contents page to find the relevant symptom page in the guide. - - Decide if the patient needs urgent attention (in the red box) and if not, follow the algorithm to either a management plan or to consider a chronic condition in the chronic condition section of the guide. • In the patient known with a chronic condition (Eg. known TB patient), - - Use the chronic Conditions contents page to find that condition in the guide. - - Go to the colour-coded Routine Care pages for that condition to manage the patient’s chronic condition using the ‘Assess, Advise and Treat’framework. • Arrows refer you to another page in PHCG: The return arrow () guides you to a new page but suggests that you return and continue on the original page. The direct arrow () guides you to continue on another page. • The assessment tables on the Routine Care pages are arranged in 3 tones to reflect those aspects of the history, examination and investigations to consider. • Refer to the glossary for abbreviations and units used in PHCG. For further information about the PHCG, contact the Clinical Service Directorate of FMOH, via e-mail at [email protected] or via telephone +251 115 514901.
  • 5. Glossary A ALP alkaline phosphatase ALT alanine aminotransferase ART antiretroviral therapy AST aspartate aminotransferase B BID twice a day BMI body mass index BP blood pressure measured in millimeters of mercury [mmHg] C CD4 count of the lymphocytes with a CD4 surface marker COPD chronic obstructive pulmonary disease CPR cardiopulmonary resuscitation CRP c-reactive protein Cu-IUD copper intrauterine device CVD cardiovascular disease D DBP diastolic blood pressure DKA diabetic ketoacidosis DMPA depot medroxyprogesterone acetate DNS dextrose in normal saline DR-TB drug-resistant tuberculosis DS-TB drug-sensitive tuberculosis DST drug susceptibility testing DVT deep vein thrombosis DW dextrose water E ECG electrocardiogram EDD estimated date of delivery eGFR estimated glomerular filtration rate ELISA enzyme-linked immunosorbent assay eMTCT elimination of mother-to-child-transmission EPTB extra pulmonary tuberculosis ESR erythrocyte sedimentation rate G GCS glasgow coma scale GGT gamma-glutamyl transferase H H202 hydrogen peroxide Hb haemoglobin HbA1c glycated haemoglobin HBsAg hepatitis B surface antigen HIV human immunodeficiency virus HPV human papillomavirus I IM intramuscular IMCI integrated management of childhood illness INR international normalized ratio IPT isoniazid preventive therapy IU international units IUD intrauterine device IV intravenous M MTB Mycobacterium tuberculosis MTB/RIF Mycobacterium tuberculosis DNA and resistance to rifampicin MU million units MUAC mid-upper arm circumference N NS normal saline NSAIDs non-steroidal anti-inflammatory drugs P PJP pneumocystis jiroveci pneumonia PCR polymerase chain reaction PEP post-exposure prophylaxis PO orally PPE papular pruritic eruption PR per rectum PTB pulmonary tuberculosis Pulse rate measured in beats per minute PVD peripheral vascular disease Q QID four times a day R RF rheumatoid factor RPR rapid plasmin reagin Respiratory rate measured in breaths per minute S SC subcutaneous SBP systolic blood pressure STI sexually transmitted infection T TAT tetanus antitoxin TB tuberculosis TBSA total body surface area TIA transient ischaemic attack TID three times a day TSH thyroid stimulating hormone V VIA visual inspection with acetic acid
  • 6. Adult contents: symptoms A Abused patient 66 Abdominal pain 32 Abnormal vaginal bleeding 42 Abnormal thoughts/behaviour 64 Aggressive patient 64 Anal symptoms 35 Arm symptoms 48 B Back pain 47 Bites 52 Blackout 20 Body pain 45 Breast symptoms 31 Breathing difficulty 29 Burn/s 51 C Cardiac arrest 12 Cervical screening 40 Chest pain 28 Collapse 20 Coma 13 Condom broken 68 Confused patient 64 Constipation 35 Convulsions 15 Cough 29 D Diarrhoea 34 Disruptive patient 63 Distressed patient 65 Dizziness 21 Dyspepsia 32 Discharge, genital 36 E Ear/hearing symptoms 25 Emergency patient 12 Eye symptoms 23 Exposure to infectious fluids 68 F Face symptoms 24 Faint 20 Falls 20 Fatigue 19 Fever 17 Foot symptoms 50 Foot care 50 Fracture 14 G Genital symptoms 36 H Headache 22 Hearing problems 25 Heartburn 32 I Injured patient 14 Itch 53 J Jaundice 60 Joint symptoms 46 L Leg symptoms 49 Lump, neck/axilla/groin 18 Lump, skin 53 Lymphadenopathy 18 M Mouth symptoms 27 N Nail symptoms 61 Nausea 33 Neck pain 48 Needlestick injury 122 Nose symptoms 26 O Overweight patient 84 P Pain, back 47 Pain, body/general 45 Pain, chest 28 Pain, neck 48 Pain, skin 53 Pap smear 40 R Rape 66 Rash 53 Respiratory arrest 12 S Scrotal symptoms 36 Seizures 15 Suicidal thoughts/self harm 62 Sexual assault 66 Sexual problems 43 Sexually transmitted infection (STI) 36 Skin symptoms 53 Sleeping difficulty 67 Smoking 102 Stings 52 Stressed patient 65 Syphilis 41 T Throat symptoms 27 Tiredness 19 Traumatised patient 66 U Ulcer, genital 36 Ulcer, skin 53 Unconscious patient 13 Unsafe sex 68 Urinary symptoms 44 V Vaginal bleeding 42 Violent patient 64 Vision symptoms 23 Vomiting 33 W Weakness 19 Weight loss 16 Wheeze 30 Wound 14 Adult contents: Address the patient's general health 10
  • 7. Adult contents: chronic conditions Tuberculosis (TB) Tuberculosis (TB): diagnosis 71 Drug-sensitive (DS) TB: routine care 72 HIV HIV: diagnosis 75 HIV: routine care 76 Malnutrition 70 Chronic respiratory disease Asthma and COPD: diagnosis 81 Using inhalers and spacers 81 Asthma: routine care 82 COPD: routine care 83 Chronic diseases of lifestyle Cardiovascular disease (CVD) risk: diagnosis 84 Cardiovascular disease (CVD) risk: routine care 85 Diabetes: diagnosis 86 Diabetes: routine care 87 Hypertension: diagnosis 89 Hypertension: routine care 90 Heart failure 91 Rheumatic heart disease/previous rheumatic fever 92 Stroke 93 Ischaemic heart disease (IHD): initial assessment 94 Ischaemic heart disease (IHD): routine care 95 Peripheral vascular disease (PVD) 96 Epilepsy 97 Mental health Admit the mentally ill patient 98 Depression: diagnosis 99 Depression and/or anxiety: routine care 100 Tobacco smoking 102 Alcohol/drug use 103 Psychosis 104 Dementia 106 Musculoskeletal disorders Chronic arthritis 107 Gout 108 Fibromyalgia 109 Women’s health Contraception 110 The pregnant patient 112 Routine antenatal care 114 Routine postnatal care 116 Menopause 119 Palliative care 120 Other pages Prescribe rationally 9 Protect yourself from occupational infection 122 Communicate effectively 124 Exposed to infectious fluid: post-exposure prophylaxis 68 Protect yourself from occupational stress 123 Support the patient to make a change 125
  • 8. Child contents Long-term health conditions A Abdominal symptoms 143 B Breathing difficulty, child 140 Burns 133 C Cardiac arrest 128 Cardiopulmonary resuscitation (CPR) 128 Coma 131 Confusion 131 Convulsions 130 Cough 140 Cough, recurrent 142 D Dehydrated child 129 Diarrhoea 144 E Ear symptoms 138 Emergency child 127 F Fever 134 H Headache 135 Head injury 127 Hearing problems 138 I Injured child 132 L Leg symptoms 146 Limp 146 Lymphadenopathy 136 M Mouth symptoms 139 P Pallor 137 R Rash, generalised 147 Rash, localised 148 Respiratory arrest 128 Resuscitation, child 128 S Seizures 130 Shock 129 T Throat symptoms 139 U Unconscious child 131 Underweight 150 Urinary symptoms 145 W Walking problems 146 Wheeze 141 Wheeze, recurrent 142 Symptoms Malnutrition 153 Epilepsy 154 Quick reference chart 155
  • 9. Adult 9 Treat the patient needing a prescription • If unsure about your medicine choice and dosing, side-effects or medication interactions, consult a medicines formulary, experienced colleagues or pharmacist. • Ensure that the prescription contains all the detail it needs - see sample prescription. Write legibly. • If the patient needs an antibiotic, try to avoid antibiotic resistance: - - Confirm that patient needs the antibiotic. - - If possible, take microbiological samples before starting antibiotic and adjust treatment with results. - - Prescribe the shortest effective course at the appropriate dose and route. Prescribe rationally Assess the patient needing a prescription Assess Note Diagnosis Confirm the patient’s diagnosis, that the medication is necessary and that its benefits outweigh the risks: consider disease severity, safety and efficacy of medication and alternatives, severity and incidence of adverse drug reactions. Other conditions It may be necessary to adjust dose (e.g. lamivudine in kidney disease) or give alternative medication (e.g. avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure or kidney disease). Other medications Check if all medication (prescribed, over-the-counter, herbal) is necessary and for possible interactions, especially if on hormonal contraception, ART, TB or epilepsy treatment. Allergies If known allergy or previous bad reaction to medication, give alternative or refer. Age If > 65 years: consider using lower medication doses (give full doses of antibiotics and ART) and avoiding unnecessary medications. If patient on diazepam, amitriptyline, theophylline, codeine, ibuprofen, amlodipine or fluoxetine or using ≥ 5 medications, consider referral to hospital. Pregnant/breastfeeding If pregnant or breastfeeding check if the medication is safe. Response to treatment • If the patient’s condition does not improve, assess adherence to treatment and consider changing the treatment or an alternative diagnosis. If on antibiotic, check for resistance. • Check for side effects and report possible adverse reaction/s to medication. Advise the patient needing a prescription • Explain why the medication is needed, what effect it will have and what will happen if it is taken incorrectly. • Explain when and how to take the medication and for how long. Ask the patient to repeat your explanation to ensure s/he understands. • Educate on the importance of adherence and that not adhering to medication may lead to relapse or worsening of the condition and possible resistance to the medication. • Advise of possible side effects to the medication and what to do if they occur. • Over-the-counter medications and herbal treatments may interfere with prescribed medication. Encourage patient to discuss with prescriber before using them. Amoxicillin 500mg PO TID for 7 days, 21 capsules
  • 10. Adult 10 Address the patient's general health 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. 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 cough ≥ 2 weeks, weight loss, night sweats, fever ≥ 2 weeks, chest pain on breathing or blood-stained sputum, exclude TB 71. Family planning Every visit • Discuss patient’s contraception needs 110 and pregnancy plans. If pregnant, give antenatal care 114. • If HIV positive and planning pregnancy, advise patient to use contraception until viral load < 1000copies/mL. Sexual health Every visit • Ask about genital symptoms 36. • Ask about risky behaviour (patient or partner has new or > 1 partner, unreliable condom use or substance use 103) and sexual problems 43. Depression Every visit In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. Substance use/ abuse Every visit In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Smoking Every visit If patient smokes tobacco 102. Support patient to change 125. Older person risk Every visit if > 65 years • If patient has a change in function, confusion or strange behavior 64. • 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 106. • Consider using lower medication doses (give full doses of antibiotics and ART) and avoiding unnecessary medications. If patient on diazepam, amitriptyline, theophylline, codeine, ibuprofen, amlodipine or fluoxetine or is using ≥ 5 medications, consider referral to hospital. Pain Every visit • If patient has pain, manage on symptom page. • If patient is terminally sick and survival is predicted to be short, also give palliative care 120. CVD risk If ≥ 40 years or ≥ 2 risk factors • Assess CVD risk 84 at first visit, then depending on risk. • Risk factors: smoking, parent/sibling with premature CVD (man < 55 years or woman < 65 years), BMI > 25, waist circumference > 80cm (woman) or 94cm (man), hypertension, diabetes, cholesterol > 190g/dL. BP First visit, then depending on result Check BP 89. BMI/MUAC Yearly • BMI = weight (kg) ÷ height (m) ÷ height (m). • If BMI > 25 84. pregnant/breastfeeding and MUAC < 23cm or if not pregnant/breastfeeding and BMI < 17.5 or MUAC < 21cm, malnutrition likely 70. Diabetes screen • If ≥ 45 years • If BMI ≥ 25 and ≥ 1 other risk factor • Check glucose 86 at first visit, then depending on result. • Other risk factors: hypertension, cardiovascular disease, physical inactivity, family history of diabetes, high risk ancestry, previous gestational diabetes or big baby, previous impaired glucose tolerance or impaired fasting glucose. HIV • If status unknown • If sexually active: yearly • If pregnant: at first visit and 36 weeks Test for HIV 75. Cervical screen When needed • If HIV negative, screen 5 yearly from age 30 to 49. • If HIV positive, screen at HIV diagnosis (regardless of age) then 5 yearly. • If abnormal 40. Breast check First visit, then yearly Check for lumps in breasts 31 and axillae 18.
  • 11. Adult 11 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 that not all tests, treatments and procedures help prevent or treat disease. Some provide little or no benefit and may even cause harm. • Help patient to choose lifestyle changes to improve and maintain his/her general health. Support the patient to change 125. Avoid substance abuse Limit alcohol intake < 2 drinks1 /day and avoid alcohol on at least 2 days of the week. • In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the- counter medications? If yes to any 103. Stress Assess and manage stress 65. Smoking If patient smokes tobacco 102. Physical activity • Aim for at least 30 minutes of moderate exercise (e.g. brisk walking) on most days of the week. • Increase activities of daily living like gardening, housework, walking instead of taking transport, using stairs instead of lifts. • Exercise with arms if unable to use legs. Be sun safe • Avoid sun exposure, especially between 10h00 and 15h00. • Use sunscreen and protective clothing (e.g. hat) when outdoors. Road safety • Use pedestrian crossings to cross the road. • Use a seat belt. • Avoid using alcohol/drugs if driving. Have safe sex • Have only 1 partner at a time. • If HIV negative, test for HIV between partners. • Advise partner to test for HIV. • Use condoms. Diet • Eat a variety of foods in moderation. Reduce portion sizes. • Increase fruit and vegetables. • Reduce fatty foods: eat low fat food, cut off animal fat. • Reduce salty processed foods and avoid adding salt to food. • Avoid/use less sugar. Treat preventively to maintain the patient’s general health • If woman planning pregnancy, give folic acid 400mcg PO daily until 3 months after delivery. • Review the patient’s immunisation history and give if needed: Vaccine When Note Tetanus If pregnant • Give 1 dose of tetanus vaccine at first antenatal visit (any gestation). • Repeat at 4 weeks, then 6, 18 and 30 months after first dose. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
  • 12. Adult 12 The emergency patient Give urgent attention to the emergency patient: Does patient respond to your voice? Assess and manage airway, breathing, circulation and level of consciousness No: call for help Feel for carotid pulse for maximum of 10 seconds. Yes No pulse felt or unsure Start CPR: • Give cycles of 30 chest compressions and 2 breaths (at rate of at least 100 compressions/minute). • Give adrenaline 1mL (1:1000 solution) IV, followed by 5mL sterile water. Repeat every 3-5 minutes. • Check pulse: - - If definite pulse returns, stop CPR and check breathing (as adjacent). - - If no pulse, continue CPR for at least 30 minutes1 . Pulse felt Is patient breathing? No • Give 1 breath every 6 seconds. • Recheck pulse every 2 minutes. • If no pulse, start CPR (as adjacent). Airway • If airway obstructed (snoring, gurgling, noisy breathing), open with head- tilt and chin-lift. If injured, use jaw-thrust instead, keeping neck stable. • Remove foreign bodies from mouth and suction fluids. • If unconscious, insert oropharyngeal airway. If patient resists, gags or vomits, use lubricated nasopharyngeal airway instead. Breathing • If difficulty breathing or oxygen saturation < 90%, give face mask oxygen. • If respiratory rate < 9 or blue lips/ tongue,connect bag valve mask to oxygen and slowly deliver each breath with the patient. • Refer if using bag valve mask and still difficulty breathing, oxygen saturation < 90% or blue lips/tongue. • If sudden breathlessness, more resonant/decreased breath sounds/ pain on 1 side, deviated trachea: tension pneumothorax likely: refer urgently for chest tube. Circulation • Establish IV access. • If systolic BP < 90, pulse ≥ 100 or heavy bleeding, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • Stop bleeding: apply pressure and elevate limb. If bleeding still severe, apply alternate tourniquet above injury until surgical intervention or referral. Level of consciousness • Assess Glasgow Coma Score (GCS): Glasgow Coma Score (GCS) Best motor response 6 Obeys commands 5 Localises to pain 4 Withdraws from pain 3 Abnormal flexion to pain 2 Extends to pain 1 None Best verbal response 5 Orientated 4 Confused 3 Inappropriate words 2 Incomprehensible sounds 1 None Eye opening 4 Spontaneous 3 To voice 2 To pain 1 None • Add scores to give single score out of 15 Yes Manage further according to disability and symptoms: • If pupils unequal or respond poorly to light, raise head by 30 degrees. If injured, keep body straight and tilt to raise head (avoid bending spine). • Apply rigid neck collar and sandbags/blocks on either side of head if injured with: head injury and GCS < 15, neck/spine tenderness, weak/numb limb or abnormal pupils. If needing to move patient, use spine board. • If GCS ≤ 8 and none of above, place in left lateral position. • 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. • Assess patient further according to symptoms. Manage symptoms as on symptom pages. If unconscious 13. If injured 14. 1 Continue CPR for longer if temperature < 35°C, patient drowned, poisoned or took medication.
  • 13. Adult 13 The unconscious patient Give urgent attention to the unconscious patient: • First assess and manage airway, breathing, circulation and level of consciousness 12. • 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 convulsions, injuries or burns, also manage on symptom pages. • If sudden diffuse rash or face/tongue swelling, anaphylaxis likely: - - Raise legs and give face mask oxygen. - - Give immediately adrenaline 0.5mL (1:1000 solution) IM into mid outer thigh. Repeat every 5-15 minutes if needed. If no response, give hydrocortisone 100mg IV and promethazine 50mg IM. - - Give normal saline 1-2L IV rapidly regardless of BP. Then, if BP < 90/60, also give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • Check blood glucose, temperature and pupils: Temperature ≤ 35°C • Remove cold/ wet clothing and cover with warm blankets. • Warm IV fluids to 40°C (avoid cold fluids). • If no response or temperature ≤ 32°C, refer to hospital. ≥ 38°C Severe pneumonia or sepsis or meningitis likely • Give ceftriaxone2 2g IV/IM or crystalline penicillin2 3-4M IU IV with chloramphenicol 500mg IV. • Check for malaria3 : if positive, give artesunate 2.4mg/kg IM or artemether 3.2mg/kg IM. • If temperature > 40°C: - - Remove clothing. - - Use fan and water spray to cool patient. - - Apply ice-packs to axillae, groin and neck. - - Stop once temperature < 39°C. Illegal drug use and/or respiratory rate < 12 Pupils If no response or overdose/poisoning with other or unknown substance, refer to hospital. Pinpoint Excessive secretions or muscle twitching Both equally dilated Unequal or respond poorly to light • Intracranial bleeding/ mass or stroke likely • Raise head by 30 degrees. • If injured, keep body straight and tilt to raise head (avoid bending spine). Blood glucose < 70mg/dL or unable to measure • Give glucose 40% 50mL IV over 2-3 minutes. Repeat if glucose still < 70mg/dL after 15 minutes. Maintain with glucose 10% solution1 . • If known alcohol user, give thiamine 100mg IV or vitamin B1+B6+B12 1 tablet PO before glucose. > 200mg/dL • Check urine for ketones: if >2+, DKA likely 87. • Otherwise, give normal saline 1L IV over 1 hour, then 500mL hourly for 4 hours, then 250mL hourly for 4 hours. Opioid overdose likely Give 100% face mask oxygen. Organophosphate poisoning likely • Give atropine 2mg IV. Repeat every 5 minutes, doubling dose of atropine each time, until secretions controlled. • Remove contaminated clothes and wash skin. Stimulant or other drug overdose likely • 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 < 90% or drop in GCS, reassess and manage airway, breathing, circulation and level of consciousness 12. 1 Add 10 vials of glucose 40% in 1L dextrose in normal saline solution at 30 drops per minute. 2 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), give chloramphenicol only and refer. 3 Test for malaria with parasite slide microscopy or if unavailable, rapid diagnostic test.
  • 14. Adult 14 The injured patient Give urgent attention to the injured patient: • First assess and manage airway, breathing, circulation and level of consciousness 12. • 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 blood in urine Wound and one or more of: • Poor perfusion (cold, pale, numb, no pulse) below injury • Excessive or pulsatile bleeding • Penetrating wound to head/ neck/chest1 /abdomen Fracture and one or more of: • Poor perfusion (cold, pale, numb, no pulse) below fracture • Increasing pain, muscle tightness, numbness in limb • Suspected femur, pelvis or spine fracture • Weakness/numbness below fracture • Open fracture • > 3 rib fractures • Severe deformity Head injury and one or more of: • Any loss of consciousness • Convulsion • Severe headache • Amnesia • Suspected skull fracture • Bruising around eyes or behind ears • Blood behind eardrum • Blood or clear fluid leaking from nose or ear • Pupils unequal or respond poorly to light • Weak/numb limb/s • Vomiting ≥ 2 times • ≥ 1 other injury • Drug or alcohol intoxication • Give normal saline 1L IV hourly for 2 hours. • Once urine output > 200mL/ hour, give 500mL hourly. • Stop if breathing worsens. • Give normal saline 1L 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • If excessive/pulsatile bleeding, apply direct pressure and elevate limb. If bleeding severe and persists, apply tourniquet above injury. • Give diclofenac 75mg IM/IV and/or tramadol 100mg IV/IM. • If poor perfusion or weakness/numbness below fracture, gently re-align into normal position. • If open fracture: remove foreign material, irrigate with normal saline and hydrogen peroxide then cover with sterile saline-soaked gauze. Give ceftriaxone2 1g IV/IM and if dirty wound add metronidazole 500mg PO. • Splint limb to immobilise joint above and below fracture. • If pelvic fracture, tie sheet tightly around hips to immobilise. • If GCS < 15, neck/spine tenderness, weak/numb limb or abnormal pupils, apply rigid neck collar and sandbags/blocks on either side of head. • If pupils unequal or respond poorly to light, keep body straight and tilt to raise head (avoid bending spine). • If convulsion, give phenytoin 20mg/kg PO (crushed and diluted in water through NG Tube). Avoid giving lorazepam/diazepam. • Refer urgently. While awaiting transport, check BP, pulse, respiratory rate, oxygen saturation and GCS every 15 minutes. • If BP < 90/60, pulse > 100 or < 50, respiratory rate > 20 or < 9, oxygen saturation < 90% or drop in GCS, reassess and manage airway, breathing, circulation and level of consciousness12. 1 Avoid suturing the wound, apply 3-side flap dressing. 2 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), give single dose erythromycin 500mg PO. 3 Inject 0.1mL TAT SC and 0.1mL normal saline at separate site as control: if wheal with redness develops around TAT site, skin test positive. Refer to hospital. 4 Advise no alcohol until 24 hours after last dose of metronidazole. 5 Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. 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 66. • If open wound, give tetanus toxoid 0.5mL IM if none in past 5 years. If unavailable, check for tetanus antitoxin (TAT) hypersensitivity3 : if no reaction, give single dose TAT 3000U SC. If < 3 tetanus vaccine doses in lifetime, also give tetanus immunoglobulin 250 units IM at different site to toxoid with separate syringe. If unavailable, refer to hospital. Fracture • Splint limb to immobilise joint above and below fracture. • Give paracetamol 1g PO QID and ibuprofen5 400mg PO QID. • Refer to hospital. Head injury • Observe for 2 hours before discharging with carer. • If mild headache, dizziness or mental fogginess, concussion likely: - - Advise complete rest for 2 days. If no symptoms after 3 days, gradually increase exertion. - - Advise that recovery can take > 1 month. - - Give paracetamol 1g PO QID as needed for up to 5 days. • Advise to return immediately if any of above symptoms of severity develop. Wound • Apply direct pressure to stop bleeding. Remove foreign material, loose/dead skin. Irrigate with normal saline or if wound dirty use instead povidone iodine solution or hydrogen peroxide solution. • If sutures needed: suture, clean the overlying skin and apply non-adherent dressing for 24 hours. • Avoid suturing if > 12 hours (body), > 24 hours (head/neck), remaining foreign material, infected, gunshot or deep puncture: - - Pack wound with saline-soaked gauze and give amoxicillin/clavulanate 500/125mg PO TID for 7 days. If penicillin allergic, give instead erythromycin 500mg PO QID for 7 days. - - Review in 2 days. Suture if needed and no infection unless gunshot/deep puncture (irrigate and dress every 2 days instead). • Give paracetamol 1g PO QID as needed for up to 5 days. • Advise to return if infection (red, warm, painful, swollen, smelly, pus): start metronidazole4 500mg PO TID for 7 days and refer. • Remove sutures after 5 days (face), 4 days (neck), 10 days (leg) or 7 days (rest of body). • Refer if unable to close wound easily, weakness/numbness below injury or cosmetic concerns.
  • 15. Adult 15 Seizures/convulsions Approach to the patient who is not convulsing now • Confirm with the patient and a witness that s/he indeed had a convulsion: abnormal, jerking movements of part of or the whole body, usually lasting < 3 minutes. • May have had tongue biting, incontinence, post-convulsion drowsiness and confusion. Yes If diagnosis uncertain, refer. Yes Give routine epilepsy care 97. No Refer to hospital. Stroke or TIA likely 93. Faint or syncope likely 20. Conversion Disorder (Hysteria) likely 99. 1 Add 10 vials of glucose 40% in 1L dextrose in normal saline solution at 30 drops per minute. 2 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), give chloramphenicol only and refer. 3 Test for malaria with parasite slide microscopy or if unavailable, rapid diagnostic test. Give urgent attention to the patient who is unconscious and convulsing: • Assess and manage airway, breathing, circulation and level of consciousness 12. • If current head injury 14. • Ensure the patient does not sustain additional trauma. Don’t leave patient alone or put anything in mouth. Place patient on side and give 100% facemask oxygen. • Secure IV access with normal saline or dextrose in normal saline. • Check glucose. If < 70mg/dl or unable to measure, give glucose 40% 50ml IV over 2-3 minutes. Repeat if glucose still < 70mg/dL after 15 minutes. Maintain with glucose 10% solution1 . If glucose ≥ 200mg/dL, control convulsion and stabilize patient, then 86 • If ≥ 20 weeks pregnant up to 1 week postpartum: consider eclampsia 112. • Give diazepam 10mg IV slowly over 2 minutes. Repeat after 5 minutes if convulsion continues. • If still convulsing 10 minutes after second dose of diazepam or patient does not recover consciousness between convulsions, status epilepticus likely: - - Givephenytoinorphenobarbitone20mg/kgPO(crushedanddilutedinwaterthroughNGTube).Givediazepam10mgIVatthesametimeandrepeatuptoatotaldoseof40-60mgifconvulsioncontinues. - - Add phenytoin or phenobarbitone 10mg/kg PO if convulsion persists after 60-90 minutes. - - Refer urgently to hospital. Collapse with twitching lasting < 15 seconds following hot feeling, nausea, prolonged standing or intense pain with rapid recovery Episodes of acute anxiety, fully conscious, responds irregularly, with abnormal body movement and usually after stressful experience No Yes Give routine epilepsy care 97. No Patient has previous history of head trauma, meningitis, family history, stroke or brain tumor? Approach to the patient who had convulsion but does not need same day referral Is the patient known with epilepsy? New sudden asymmetric weakness or numbness of face arm or leg; difficulty speaking or visual disturbance Refer patient same day if one or more of: • Neck stiffness/meningism, temperature ≥ 38°C, meningitis likely: give ceftriaxone2 2g IM/IV or crystalline penicillin2 4M IU IV with chloramphenicol 500mg IV • Malaria test3 positive: give artesunate 2.4mg/kg IM or artemether 3.2mg/kg IM. • HIV patient: consider CNS toxoplasmosis, CNS TB, cryptococcal meningitis or HIV associated dementia • Reduced level of consciousness for more than 1 hour after convulsions stopped: suspect complications • New sudden asymmetric weakness or numbness, difficulty speaking or visual disturbance: consider stroke • New/different headache or headache getting worse/more frequent: consider sub-arachnoid hemorrhage • BP ≥ 180/110 one hour after convulsion has stopped: consider hypertensive emergency • Substance abuse: consider overdose or withdrawal • Head injury within past 6 weeks: consider subdural hematoma • Pregnant or up to 1 week postpartum: consider eclampsia 112.
  • 16. Adult 16 Weight loss Check that the patient who says s/he has unintentionally lost weight has indeed done so. Compare current weight with previous records and ask if clothes still fit. • Calculate the percentage of weight loss in the last 6 months: Investigate if ≥ 5%. • Ensure you work through steps 1-5 in this first visit. If above excluded, ask about food intake: Step 4. Food intake inadequate: look for cause/s Food intake is adequate • If any of: pulse ≥ 100, palpitations, tremor, dislike of hot weather or thyroid enlargement – thyrotoxicosis likely, refer to hospital. • In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. • In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Step 5. Consider malnutrition Check patient’s BMI and mid-upper arm circumference (MUAC): if pregnant/breastfeeding and MUAC < 23cm or if not pregnant/breastfeeding and BMI < 17.5 or MUAC < 21cm, malnutrition likely 70. Nausea and/or vomiting Loss of appetite Assess and manage stress 65. Food insecure (drought, crop failure or unemployed) Sore mouth or difficulty swallowing 33. • Eat small frequent meals. • Advise patient to eat nutrient dense foods (soya, meat, fish, nuts and seeds, beans, lentils, potatoes, rice, barley, wheat, maize). Refer to food safety net program. Oral/oesophageal candida likely 27. Step 3. Ask about symptoms of common cancers Abnormal vaginal discharge/bleeding Consider cervical cancer. Do a speculum examination and VIA 40. Breast lump/s or nipple discharge Consider breast cancer. Examine breasts and axillae 31. Amenorrhea with lower abdominal swelling Consider ovarian tumor. Refer. Change in bowel habit Consider bowel cancer. If mass on abdominal or rectal examination or stool occult blood positive, refer. Cough ≥ 2 weeks, bloody sputum, long smoking history Consider lung cancer. Arrange chest x-ray and refer. Step 1. First check for TB, HIV and diabetes Step 2. Ask about symptoms of common chronic infections • If diarrhoea 34 • If abdominal swelling in schistosomiasis endemic area, consider schistosomiasis and refer to hospital. • If fever, night sweats resident in northwestern borders of Ethiopia, consider leishmaniasis and refer to hospital Exclude TB • Start workup for TB 71. • At the same time test for HIV 75 and diabetes 86 and consider other causes below. Test for HIV Test for HIV 75. If HIV positive, give routine care 76. Check for diabetes Check glucose 86. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
  • 17. Adult 17 Fever Give urgent attention to the patient with fever (temperature ≥ 38°C now or in the past 3 days) and one or more of: • Convulsion 15 • Drowsiness, confusion or agitation • Neck stiffness/meningism • Respiratory rate > 30 or difficulty breathing • BP < 90/60 • Severe abdominal or flank pain • Jaundice • Easy bleeding or bruising • Unable to sit up or walk unaided • Purple rash Management and refer urgently: • If BP < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • Give ceftriaxone1 2g IV/IM or crystalline penicillin1 4M IU IV with chloramphenicol 500mg IV. Give single dose paracetamol 1g. • Check for malaria2 : if positive, give artesunate 2.4mg/kg IM or artemether 3.2mg/kg IM; and if glucose < 70mg/dl give glucose 40% 50mL IV. Repeat if glucose still < 70mg/dl after 15 minutes. • If patient started nevirapine or abacavir in last 4 weeks, check for urgent side effects 80. Approach to the patient with fever (temperature ≥ 38°C now or in the past 3 days) not needing urgent attention • Check for associated symptoms: cough 29; sore throat 27; blocked/runny nose 26; lower abdominal pain 32; vaginal discharge 38; urinary symptoms 44; diarrhoea 34; ear pain/discharge 25; skin rash 53; joint pain/swelling 46. • Give paracetamol 1g PO TID as needed for up to 5 days. 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), give chloramphenicol only and refer. 2 Test for malaria with parasite slide microscopy or if unavailable, rapid diagnostic test. 3 Avoid if pregnant. Do a peripheral blood film examination or a malaria rapid diagnostic test Positive for malaria Advise patient to return if no better. If fever persists beyond seven days • Check adherence to treatment and repeat peripheral blood film examination. Check for associated symptoms as above and manage as on symptoms pages. • Consider other causes of fever: If fever ≥ 2 weeks, exclude TB 71; Test for HIV 75. • If cause uncertain, refer. Plasmodium falciparum or Plasmodium vivax seen Positive for Borrelia (relapsing fever) Negative for malaria and Borrelia • If none of the above, advise cold compresses and review after 2 days. • If cause uncertain, or no better after treatment, refer. • Avoid Widal and Weil-Felix tests as they are not specific and do not show new infection. • Ask about pattern of fever, personal hygiene, headache, diarrhoea/constipation and look for lice on body: • Delouse the patient, shave hair and change clothing. • Give procaine penicillin 400,000IU IM. Ensure patient does not become shocked: - - Establish IV access with normal saline. - - Check BP every 15 minutes for first 2 hours, every 30 minutes for next 4 hours, then 6 hourly. If BP < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. If breathing worsens, stop and refer. • If penicillin allergic, give instead tetracycline3 250mg PO TID for 3 days. • Repeat peripheral blood film after 12 hours: - - If negative: give tetracycline 250mg PO TID for 3 days. - - If positive: repeat procaine penicillin 400,000IU IM and check BP as above. • Discharge after 12 hours and give tetracycline3 250mg PO TID for 3 days. If signs of severity as above, refer. • Educate patient and family on personal hygiene. Both Plasmodium falciparum and Plasmodium vivax seen • Give artemether/ lumefantrine 20/120mg: 4 tabs PO BID for three days and primaquine 0.25mg/kg PO daily for 14 days. • If pregnant in 1st trimester, give quinine sulphate 10mg/kg PO TID with food for 7 days. If intermittent fever with any of: headache, lives in overcrowded setting, poor personal hygiene or body lice, typhus fever likely: • Give doxycycline3 100mg PO BID for 7-10 days or tetracycline3 250mg PO QID for 7 days or chloramphenicol 500mg PO QID for 7 days. If persistent fever with any of: diarrhoea followed by constipation or poor food hygiene, typhoid fever likely: • Give ciprofloxacin3 500mg PO BID for 10-14 days or amoxicillin 1g PO TID for 14 days. If fever ≥ 2 weeks, exclude TB 71 and test for HIV 75. Plasmodium vivax seen • Give chloroquine: PO 4 tabs on days 1 and 2, 2 tabs on day 3 and primaquine 0.25mg/kg PO daily for 14 days. • If pregnant in 1st trimester, omit primaquine. Plasmodium falciparum seen • Give artemether/ lumefantrine 20/120mg: 4 tabs PO BID for three days and single dose primaquine PO 0.25mg/kg. • If pregnant in 1st trimester, give quinine sulphate 10mg/kg PO TID with food for 7 days.
  • 18. Adult 18 Lump/s in neck, axilla or groin Approach to the patient with lump/s in neck, axilla or groin • If lump is in the skin 53. • If lump is beneath the skin, first exclude thyroid mass, hernia and aneurysm: - - Lump in neck that moves up when patient swallows, thyroid mass likely: refer for further investigation. - - Lump in groin that gets bigger when patient stands up or coughs, inguinal hernia likely: refer. If severe pain or cannot be reduced, refer urgently. - - Pulsating lump, aneurysm 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 lymphadenopathy Neck Check scalp, face, eyes, ears, nose, mouth and throat. Axilla • Check arms, breasts, chest, upper abdomen and back. • If lump in breast 31. • Manage as on symptom page. • If lymph node persists > 4 weeks, refer. Ulcer 39 Look for cause: Check lower abdomen, legs, buttocks, genitals, anal region. Refer to hospital. Groin Is there risk of STI ( Age < 25 years, > 1 partner, new partner or unprotected sex in last 3 months, or partner/s with STI)? No Treat patient and partner for lymphogranuloma venereum (Bubo) • First assess and advise the patient and partner 36. • Give ciprofloxacin 500mg PO BID for 3 days and doxycycline 100mg PO BID for 14 days. • If pregnant/breastfeeding, give instead erythromycin 500mg PO QID for 14 days. • If fluctuant lymph node, aspirate pus through healthy skin in sterile manner every 3 days as needed. • Review after 14 days. If no better, refer. Has a cause been found? How to aspirate lymph node for TB microscopy and cytology • Clean skin over largest node with ethanol or povidone iodine. Hold node in fixed position with one hand so that it will not move. • Insert 22 gauge needle into node, draw back plunger 2-3mL to create vacuum. • Partially withdraw and reinsert needle at different angles several times through node (avoid withdrawing needle completely, maintain continuous vacuum). • Release vacuum pressure before withdrawing needle completely. • Remove syringe from needle, pull 2-3mL air into syringe, re-attach needle and gently spray contents of needle on to a glass slide. • Lay another slide on top and pull the slides apart to spread the material. • Allow one slide to air dry and fix other slide with cytology spray. • If enough aspirate, also send for TB and bacterial culture and sensitivity. • If aspirate unsuccessful or does not confirm a diagnosis, refer. No Is the groin lump hot and tender? No No Yes Yes Yes Localised lymphadenopathy Ask about other symptoms and look for cause (infection, skin lesion, rash, bite): • Test for HIV 75. If HIV positive, give routine care 76. • If cough ≥ 2 weeks, weight loss, night sweats or fever ≥ 2 weeks, check for TB 71. • If no TB found and symptoms persist, refer same week. • Check complete blood count and ESR. If abnormal, refer to hospital. • Review medication: atenolol, allopurinol, co-trimoxazole, antibiotics and phenytoin can cause lymphadenopathy. Consider changing medication. • If no cause found, refer. Yes Is an ulcer present?
  • 19. Adult 19 Weakness or tiredness Give urgent attention to the patient with weakness or tiredness and one or more of: • If new sudden asymmetric weakness or numbness of face, arm or leg; difficulty speaking or visual disturbance: consider stroke or TIA 93. • Chest pain 28 • Respiratory rate > 30 or difficulty breathing 29. • Glucose < 70mg/dL: if known diabetes 87. If not, manage as below. • Glucose > 200mg/dL if known diabetes 87. If not 86. • Severe dehydration: decreased urine output, drowsiness/confusion, BP < 90/60, pulse ≥ 100. • Dehydration: thirst, dry mouth, poor skin turgor, sunken eyes, decreased urine output, drowsiness/confusion, BP < 90/60, pulse ≥ 100. • Worsening weakness of leg/s • If on ART, check for urgent side effects 80. Management: • If dehydrated, give oral rehydration solution. If unable to drink or BP < 90/60, give normal saline 250mL IV rapidly, 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 < 70mg/dL or unable to measure, give oral glucose 20g. If unable to take orally, give instead glucose 40% 50mL IV over 2-3 minutes. Repeat if glucose still < 70mg/dL after 15 minutes. Maintain with glucose 10% solution1 . If glucose better and patient able to take orally, encourage patient to eat and drink. If weakness/tiredness persists, refer same day. • If worsening weakness of leg/s, refer urgently. Approach to the patient with weakness or tiredness not needing urgent attention Tiredness is a problem when it persists so that the patient is unable to complete routine tasks and it disrupts work, social and family life. Look for a cause of the patient’s weakness/tiredness: • If temperature ≥ 38˚C 17. If < 38˚C but had a fever in past 3 days, exclude malaria 17. • If cough, weight loss, night sweats or fever, exclude TB 71. • Test for HIV 75. If HIV positive, give routine care 76. • Exclude pregnancy. If pregnant 112. • Assess and manage stress 65 and if patient has difficulty sleeping 67. • If patient is terminally sick and survival is predicted to be short, give palliative care 120. If none of the above: • If difficulty breathing worse on lying flat and leg swelling, heart failure likely 91. • Exclude anaemia: Check Hb: - - If Hb 11-12g/dL (woman) or 11-13g/dL (man): If no infection, cancer or bleeding, give ferrous sulphate 200mg PO BID for 1 month. Give also single dose albendazole 400mg PO. Repeat Hb after 1 month: If repeat Hb not increased by at least 1g/dL , refer to hospital. - - If Hb <11g/dL, refer for further investigation. • Exclude diabetes: check glucose 86. • Look for kidney disease: do urine dipstick. If patient has proteinuria on dipstick, diabetes, hypertension or is > 50 years, refer for further investigation. • If weight gain, low mood, dry skin, constipation or cold intolerance, hypothyroidism likely. Refer to hospital • Review medication and refer if patient taking any of: loratidine, enalapril, amlodipine, propranolol, atenolol, fluoxetine, amitriptyline, metoclopramide, valproic acid, phenytoin and spironolactone. • In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. • Screen for substance use/abuse: In the past year, has patient: 1) drunk ≥ 4 drinks2 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. If persistent weakness or tiredness and no obvious cause, refer. 1 Add 10 vials of glucose 40% in 1L dextrose in normal saline solution at 30 drops per minute. 2 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
  • 20. Adult 20 Collapse/faint Approach to the patient who has collapsed/fainted not needing urgent attention • Refer patient for further investigation, including ECG. • Screen for substance use/abuse: - - If current drug or alcohol intoxication 103. - - In the past year, has patient: 1) drunk ≥ 4 drinks2 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. • Check for orthostatic hypotension: measure BP lying and repeat after standing for 3 minutes: Systolic BP drops by ≥ 20 (or ≥ 30 if known hypertension) or diastolic BP drops by ≥ 10 • This is common in the elderly. • If thirsty and pulse on standing ≥ 100, dehydration likely. Give oral rehydration solution and look for and manage cause. • Check Hb: if < 11g/dL, refer to hospital. • Review medication: amitriptyline, amlodipine, enalapril, furosemide, glyceryl trinitrate, hydrochlorothiazide and metoprolol. Consider changing medication. • Advise patient to sit first before standing up from lying down. Yes Common faint (Syncope) likely • May have had twitching of limbs that last < 15 seconds (not a convulsion). • Advise to avoid overheating, prolonged standing, crowded environment and situations where fainting has occurred previously. • Assess and manage stress 65. No Was collapse associated with a specific action (e.g. coughing, swallowing, head turning or passing urine)? No Is there known diabetes? Give routine diabetes care 87. Yes Refer to hospital. No If cause for collapse is uncertain, refer. Systolic BP does not drop by ≥ 20 (or ≥ 30 if known hypertension) and diastolic does not drop by ≥ 10 Before the collapse did patient experience flushing, dizziness, nausea, sweating? Give urgent attention to the patient who has collapsed/fainted and one or more of: • If new sudden asymmetric weakness or numbness of face, arm or leg; difficulty speaking or visual disturbance: consider stroke or TIA 93. • Unconscious 13 • Convulsion 15 • Chest pain 28 • Difficulty breathing 29 • Recent injury • Systolic BP < 90 • Pulse < 50 or irregular • Palpitations • Family history of collapse or sudden death • Known heart problem • Collapse with exercise • Vomited blood or blood in stool • Pregnant or missed/overdue period with abdominal pain and vaginal bleeding • Severe back or abdominal pain • Sudden diffuse rash or face/tongue swelling: anaphylaxis likely Management: • If glucose < 70mg/dL or unable to measure, give oral glucose 20g. If unable to take orally, give instead glucose 40% 50mL IV over 2-3 minutes. Repeat if glucose still < 70mg/dL after 15 minutes. Maintain with glucose 10% solution1 . • If glucose > 200mg/dL 86. • If anaphylaxis likely: - - Raise legs and give face mask oxygen. - - Give immediately adrenaline 0.5mL (1:1000 solution) IM into mid outer thigh. Repeat every 5-15 minutes if needed. If no response, give hydrocortisone 100mg IV and promethazine 50mg IM. - - Give normal saline 1-2L IV rapidly regardless of BP. • If BP < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • Refer same day. Yes 1 Add 10 vials of glucose 40% in 1L dextrose in normal saline solution at 30 drops per minute. 2 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
  • 21. Adult 21 Dizziness/vertigo Approach to the patient with dizziness not needing urgent attention • Ask about ear symptoms. If present 25. If hearing loss, refer same week. • Ask about fainting/collapse attacks. If present, do ECG. If ECG abnormal, refer same day. • Screen for substance use/abuse: - - If current drug or alcohol intoxication 103. - - In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. • Review medication: antidepressants, hypertension and epilepsy treatment, furosemide and efavirenz can cause dizziness. Refer. • If diabetic, check glucose 87. • Check Hb: if < 11g/dL, refer to hospital same week. • Check BP: if > 140/90 89. Assess for orthostatic hypotension: measure BP lying and repeat after standing for 3 minutes: • If none of the above, refer to hospital. • Refer if no cause is found, dizziness/vertigo persists despite above treatment or uncertain of diagnosis. Systolic BP drops by ≥ 20 (or ≥ 30 if known hypertension) or diastolic BP drops by ≥ 10 Orthostatic hypotension likely • This is common in the elderly. • If thirsty and pulse on standing ≥ 100, dehydration likely. Give oral rehydration solution and look for and manage cause. • Advise patient to sit first before standing up from lying down. Systolic BP does not drop by ≥ 20 (or ≥ 30 if known hypertension) and diastolic BP does not drop by ≥ 10 Ask patient to breathe rapidly for 2 minutes. Are symptoms reproduced? Yes Yes Refer to hospital. Hyperventilation likely • Reassure and encourage patient to breathe at a normal rate. • Assess and manage stress 65. Sudden dizziness/vertigo lasts seconds, precipitated by head movements Positional vertigo likely Reassure patient that dizziness is self-limiting and usually resolves within 6 months. Sudden dizziness/vertigo lasts hours/days with nausea/vomiting. May have preceding flu-like illness. Vestibular neuritis likely • If nausea/vomiting, give metoclopramide 10mg PO TID as needed for up to 5 days. • Encourage to be mobile as soon as possible • If no better after 2 weeks, or if hearing loss or tinnitus occurs, refer. No No Ask about associated symptoms and length of dizziness/vertigo. Is there hearing loss, headaches, visual symptoms or tinnitus (ringing/buzzing in ear/s)? 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. Give urgent attention to the patient with dizziness (spinning/feeling of rotation of self or surroundings) and one or more of: • If new sudden asymmetric weakness or numbness of face, arm or leg; difficulty speaking or visual disturbance: consider stroke or TIA 93. • BP < 90/60 • Pulse < 50 or irregular • Chest pain 28 • Difficulty breathing, especially on lying flat with leg swelling 91 • Recent head injury • Unable to stand without support • New sudden severe dizziness/ vertigo with nausea/vomiting, abnormal eye movements or walk Management: • If BP < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • Refer same day.
  • 22. Adult 22 Headache Approach to the patient with headache not needing urgent attention Is headache disabling and recurrent with nausea or light/noise sensitivity, that resolves completely? Yes Migraine likely • Give immediately, and then as needed: ibuprofen3 400mg PO QID with food or paracetamol 1g PO QID for up to 5 days. • If nausea, also give metoclopramide 10mg PO TID as needed up to 5 days. • Give oral hydration. • Advise patient to recognise and treat migraine early, rest in dark, quiet room. • Advise regular meals, keep hydrated, regular exercise, good sleep hygiene. • Keep a headache diary to identify and avoid migraine triggers like lack of sleep, hunger, stress, some food or drink. • Avoid oestrogen-containing contraceptives 110. • If ≥ 2 attacks/month, refer for medication to prevent migraines. No Pain when pushing on forehead or cheek/s, recent common cold, runny/blocked nose? Yes • Give amoxicillin/clavulanate 500/125mg PO TID for 7-10 days. • If penicillin allergic, give instead azithromycin 500mg PO daily for 3 days, if available or refer. No • Give amoxicillin 500mg PO TID for 7 days. • If penicillin allergic, give instead doxycycline5 100mg PO BID for 7 days. • In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. • 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 100.. Constant aching pain, tender neck muscles > 50 years, pain over temples Giant cell arteritis likely Check ESR. If > 30mm/h, give single dose prednisolone 60mg PO and refer same day. • Warn patient to avoid overusing analgesics. • If uncertain of diagnosis or poor response to treatment, refer. Give urgent attention to the patient with headache and one or more of: • Sudden severe headache • New/different headache, or headache that is getting worse and more frequent • Headache that wakes patient or is worse in the morning • Temperature ≥ 38°C, neck stiffness/meningism or vomiting • Worsening/persistent headache in HIV patient recently started on ART • BP ≥ 180/110 and not pregnant 89 • Pregnant or 1 week post-partum, and BP ≥ 140/90 112 • Decreased level of consciousness • Confusion • Sudden dizziness • Vision problems (e.g. double vision) or eye pain 23 • Following a first convulsion • Recent head trauma • Sudden weakness or numbness of face, arm or leg 93 • Speech disturbance • Pupils different in size Management: • If temperature ≥ 38°C or neck stiffness/meningism, give ceftriaxone1 2g IV/IM or crystalline penicillin1 4M IU IV with chloramphenicol 500mg IV. If malaria test2 positive, also give artesunate 2.4mg/kg IM or artemether 3.2mg/kg IM. • Refer urgently. Sinusitis likely • Give paracetamol 1g PO QID as needed for up to 5 days. • If tooth infection, swelling over sinus or around eye, refer. • If patient has recurrent sinusitis, test for HIV 75. • If nasal discharge for > 10 days or symptoms worsen after initial improvement, give antibiotic: - - Is there risk of severe infection (> 65 years, alcohol abuse or impaired immunity4 )? Yes No • If using analgesia > 2 days/week for ≥ 3 months it can cause headaches: - - Advise against regular use and to cut down on amount used. - - Headache should improve within 2 months of decreased use. • Consider muscular neck pain or giant cell arteritis: 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), give chloramphenicol only and refer. 2 Test for malaria with parasite slide microscopy or if unavailable, rapid diagnostic test. 3 Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. 4 Known with HIV, diabetes or cancer, pregnant or receiving chemotherapy or corticosteroids. 5 Avoid if pregnant. Muscular neck pain likely 48.
  • 23. Adult 23 Eye/vision symptoms Give urgent attention to the patient with eye/vision symptoms and one or more of: • If new sudden asymmetric weakness or numbness of face, arm or leg; difficulty speaking or visual disturbance: consider stroke or TIA 93. • BP ≥ 180/110 and not pregnant 89 • Pregnant or up to 1 week post-partum, and BP ≥ 140/90: treat as severe pre-eclampsia 112. • Yellow eyes: jaundice likely 60. • Single painful red eye • Sudden loss or change in vision (including blurred or reduced vision) • New onset hazy cornea • Painful red skin with blisters involving eye, eyelid or nose: herpes zoster (shingles) likely • Whole eyelid swollen, red and painful: orbital cellulitis likely • Penetrating eye trauma • Foreign body that is metal, or from hammering, mechanical saw, welding, grinding or explosion • Chemical burn to eye/s: immediately wash eye/s for at least 15 minutes continuously with normal saline or clean water. • If painful eye with redness, blurred vision, haloes around light, dilated unreactive pupil, headache or nausea/ vomiting, acute glaucoma likely Manage and refer urgently to ophthalmology centre: • If orbital cellulitis likely, give ceftriaxone1 2g IV/IM. Approach to the patient with eye/vision symptoms not needing urgent attention Red or swollen eyelid margins with crusting Blepharitis likely • Apply warm/ cool compress for 5-10 minutes BID. • Advise to gently wash eyes with baby shampoo. to remove crusts. If no better, give erythromycin eye drops 1 drop daily for 2 weeks. • If no better after 2 weeks, refer. • Exclude diabetes 86 and hypertension 89. • Test for HIV 75. • Refer for visual assessment. Superficial foreign body • Wash eye with clean water or normal saline and clean corners of eye with damp cotton- tipped bud. Advise regular hydration • Attempt removal of foreign body • Refer to hospital if: - - Unable to remove foreign body as above - - Damage to eye - - Abnormal vision or eye movement - - No better 2 days after removal of foreign body Gradual change in vision Yes: Is there eczema, allergic rhinitis or asthma and both eyes involved? No: Is the discharge pus or clear? Clear Viral conjunctivitis likely • Advise cool compresses. • Advise patient to wash hands regularly and not share towels or bedding. Patient can return to work after 1 week. • Give normal saline or clean water eye washes up to 4 times per day If no better after 2 days, refer. 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid ceftriaxone and refer. Pus Bacterial conjunctivitis likely If no yellow bumps: • Give chloramphenicol 1% ointment QID or gentamycin 0.3% eye drops 1 drop 4-6 hourly for 10-15 days. • Advise patient to wash hands regularly, not share towels/bedding. • Patient can return to work after 2 days. Check under upper eyelid for yellows bumps: if present, trachoma likely. Refer same day. © BMJ Best Practice Yes Allergic conjunctivitis likely • Advise cool compresses and normal saline eye drops as needed. • Help to identify and advise to avoid allergens that worsen/ trigger symptoms. • Avoid steroid eye drops • Give oxymetazoline eye drops 1 drop 3-4 times a day for 5 days. • Give loratadine 10mg PO daily or chloropheniramine 4mg PO at night as needed. • If no better after 4 weeks, refer. No Localised cause likely • Wash eye with clean water. • Identify and remove the cause. • If no better after 24 hours, refer. Eye/s discharging or watery Is there prominent itch?
  • 24. Adult 24 Face symptoms Give urgent attention to the patient with face symptoms and one or more of: • If 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 93. • New facial swelling with abnormal urine dipstick: kidney disease likely • Sudden face/tongue swelling with difficulty breathing, BP < 90/60 or collapse, anaphylaxis likely • Painful red facial swelling and temperature ≥ 38°C: facial cellulitis likely Management: • If anaphylaxis likely: - - Raise legs and give face mask oxygen. - - Give immediately adrenaline 0.5mL (1:1000 solution) IM into mid outer thigh. Repeat every 5-15 minutes if needed. If no response, give hydrocortisone 100mg IV and promethazine 50mg IM. - - Give normal saline 1-2L IV rapidly regardless of BP. Then, if BP < 90/60, also give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • Refer urgently. Approach to the patient with face symptoms not needing urgent attention Face pain Pain of cheek or jaw and on tapping or biting on involved tooth. May be swollen. Gum/tooth infection likely • Give paracetamol 1g PO QID as needed for up to 5 days. • If temperature ≥ 38°C or difficulty opening mouth, give amoxicillin 500mg PO TID for 5 days and metronidazole1 500mg PO TID for 5 days. If penicillin allergic, replace amoxicillin with doxycycline2 100mg PO BID for 5 days. • Advise good oral hygiene and a soft diet for a few days. • Refer to dentist same week. Sudden progressive weakness of 1 side of face and unable to wrinkle forehead or close eye. May have impaired taste or dry eye. Bell’s palsy likely • Give prednisolone as soon as possible: give 60mg PO daily for 5 days. Then reduce dose by 10mg daily. If no better after 3 weeks, refer. • If severe/complete weakness, also give aciclovir 400mg PO 5 times a day for 10 days. • Protect eye: - - Advise patient not to rub eye. - - Keep eye moist with drops. - - Cover eye with transparent eye shield during the day. - - Tape eyelid closed at night. • Refer same day if: - - Otitis media - - Any change in hearing - - Recent head trauma - - Damage to cornea - - Unsure of diagnosis Swelling of face Painless swelling in patient on enalapril Painful swelling of one/both sides of face with low-grade fever, headache, body pain. Parotitis (mumps) likely • Give paracetamol 1g PO QID as needed for up to 5 days. • Advise patient s/he can return to work after 5 days and that symptoms usually resolve within 1 to 2 weeks. • Refer if: - - Neck stiffness/ meningism - - Painful scrotal swelling - - Loss of hearing Pain when pushing on forehead or cheek/s, headache, recent common cold, runny/blocked nose Yes No Sinusitis likely • Give paracetamol 1g PO QID as needed for up to 5 days. • If neck stiffness/meningism, tooth infection or swelling over sinus/around eye, refer. • If patient has recurrent sinusitis, test for HIV 75. • If nasal discharge for > 10 days or symptoms worsen after initial improvement, give antibiotic: - - Is there risk of severe infection (> 65 years, alcohol abuse or impaired immunity3 )? Angioedema likely • Stop enalapril and never start it again. • Give loratadine 10mg PO daily until swelling resolved. • Referto hospital for review of medication. • Advise patient to return urgently should difficulty breathing occur or symptoms worsen and that s/he should never take enalapril again. • Give amoxicillin/clavulanate 500/125mg PO TID for 7-10 days. • If penicillin allergic, give instead azithromycin 500mg PO daily for 3 days, if available or refer. • Give amoxicillin 500mg PO TID for 7 days. • If penicillin allergic, give instead doxycycline2 100mg BID for 7 days. If rash on face 53. 1 Advise no alcohol until 24 hours after last dose of metronidazole. 2 Avoid if pregnant. 3 Known with HIV, diabetes or cancer, pregnant or receiving chemotherapy or corticosteroids.
  • 25. Adult 25 Ear/hearing symptoms 1 Cleaning the ear (dry mopping): roll a piece of clean paper towel or absorbent cloth 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 the ear. 2 Known with HIV, diabetes or cancer or receiving chemotherapy or corticosteroids. Itchy ear Otitis externa likely • Clean ear1 . • Give paracetamol 500mg PO QID as needed for up to 5 days. • If severe pain, temperature ≥ 38°C, impaired immunity2 give cloxacillin 500mg PO QID for 5 days. If penicillin allergy, give instead erythromycin 500mg PO QID for 5 days. • If no response after 2 days, refer. Referred pain likely • Look for cause: - - If dental problem, refer to dentist. - - If throat problem 27. - - If pain in temporo- mandibular joint, check for joint problem 46. - - If painful swelling of one/ both sides of face, consider mumps likely 24. Acute otitis media likely • Give paracetamol 500mg PO QID as needed for up to 5 days. • Clean ear1 if discharge. • Give amoxicillin 500mg PO TID for 5 days. If penicillin allergic, give instead erythromycin 500mg PO QID for 5 days. • Refer if: - - No response to antibiotics after 5 days - - Recurrent otitis media • Refer urgently if: - - Painful swelling behind ear - - Neck stiffness/ meningism Chronic suppurative otitis media likely • Clean ear1 3 times a day. The ear can heal only if dry. • Give hydrogen peroxide solution 3% 5-10 drops into affected ear BID. • Refer if: - - No better after 2 weeks - - Foul-smelling discharge or yellow/white deposit on eardrum, cholesteotoma likely. - - Large perforation - - Hearing loss - - Pain in ear • Refer urgently if: - - Painful swelling behind ear - - Neck stiffness/meningism • If poor response to treatment, check for TB 71 and HIV 75. Painful ear Is ear itchy, painful, discharge from ear, difficulty hearing or tinnitus (ringing/buzzing in ear/s)? Then look in ear. Discharge from ear Difficulty hearing or tinnitus Wax • Syringe ear with warm water and/ or dilute hydrogen peroxide. If unsuccessful after 3 attempts or causes pain, stop and refer. • If hearing does not improve after wax removal, refer. • Look for and if possible remove cause: - - Ask about prolonged exposure to loud noise. - - Review medication: aspirin, NSAIDs and furosemide. • Refer if: - - Sudden onset - - One-sided - - Dizziness/vertigo - - Patient taking kanamycin - - No cause found or no better 2 weeks after removing cause. • If insect, instil oil and if possible remove using forceps. • Otherwise, syringe ear with warm water. • If unsuccessful after 3 attempts or causes pain, stop and refer. Normal looking ear Foreign body • If tinnitus, refer to hospital. • If itchy/painful ear or discharge from ear, see adjacent column/s. • Check for wax and foreign body: Redness and/or pus in ear canal © University of Cape Town Normal drum and canal © University of Cape Town Symptoms < 2 weeks; red or bulging eardrum. May have fever and/or difficulty hearing. © University of Cape Town Symptoms ≥ 2 weeks; perforated eardrum. Painless, may have difficulty hearing © University of Cape Town How to syringe an ear Fill a large syringe (50-200mL) with warm water. Ask patient to hold container under ear against neck to catch water. Gently pull ear upwards and backwards to straighten ear canal. Place tip of syringe at ear canal opening (no further than 8mm into canal) and direct water spray upwards in ear canal.
  • 26. Adult 26 Nose symptoms • Advise patient to avoid contact with others to prevent spread, use tissues when sneezing/coughing and dispose of these carefully, and to wash hands regularly. • Give paracetamol 500mg PO QID or ibuprofen1 400mg PO TID needed for up to 5 days. • Explain that antibiotics are not necessary. • Advise patient to return if symptoms persist > 4 days. Common cold likely Influenza (flu) likely Sore throat or fever Body aches/muscle pains or chills Pain when pushing on forehead or cheek/s, headache, recent common cold Runny or blocked nose Ask about duration and associated symptoms. Recurrent episodes of sneezing and itchy nose on most days for > 2 weeks. May have itchy eyes, ears or throat. Allergic rhinitis likely • Advise patient to identify and avoid allergens that worsen/ trigger symptoms. • Give loratadine 10mg daily for up to 5 days or cetirizine 10mg daily only when symptoms worsen. • If symptoms occur on ≥ 4 days per week for > 1 month, give beclometasone nasal spray long term 100mcg (2 sprays) in each nostril daily. Once symptoms controlled, use lowest effective dose to maintain control. • If no better with above treatment and symptoms debilitating, refer. • Firmly pinch nostrils together for 10 minutes. • Check BP: - - If < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. - - If ≥ 140/90 89. • If still bleeding: - - Insert cotton strips or swabs saturated with mixture of lidocaine 4% and xylometazoline 0.05% into bleeding nostril/s for 15 minutes. - - If bleeding persists, refer. • If patient has recurrent episodes: - - Advise patient to apply petroleum jelly or saline spray inside nostrils and avoid nose-picking or rubbing, contact sports and trauma to nose. - - Advise patient to avoid aspirin and NSAIDs (e.g. ibuprofen) as they may prolong bleeding. - - Educate patient to firmly pinch nostrils together if bleeding occurs. Bleeding nose Yes No • Give amoxicillin/ clavulanate 500/125mg PO TID for 7-10 days. • If penicillin allergic, give instead azithromycin 500mg PO daily for 3 days if available or refer. • Give amoxicillin 500mg PO TID for 7 days. • If penicillin allergic, give instead doxycycline3 100mg PO BID for 7 days. Sinusitis likely • Give paracetamol 1g PO QID as needed for up to 5 days. • If neck stiffness/meningism, tooth infection, swelling over sinus or around eye, refer. • If patient has recurrent sinusitis, test for HIV 75. • If nasal discharge for > 10 days or symptoms worsen after initial improvement, give antibiotic: - - Is there risk of severe infection (> 65 years, alcohol abuse or impaired immunity2 )? Yes No 1 Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. 2 Known with HIV, diabetes or cancer, pregnant or receiving chemotherapy or corticosteroids. 3 Avoid if pregnant.
  • 27. Adult 27 Mouth and throat symptoms Give urgent attention to the patient with mouth/throat symptoms and one or more of: • Unable to open mouth – consider Ludwig’s angina, dental infections/abscess, jaw dislocation or tetanus • Unable to swallow at all – consider severe tonsillitis with abscess, severe oesophageal thrush Management: • Refer same day. Approach to the patient with mouth/throat symptoms not needing urgent attention • Ask about dry mouth and swallowing problems (difficulty or painful swallowing). If food/liquid gets stuck with swallowing, consider oesophageal cancer or stricture, refer. • Examine the mouth and throat for redness, white patches, blisters, ulcers or cracks. • Advise the patient with a sore mouth/throat to avoid spicy, hot, sticky, dry or acidic food and to eat soft, moist food. • Advise to keep mouth and teeth clean by brushing and rinsing regularly. Red throat Viral pharyngitis likely • Give paracetamol 1g PO QID as needed for up to 5 days. • Rinse with salt water or H2O2 3% mouthwash after meals • Reassure that antibiotics are not necessary. Bacterial pharyngitis/ tonsillitis likely • Give paracetamol 1g PO QID as needed for up to 5 days. • Rinse with salt water or H2O2 3% mouthwash after meals • Give single dose benzathine penicillin 1.2MU IM or amoxicillin 500mg PO QID for 10 days; If penicillin allergic give instead erythromycin 500mg PO QID for 10 days. If > 4 episodes in 1 year, refer for ENT assessment. White patches on cheeks, gums, tongue, palate; may have cracks in corners of mouth If difficulty or pain on swallowing, oesophageal candida likely • Give fluconazole 200mg PO daily for 14 days. • If no response, refer. Oral thrush/candida likely • Test for HIV 75 and diabetes 86. • Give miconazole oral gel 60mg or nystatin 500 000IU tablet PO QID for 7 days. Keep in mouth as long as possible. • If patient uses inhaled corticosteroids, ensure s/he uses spacer and rinses mouth with water after use 81. • If patient is terminally sick and survival is predicted to be short, give palliative care 120. Painful blisters on lips/mouth Herpes simplex likely • Apply tetracaine 0.5% on blisters or gentian violet 0.5% solution painted in mouth TID and paracetamol 1g PO QID up to 5 days. • Give aciclovir 400mg PO TID for 7 days if: - - HIV patient - - Blisters for ≤ 12 hours or new blisters forming - - Ulcers are extensive, recurrent or present for > 1 month - - Severe pain • Avoid touching the lesions and kissing. • Advise frequent hand washing. Painful ulcer/s in mouth/throat Red, cracked corners of mouth If no better or uncertain of cause: • Check hemoglobin. • Test for HIV 75 and diabetes 86. • If still uncertain, refer. Dry mouth • If thirst, urinary frequency or weight loss, check for diabetes 86. • If runny or blocked nose 26. • Look for and treat oral candida as in adjacent column. • Review medication: furosemide, amitriptyline, chlorpheniramine antipsychotics and morphine can cause dry mouth. Consider changing medication. • Advise patient to sip fluids frequently. Sucking on oranges, pineapple, lemon or passion fruit may help. • If patient is terminally sick and survival is predicted to be short, give palliative care 120. Aphthous ulcer/s likely • Apply triamcinolone acetonide 0.1% (Oropaste®) TID on the lesions for 7 days or crushed prednisolone 5mg tablet BID until healed • Apply tetracaine 0.5% on ulcers • Give paracetamol 1g PO QID as needed. • Rinse with chlorhexidine 0.12% solution 10ml BID • Test for HIV 75 • Refer if: - - Not healed within 2 weeks - - Ulcer diameter > 1cm Angular cheilitis likely • Apply petroleum jelly (Vaseline®) TID. • If crusts and blisters around mouth, impetigo likely 59. • If very itchy, contact dermatitis likely. Identify and remove irritant. • If using inhaled corticosteroids, advise to rinse mouth after use. Are there 2 or more of: • Fever • No cough • Pus/patches on tonsils • Tender neck lymph nodes No Yes
  • 28. Adult 28 Chest pain Give urgent attention to the patient with chest pain and one or more of: • Respiratory rate > 30 or difficulty breathing • BP ≥ 180/110 or < 90/60 • Pulse irregular, ≥ 100 or < 50 • Severe pain • New pain or discomfort in centre or left side of chest • Pain radiates to neck, jaw, shoulder/s or arm/s • Nausea or vomiting • Pallor or sweating • Known with ischaemic heart disease • At risk of heart attack (diabetes, smoker, hypertension, high cholesterol, known CVD risk > 20%, family history) Is chest pain worse on palpating the chest or when patient lies down or breathes deeply? Yes No Assess for ischaemic heart disease 94 Manage and refer urgently: • If oxygen saturation < 90%, oxygen saturation machine 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: refer for urgent chest tube. • If BP < 90/60, give normal saline 250mL IV rapidly. Repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • If BP ≥ 180/110, repeated after 5 minutes to confirm, give single dose metoprolol 25mg PO and refer. • If temperature ≥ 38°C, give ceftriaxone1 1g IV/IM. 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid ceftriaxone and refer. 2 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. If uncertain of diagnosis, refer same week. 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 94. • If cough, fever or pain on breathing deeply 29. • Ask about site of pain and associated symptoms: Retrosternal or epigastric pain with eating, hunger or lying down/bending forward Tender at costochondral junction, no fever or cough Burning pain on one side of body with or without rash Dyspepsia (heartburn) likely • Advise to avoid caffeine and if heartburn at night, prop up head of bed and avoid eating late at night. Stop NSAIDS (e.g. ibuprofen), aspirin. • Ask about smoking. If patient smokes tobacco 102. Support patient to change 125. • If drinks alcohol ≥ 4 drinks2 /session 103. • If waist circumference > 80cm (woman) or 94cm (man), encourage weight loss and assess CVD risk 84. • Give omeprazole 20mg PO daily for 4 weeks. • Refer same week if any of: no better after 14 days of omeprazole, new onset pain and > 50 years, pain on swallowing, persistent vomiting, weight loss, loss of appetite, early fullness, blood in stool or occult blood positive or abdominal mass. Herpes zoster (shingles) likely 54. Musculoskeletal problem likely • Give ibuprofen 400mg PO TID with food up to 10 days (avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • If pain persists > 4 weeks, refer.
  • 29. Adult 29 Cough or difficulty breathing Approach to the patient with cough or difficulty breathing not needing urgent attention • Test for HIV 75. If on ART, check for urgent side effects 80. • Ask about duration of cough or difficulty breathing: If wheeze/tight chest and no rash or face/tongue swelling 30. Relieve cough or difficulty breathing in the patient needing palliative care 120: • If thick sputum, give steam inhalations. If more than 30mL/day, try deep fast breathing with postural drainage. • If excess thin sputum, give hyoscine 10mg TID. If annoying dry cough, give dextromethorphan syrup 10mg/5ml or diphenhydramine syrup 10mg/5mL three times a day. • Exclude TB 71. • Consider asthma and COPD 81 and other cause for cough or difficulty breathing: Cough or difficulty breathing ≥ 2 weeks Cough or difficulty breathing < 2 weeks Acute bronchitis or common cold likely • Reassure patient antibiotics are not necessary. • Advise to return if symptoms worsen or fever develops. Pneumonia likely Yes Give amoxicillin1 1g PO TID and doxycycline3 100mg PO BID for 5-7 days. • If symptoms worsen after 2 days of antibiotics, refer. • If not better after 7 days of antibiotics, consider TB 71 • If no cause found, refer to hospital. HIV with CD4 < 200cells/mm3 with dry cough, worsening breathlessness on exertion Pneumocystis pneumonia likely Refer to hospital for x ray and inpatient treatment. Smoker • If patient smokes tobacco 102. • Has patient lost weight? Consider lung cancer. Refer to hospital. Coughing sputum most days of 3 months for ≥ 2 years, chronic bronchitis likely. Refer to hospital for COPD workup Recent common cold, no difficulty breathing Post-infectious cough likely Advise that cough should resolve within 8 weeks. No Give doxycycline3 100mg PO BID for 7 days. Is there risk of severe infection (> 65 years, alcohol abuse or impaired immunity2 )? Sputum, chest pain, pulse ≥ 100 or temperature ≥ 38°C? No No Yes Yes Give urgent attention to the patient with cough and/or difficulty breathing and one or more of: • Breathless at rest or while talking • Difficulty breathing worse on lying flat and leg swelling: heart failure likely 91. • Rapid deep breathing with glucose > 200mg/dl: consider DKA 86. • Sudden diffuse rash or face/tongue swelling: anaphylaxis likely • Temperature ≥ 39°C • Respiratory rate > 30 • Coughs ≥ 1 tablespoon fresh blood • Confused or agitated • BP < 90/60, shock • Swelling and pain in one calf Manage and refer urgently: • Give face mask oxygen (if known COPD give 24-28% face mask oxygen). Temperature ≥ 38°C, pneumonia likely Give ceftriaxone1 1g IV/IM or amoxicillin1 1g PO. Sudden breathlessness, more resonant/ decreased breath sounds/pain on one side, deviated trachea, tension pneumothorax likely Arrange urgent chest tube. If BP < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. Sudden diffuse rash or face/tongue swelling, anaphylaxis likely • Raise legs and give immediately adrenaline 0.5mL (1:1000 solution) IM into mid outer thigh. Repeat every 5-15 minutes if needed. If no response, give hydrocortisone 100mg IV and promethazine 50mg IM. • Give normal saline 1-2L IV rapidly, regardless of BP. 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid and refer. 2 Known with HIV, diabetes or cancer, pregnant or receiving chemotherapy or corticosteroids. 3 If pregnant, give instead erythromycin 500mg PO QID for 5 days.
  • 30. Adult 30 Wheeze/tight chest 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? Mild or moderate No No Yes Yes • Give inhaled salbutamol via spacer1 400-800mcg (4- 8 puffs). If no better, repeat salbutamol every 20 minutes during first hour. • If known asthma or COPD, give prednisolone 40mg PO. If unable to take oral medication, give instead hydrocortisone 100mg IV. • Give face mask oxygen between each dose of salbutamol (if known COPD, give 24-28% face mask oxygen). • Monitor response regularly: Improving or no change at 1 hour Check respiratory rate. Can patient talk normally? • Refer urgently. • While awaiting transport: - - Give inhaled salbutamol 400-800mcg (4-8 puffs) every 20 minutes via spacer1 . - - Give face mask oxygen between doses (if known COPD, give 24-28% face mask oxygen). - - Give hydrocortisone 100mg IV if not already given. Severe Worsening despite treatment Able to talk normally and respiratory rate < 20 Unable to talk normally or respiratory rate > 20 Wheeze/tight chest resolved • If first episode of wheeze/tight chest, assess for asthma and COPD 81. • If known asthma/COPD, give routine care: if asthma 82, if COPD 83. Wheeze/tight chest still present • Repeat salbutamol hourly or as needed. • Is wheeze/tight chest still present at 3 hours? Continue salbutamol and refer. • If sudden diffuse rash or face/tongue swelling, anaphylaxis likely 29. • If difficulty breathing worse on lying flat and leg swelling, heart failure likely 91. 1 If conventional spacer unavailable, make a hole in the bottom of a 500mL plastic bottle to fit the size and shape of inhaler spray opening.
  • 31. Adult 31 Breast symptoms Approach to the patient with a breast symptom who is not breastfeeding Ensure the breastfeeding HIV patient and her baby receive routine HIV care 76 and 116. Approach to the patient with a breast symptom who is breastfeeding Painful/cracked nipple/s Usually in first few days of breastfeeding due to poor latching • Avoid soap on nipples. • Advise patient to continue breastfeeding and help patient to latch properly. • Advise patient to apply breastmilk to nipples after feeding and expose to the air. • Advise HIV patient to stop feeding from the breast, express and heat-treat1 the milk, and cup-feed baby until cracks have healed. Painful breast/s Is there a breast lump? No Temperature ≥ 38°C or body pain? Yes Mastitis likely • Give cloxacillin 500mg PO QID for 10 days. If penicillin allergic, give instead erythromycin 500mg PO QID for 14 days. • Give paracetamol 1g PO QID as needed for up to 5 days. • Advise warm compresses and, if HIV negative, frequent breastfeeds. • Advise HIV patient to stop feeding from the breast, express and heat-treat1 the milk, and cup-feed baby until mastitis resolves. • If no better after 2 days, refer. No No Yes Engorgement likely Blocked duct likely Breast abscess likely • Give single dose ceftriaxone2 1g IM and refer same day. • Advise HIV patient to stop feeding from the breast, express and heat-treat1 the milk, and cup-feed baby until abscess resolves. • Advise frequent breastfeeding, warm compresses and to gently massage breast. • Advise to return to clinic if worse/no better. Yes Temperature ≥ 38°C or body pain? Breast lump/s Both breasts, with/without pain One breast This is likely to be cyclical. • Reassure. • If on hormonal contraceptive, consider non-hormonal method 110. • If symptoms change/worsen, refer. No Yes Re-examine breast on day 7 of menstrual cycle. If lump persists, refer same week. Rash on breast • Check for breast lump. • Check axilla for lymph node 18. • Check for nipple discharge • If none of the above 53 Refer same week. Breast pain • Reassure patient that breast cancer rarely causes pain. • Advise a well-fitting bra. • If pregnant, reassure and give antenatal care 114. • Give paracetamol 1g PO QID as needed for up to 5 days. • May be a side effect of hormonal contraceptive. If no better after 3 months, change method 110. Nipple discharge Any one of: blood-stained or one-sided discharge, patient ≥ 50 or a man, skin/ nipple changes, breast/axillary lump? One breast Both breasts • Confirm that this is not obesity. If BMI > 25 assess CVD risk 84. • Review medication: efavirenz and amlodipine can cause breast enlargement. Consider changing medication. Refer same week. Yes Refer same week. No • If pregnant, reassure and give antenatal care 114. • Review medication: haloperidol, antidepressants, oral contraceptive and metoclopramide can cause nipple discharge. Consider changing medication. • If discharge persists, refer. Breast enlargement/feels different 1 Heat-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. 2 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid ceftriaxone and refer. Any one of: man, patient > 30 years, family history of breast cancer, irregular fixed lump, skin/nipple changes, nipple discharge or axillary lymph node?
  • 32. Adult 32 Abdominal pain (no diarrhoea) Give urgent attention to the patient with abdominal pain and one or more of: • Unable to pass urine and distended abdomen: consider acute urinary obstruction 44 • Chest pain: consider heart attack 28 • Pregnant or up to 1 week post-partum and BP ≥ 140/90: consider pre-eclampsia 112 • Recent abortion/delivery: consider puerperal sepsis 116 • Pregnant and vaginal bleeding, consider ectopic pregnancy or abortion 112 • If drowsiness, confusion, nausea/vomiting, rapid deep breathing: consider DKA, check glucose 86. • If on ART, check for urgent side effects such as lactic acidosis 80. • Peritonitis (guarding, rigidity or rebound tenderness): consider acute abdomen • Jaundice (yellow eyes): consider bile duct infection, hepatitis • Temperature ≥ 38°C: consider severe infection of any abdominal organ/structure • No stool or flatus for last 24 hours with/without vomiting: consider intestinal obstruction • Sudden severe upper abdominal pain spreading to back with nausea/vomiting: consider perforated duodenal ulcer or pancreatitis • Pulsatile abdominal mass: consider abdominal aortic aneurysm • Severe pain just before or during menses, severe dysmenorrhea likely Manage and refer urgently: • If temperature ≥ 38°C, jaundice or peritonitis, give single dose ceftriaxone1 1g IV or IM. • If severe dysmenorrhea, give single dose tramadol 50mg IM. If pain subsides, manage below, otherwise refer. Approach to the patient with abdominal pain not needing urgent attention • If sexually active woman with lower abdominal pain and abnormal vaginal discharge 38. • If pain just before or during menses, dysmenorrhea likely: if abdominal mass refer. Otherwise reassure patient and give ibuprofen 400mg PO TID, starting at onset of pain for few days of menses every month for 4 to 6 months. If no better, refer. • If the patient has urinary symptoms 44. If the patient is constipated 35. • Do stool microscopy: - - If positive give the following treatment: • If giardiasis, give single dose tinidazole 2g PO. • If amoebiasis, give metronidazole 500mg PO TID for 5-7 days. • If strongyloidiasis, give albendazole 400mg PO BID for 3 days. • If other parasites, give albendazole 400mg PO once daily for 3 days. - - If stool microscopy negative, manage below: Yes Dyspepsia (heartburn) likely • Advise to avoid caffeine and if heartburn at night, prop up head of bed and avoid eating late at night. • Stop NSAIDS (e.g. ibuprofen), aspirin. • Ask about smoking. If patient smokes tobacco 102. Support patient to change 125. • If drinks alcohol ≥ 4 drinks2 /session 103. • If waist circumference > 80cm (woman) or 94cm (man), encourage weight loss and assess CVD risk 84. • Avoid serologic H pylori tests as they are not specific and not useful for management decisions. • Give omeprazole 20mg BID for 4 weeks. Refer if any of: no better after 14 days of omeprazole, new onset pain and > 50 years, pain on swallowing, persistent vomiting, weight loss, loss of appetite, early fullness, blood in stool or occult blood positive, abdominal mass or uncertain of diagnosis. No Has patient lost weight? Does patient have epigastric pain which is worse with eating, hunger or lying down/bending forward? • Give paracetamol 1g PO QID as needed for up to 5 days. • Review regularly until pain resolves or a cause is found. Yes Does patient have any of: cough, night sweats, fever or HIV? No Consider cancer. Refer same week. Yes • Tapeworm or worm segments: give single dose praziquantel 600mg PO or albendazole 400mg PO once daily for 3 days. • Other worm or unsure: give single dose albendazole 400mg. • Educate on personal hygiene. No If pain is recurrent and relieved when passing stool, with constipation and/ or diarrhoea and bloating, irritable bowel syndrome likely. Refer to hospital. No Does the patient report worms? Yes Exclude TB 71. 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid ceftriaxone and refer. 2 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
  • 33. Adult 33 Nausea or vomiting Give urgent attention to the patient with nausea or vomiting and one or more of: • Headache: consider brain bleeding, meningitis, abscess or tumor22 • Chest pain: consider heart attack 28 • Sudden severe upper abdominal pain spreading to back: consider perforated duodenal ulcer or pancreatitis • Signs of severe dehydration: decreased urine output, drowsiness/confusion, BP < 90/60, pulse ≥ 100 • Peritonitis (guarding, rigidity or rebound tenderness): consider acute abdomen • Vomiting blood: consider gastric/duodenal ulcer or oesophageal bleeding • Jaundice (yellowish eyes): consider hepatitis, bile duct obstruction or gall bladder infection • Abdominal pain/distention and no stools or flatus: consider intestinal obstruction. • If drowsiness, confusion, abdominal pain, rapid deep breathing: consider DKA, check glucose 86. • If pregnant, signs of severe dehydration and ketone in urine, hyperemesis gravidarum likely. • If on ART, check for urgent side effects such as lactic acidosis 80. Management: • Secure IV line with normal saline and advise patient not to take anything by mouth • If severe dehydration, give normal saline 1L IV rapidly, repeat until systolic BP > 90. Stop if breathing worsens. • If hyperemesis gravidarum, give normal saline as above: add 2 vials of glucose 40% and 2 ampoules of vitamin B complex in each 1L bag. Also give chlorpromazine 25mg IM or promethazine 25mg IM. • Refer urgently. Approach to the patient with nausea or vomiting not needing urgent attention • Exclude pregnancy. • If associated dizziness 21. • Review medication: NSAIDs (e.g. ibuprofen), metformin, contraceptives, hormone therapy, theophylline, chemotherapy and morphine can cause nausea/vomiting. If on TB medication 73 or ART 80. • Screen for substance use/abuse: in the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. • If patient is terminally sick and survival is predicted to be short, also give palliative care 120. Does patient have epigastric pain which is worse with eating, hunger or lying down/bending forward? Dyspepsia (heartburn) likely • Advise to avoid caffeine and if heartburn at night, prop up head of bed and avoid eating late at night. • Stop NSAIDS (e.g. ibuprofen), aspirin. • Ask about smoking. If patient smokes tobacco 102. Support patient to change 125. • If waist circumference > 80cm (woman) or 94cm (man), encourage weight loss and assess CVD risk 84. • Give omeprazole 20mg BID for 4 weeks. Refer if any of: no better after 14 days of omeprazole, new onset pain and > 50 years, pain on swallowing, persistent vomiting, weight loss, loss of appetite, early fullness, blood in stool or occult blood positive, abdominal mass or uncertain of diagnosis. No Viral infection or food poisoning likely • If new onset vomiting, usually with diarrhoea, cramping abdominal pain, loss of appetite, body pains and weakness, reassure patient that vomiting/diarrhoea should resolve within 1-3 days. • Give metoclopramide 10mg TID as needed for up to 5 days. • If vomiting/diarrhoea, give oral rehydration solution. • Advise patient to drink lots of fluids, eat small frequent meals as able and avoid fatty food. • Refer if any of: - - Vomiting persists > 3 days - - Not tolerating oral fluids or needing urgent attention as above - - Nausea persists > 2 weeks - - Uncertain of cause Yes 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
  • 34. Adult 34 Give urgent attention to the patient with diarrhoea and one or more of: • Dehydration: thirst, dry mouth, poor skin turgor, sunken eyes, decreased urine output, drowsiness/confusion, BP < 90/60 or postural drop of systolic BP > 20mmHg, pulse ≥ 100 • Large volumes of watery stools: cholera likely Management: • Give oral rehydration solution (ORS). If unable to drink or BP < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. If no improvement after IV rehydration, refer to hospital. • If cholera likely: Isolate patient and follow standard infection prevention precautions 122; manage according to degree of dehydration: - - If no/some dehydration, give oral rehydration solution. - - If unable to drink or severe dehydration, give Ringer’s lactate IV: 30mL/kg over 30 minutes followed by 70ml/kg over 2 and ½ hours and single dose doxycycline1 300mg. - - Discuss with the head of the facility and/or Woreda Health Office and review after 6 hours: • If no dehydration and < 3 liquid stools in past 6 hours, consider discharge. Give enough ORS for home treatment for 2 days. Advise patient to return if vomiting, diarrhea worsens or drinking/ eating poorly. • If still dehydrated or > 3 liquid stools in past 6 hours, continue rehydration. If patient is known with diabetes, heart disease or has no urine output, refer to hospital. Diarrhoea Approach to the patient with diarrhoea not needing urgent attention • Confirm patient has diarrhoea: ≥ 3 watery or loose stools/day. Ask about duration of diarrhoea. • Do stool microscopy for ova or parasite and inflammatory cells. • Advise patient to take more fluids, eat small frequent meals when able and avoid sweet/caffeinated drinks. • Give oral rehydration solution to prevent dehydration. If patient is terminally sick and survival is predicted to be short, give palliative care 120. Positive Negative If diarrhoea persists despite treatment or cause is not clear, refer to hospital. Review stool microscopy result. Avoid antibiotics. Diarrhoea for ≤ 2 weeks HIV negative/unknown HIV positive Diarrhoea for > 2 weeks Knowing the patient’s HIV status helps in the management. Test for HIV 75. • Avoid antibiotics. • Review medication: omeprazole, NSAIDs (e.g. ibuprofen) and metformin can cause diarrhoea. Consider change of medication if diarrhoea persists. • Give loperamide 4mg PO initially, then 2mg after each loose stool, maximum 16mg/day. • Give routine HIV care 76. • Lopinavir/ritonavir can cause ongoing diarrhoea. • ART not started or ART failed, treat for possible Isospora belli and microsporidiosis with co-trimoxazole 2 tablets of 960mg PO BID for 21 days and albendazole 400mg PO BID for 14 days. • Give loperamide 4mg PO initially, then 2mg after each loose stool, maximum 16mg/day. Review in 2 weeks if diarrhoea still present. If diarrhoea for > 2 weeks, test for HIV 75. • Give metronidazole2 500mg PO TID for 5-7 days. • If no response within 2 days, add ciprofloxacin1 500mg BID for 5 days Amoebic trophozoite and RBC/WBC seen • Give ciprofloxacin 500mg PO BID for 5 days. • If pregnant, give instead azithromycin 1g PO daily for 5 days. RBC/WBC only seen • If amoebiasis, give metronidazole2 500mg PO TID for 5-7 days. • If giardiasis, give single dose tinidazole2 2g PO. • If strongyloidiasis, give albendazole 400mg PO BID for 3 days. • If other parasites, albendazole 400mg PO daily for 3 days. Ova or parasite only seen 1 Avoid if pregnant. 2 Advise no alcohol until 24 hours after last dose of metronidazole/tinidazole.
  • 35. Adult 35 Constipation Anal symptoms Give urgent attention to the patient with constipation and: • No stools or flatus/wind in the last 24 hours with abdominal pain/distention and vomiting Management: • Refer same day. Give urgent attention to the patient with anal symptoms and one or more of: • Extremely painful lump on anus • Unable to pass stool because of anal symptoms Management: • 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). • Ask about regular use of enemas or laxatives. • Exclude pregnancy. If pregnant 112. • If weakness/tiredness, weight gain, low mood, dry skin or cold intolerance, hypothyroidism likely. Refer to hospital • If patient is terminally sick and survival is predicted to be short, give palliative care 120. • If > 65 years, bed-bound or receiving palliative care, check for impaction (solid immobile bulk of stool in rectum). If impacted, gently remove stool from rectum using lubrication. Follow with liquid paraffin 10ml TID per-rectum as needed. If bleeding or severe pain, stop and refer. • Advise a high fibre diet (vegetables, fruit, wholemeal cereals, 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 bisacodyl 5mg daily at night, increasing to maximum of 15mg as needed for 3-5 days. If on codeine/morphine, continue bisacodyl 5-10mg daily at night. • If no response after 1 week of laxative use, recent change in bowel habits, weight loss, blood in stool or occult blood positive, or uncertain cause for constipation, refer. Assess patient with anal pain, bleeding, discharge or itch/irritation. If patient has anal sex, also ask about genital symptoms 36. Crack/s Lump/pile Ulcer/s • Advise as for constipation above and to take sits baths. • If constipated, give bisacodyl as above. • Give bismuth compound one suppository BID for 5 days. • Advise as for constipation above and to avoid straining. • Apply hydrocortisone 1% cream BID for 5 days. If no better with treatment, refer. Treat as for genital ulcer 39. Perianal warts Red/raw skin Suspected worms Treat as for genital warts 40. • Advise good hygiene. • Look for contact cause. If diarrhoea 34. • Apply petroleum jelly to raw areas. If severe itching, also apply hydrocortisone 1% cream BID for 5 days. • Give single dose mebendazole 100mg and repeat dose 14 days later. If pregnant, give instead pyrantel pamoate 11mg/kg and repeat dose 14 days later. • Treat family members at the same time.
  • 36. Adult 36 Genital symptoms 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), omit ceftriaxone and increase azithromycin dose to 2g orally. 2 Avoid if pregnant. Assess the patient with genital symptoms and his/her partner/s Assess Note Symptoms Ask about genital discharge, rash, itch, lumps, ulcers and manage as below. Manage other symptoms as on symptom pages. STI risk Ask if patient or his/her regular partner has new or multiple partner/s, unreliable condom use or substance abuse 103. Abuse Ask about sexual assault. If yes 66. Ask if patient is unhappy in relationship. If yes 65. Family planning Assess patient’s contraception needs 110 and discuss infertility. Exclude pregnancy. If pregnant 112. Examination • Woman: examine abdomen for masses, look for genital discharge, ulcers, rash, lumps. Do bimanual palpation for cervical tenderness or pelvic masses and speculum examination for cervical abnormalities. • Man: look for discharge, inguinal lymph nodes, ulcers, scrotal swelling or masses. HIV If status unknown, test for HIV 75. Syphilis Test for syphilis if patient has an STI, is pregnant, was raped or whose partner has an STI. If positive 41. Cervical screen • If HIV negative, screen 5 yearly from age 30 to 49. If HIV positive, screen at HIV diagnosis (regardless of age) then 5 yearly. If abnormal 40. • Do cervical screen once an abnormal discharge has been treated 38. If cervix looks suspicious of cancer, refer same week. Advise the patient with genital symptoms and his/her partner/s • Discuss safe sex: provide male and female condoms, advise patient to stick to one partner at a time. • If patient has a sexually transmitted infection (STI) : - - Educate patient about cause and that an STI increases risk of HIV transmission. Urge patient to adhere to treatment and abstain from sex for duration of treatment and until at least 1 week after treatment. - - Stress importance of partner treatment and issue partner notification slip with the patient’s diagnosis for each partner. Treat the patient with genital symptoms and his/her partner/s Scrotal swelling/pain 37 Ulcer/s 39 Lump/s Groin 18 Skin 40 Discharge Man 37 Woman 38 Itch Discharge in woman 38 Glans penis 37 Pubic area 40 Patient’s diagnosis Treat the patient’s partner/s according to the patient’s diagnosis as well as the partners’ symptoms (if any) Cervicitis (Vaginal discharge) Give partner ciprofloxacin 500mg PO stat or ceftriaxone1 250mg IM and azithromycin 1g PO stat or doxycycline 100mg PO BID for 7 days. Pelvic inflammatory disease (Lower abdominal pain) Give partner ciprofloxacin 500mg PO stat or ceftriaxone1 250mg IM and azithromycin 1g PO stat or doxycycline 100mg PO BID for 7 days. Male urethritis (Urethral discharge) Give partner ciprofloxacin2 500mg PO stat or ceftriaxone1 250mg IM and azithromycin 1g PO stat or doxycycline2 100mg PO BID for 7 days. Epididymitis/epididymo-orchitis (Scrotal swelling) Give partner ciprofloxacin2 500mg PO stat or ceftriaxone1 250mg IM and azithromycin 1g PO stat or doxycycline2 100mg PO BID for 7 days. Genital ulcer disease Give partner single dose benzathine benzylpenicillin 2.4MU IM and either ciprofloxacin2 500mg PO BID for 3 days or single dose azithromycin 1g PO or erythromycin 500mg PO QID for 7 days. If penicillin allergic, replace benzylpenicillin with doxycycline2 100mg PO BID for 14 days. RPR positive Give partner single dose benzathine benzylpenicillin 2.4MU IM. If penicillin allergic, give instead doxycycline 100mg PO BID for 14 days. If pregnant, avoid doxycycline 41. Balanitis/balanoposthitis Give female partner clotrimazole vaginal tablet 200mg inserted at night for 3 days or clotrimazole 1% vaginal cream applied once at night for 7 days. Pubic lice Give partner permethrin 1% or 5% thin film to be applied for 10 minutes then washed off 40. Inguinal bubo (swelling) without ulcer Give partner doxycycline 100mg PO BID for 14 days. If pregnant, give instead erythromycin 500mg PO QID for 14 days.
  • 37. Adult 37 Genital symptoms in a man Approach to the man with genital symptoms not needing urgent attention First assess and advise the patient and his partner/s 36. Male urethritis likely • Give single dose: ceftriaxone 250mg IM or spectinomycin 2g IM or ciprofloxacin 500mg PO and • Give single dose azithromycin 1g PO or doxycycline 100mg PO BID for 7 days. • If partner has cervicitis/vaginitis, also give single dose metronidazole1 2g PO. • Treat patient’s partner/s 36. Balanitis/balanoposthitis likely • Advise patient to wash daily with water, avoid soap. Retract foreskin while washing then dry fully. • Give clotrimazole cream BID for 7 days. • Offer referral for medical male circumcision, especially if persistent/ recurrent or difficulty retracting foreskin. • Treat patient’s partner/s 36. • Advise patient to return in 7 days if symptoms persist: - - If adherence poor, repeat treatment. - - Test for diabetes 86 and HIV 75. • If still no better, refer. Give urgent attention to the man with genital symptoms and one or more 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 reduced with swollen and very painful glans: paraphimosis likely • Prolonged erection > 4 hours: priapism likely Management: • If torsion of testicle or priapism likely: refer urgently. • If paraphimosis likely: - - If glans blue/black: refer urgently. - - If not, attempt manual reduction: apply lidocaine 2% gel to glans, then wrap glans in gauze. Apply increasing pressure for 10-15 minutes until foreskin can be replaced over glans. If unsuccessful, refer urgently. Advise patient to return in 7 days if symptoms persist: • If not adherent or was re-exposed, repeat treatment. • If fully adherent and no re-exposure: - - Give single dose ceftriaxone 250mg IM and - - Single dose azithromycin 2g PO and - - Single dose metronidazole1 2g PO (if not already given) or tinidazole1 1g PO once daily for 3 days. - - If severe penicillin allergy2 , omit ceftriaxone and refer. Painless swelling Pain with/without swelling Urethral discharge © University of Cape Town Scrotal symptoms © University of Cape Town Painful, itchy or smelly glans © University of Cape Town 1 Advise no alcohol until 24 hours after metronidazole or last dose of tinidazole. 2 Penicillin allergy with angioedema, anaphylaxis or urticaria. • If firm lump, testicular cancer likely: refer to hospital. • If soft lump, hydrocele likely: if large or uncomfortable, refer to hospital; otherwise advise patient to return if it becomes larger, painful or uncomfortable. Epididymitis/epididymo-orchitis likely • Give single dose ceftriaxone 250mg IM or spectinomycin 2g IM or ciprofloxacin 500mg PO and • Give doxycycline 100mg PO BID for 14 days. • Treat patient’s partner/s 36. • For pain, give paracetamol 1g PO QID as needed for up to 5 days. If no response, also give ibuprofen 400mg PO TID with food for up to 5 days (avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • If no better after 7 days, refer.
  • 38. Adult 38 Vaginal symptoms Is there lower abdominal pain or cervical motion tenderness? If abnormal vaginal bleeding 42. If vaginal discharge or mass, manage below. Vaginal discharge • It is normal for a woman to have a vaginal discharge. Abnormal discharges are itchy or different in colour or smell. Not all women with a discharge have an STI. • First assess and advise the patient and her partner/s 36. If the vulva is red, scratched and inflamed or cheese/curd-like discharge, vaginal candida likely: • Give clotrimazole vaginal tablet 200mg inserted at night for 3 days or single dose fluconazole 150mg PO. • If severe, give instead single dose fluconazole 150mg PO and repeat after 3 days. If patient known with cervical cancer, and survival is predicted to be short, give palliative care 120. Vaginal mass Vaginal/uterine prolapse likely • If cough 29; constipation 35; menopause 119. • Examine to confirm prolapse. If unsure, refer. • If no ulcer on prolapse, refer for surgery. • If ulcer present on prolapse: - - Apply oestrogen cream or crushed oral contraceptives in petroleum jelly daily for 1 month. - - Advise patient to reinsert prolapse regularly and avoid strenuous activity. - - Review after 1 month: If healed, refer for surgery. If not healed, refer for further evaluation. No Treat for vaginitis (trichomoniasis/bacterial vaginosis): • Give metronidazole1 500mg PO BID for 7 days. • If recurrent vaginitis, also give partner single dose metronidazole1 2g PO. Does patient have any of: < 25 years, > 1 partner, new partner and unprotected sex in last 3 months, ever traded for sex or partner/s with STI? Review in 7 days: • If ongoing discharge: examine cervix for cancer and do cervical screen40. • If ongoing vaginal candida also test for diabetes 86 and HIV 75. • Refer same week. Give urgent attention to the patient with vaginal discharge and lower abdominal pain/cervical motion tenderness and any of: • Recent miscarriage/delivery/abortion • Pregnant or missed/overdue period • Peritonitis (guarding, rigidity or rebound tenderness) • Abnormal vaginal bleeding • Temperature ≥ 38°C • Abdominal mass Management: • If BP < 90/60, give normal saline 1L IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • Give ceftriaxone 1g IV and metronidazole1 500mg IV infusion/orally. If severe penicillin allergy3 , omit ceftriaxone and refer. • Refer same day for surgical/gynaecological assessment. Approach to the patient with lower abdominal pain or cervical motion tenderness not needing urgent attention: Lower abdominal pain only, no cervical motion tenderness Check urine dipstick. If WBC/nitrites positive, urinary tract infection likely 44. If WBC/nitrites negative, treat below. Also treat for cervicitis (gonorrhoea & chlamydia): • Give single dose ceftriaxone 250mg IM and • Give doxycycline2 100mg PO BID for 7 days or single dose azithromycin 1g PO, if available. • If severe penicillin allergy3 , omit ceftriaxone and increase azithromycin to 2g. • Treat the patient’s partner/s 36. Cervical motion tenderness with or without lower abdominal pain Pelvic inflammatory disease likely • Give single dose ceftriaxone 250mg IM or if severe penicillin allergy3 , give instead single dose ciprofloxacin 500mg PO and • Give doxycycline 100mg PO BID for 14 days and metronidazole1 500mg PO BID for 14 days. • For pain, give paracetamol 1g PO QID as needed for up to 5 days. If no response, also give ibuprofen 400mg PO TID with food for up to 5 days (avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • Treat the patient’s partner/s 36. • Review within 3 days. If no better, refer same day. 1 Advise no alcohol until 24 hours after last dose of metronidazole. 2 Avoid if pregnant and give single dose azithromycin 1g PO instead. 3 Penicillin allergy with angioedema, anaphylaxis or urticaria. Yes Yes No
  • 39. Adult 39 • First assess and advise the patient and his/her partner/s 36. • The patient may have blister/s, sore or ulcer. Also treat for early syphilis and chancroid: • Give single dose benzathine benzylpenicillin 2.4MU IM or if penicillin allergic and not pregnant/breastfeeding, doxycycline 100mg PO BID for 14 days and • Give single dose azithromycin 1g PO or ciprofloxacin 500mg PO BID for 3 days or erythromycin 500mg PO QID for 7 days. - - If penicillin allergic and pregnant/breastfeeding, give ceftriaxone 1g IM daily for 8-10 days. - - If penicillin allergic, do baseline RPR. Advise patient to return for repeat RPR in 6 and 12 months. If RPR positive after 12 months, refer. • If vaginal/urethral discharge, also treat patient and partner/s for gonorrhoea (chlamydia already covered for above): give single dose ceftriaxone2 250mg IM. No No Check if patient also has hot tender swollen inguinal nodes (discrete, movable and rubbery). Also treat patient and partner/s for lymphogranuloma venereum: • Give ciprofloxacin 500mg PO BID for 3 days and doxycycline 100mg PO BID for 14 days. If pregnant/breastfeeding, give instead erythromycin 500mg PO QID for 14 days. • If fluctuant lymph node (hernia and aneurysm excluded), aspirate pus through healthy skin in sterile manner every 3 days as needed. Avoid making incisions. • Review after 14 days. If no better, refer. © University of Cape Town Yes Yes If no better after 7 days, refer. First episode, solitary or non-vesicular ulcer? Genital ulcer Treat for herpes: • Start as soon as possible after onset of symptoms: - - If first episode, give aciclovir 400mg PO TID for 10 days. - - If recurrent episode, give aciclovir 400mg PO TID for 5 days. If impaired immunity1 , give aciclovir 400mg PO TID for 10 days. • For pain: - - Advise sitz baths as needed (sit for 10 minutes in lukewarm water with no salts). - - Give lidocaine 2% gel applied topically to lesions TID as needed. - - Give paracetamol 1g PO QID as needed for up to 5 days. If no response, also give ibuprofen 400mg PO TID with food for up to 5 days (avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • Keep lesions clean and dry. • Explain that herpes infection is lifelong and that herpes transmission can occur even when asymptomatic. Advise patient to use condoms and to abstain from sex when symptomatic. The likelihood of HIV transmission is increased when there are ulcers. • If recurrent episodes are severe or > 6 in 1 year or cause distress, refer © University of Cape Town 1 Known with HIV or lymphoma, pregnant or receiving chemotherapy or corticosteroids. 2 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), omit ceftriaxone and refer.
  • 40. Adult 40 Other genital symptoms Cervical screening First assess and advise patient and partner/s 36. • A cervical screen detects cervical abnormalities which occur before cancer develops. Cervical cancer is caused by certain types of human papilloma virus (HPV) which is usually transmitted sexually. • Visual inspection with acetic acid (VIA) is the cervical screening method that is recommended at health centers and should be performed by trained personnel. • Women who smoke are more likely to have cervical abnormalities. If patient smokes tobacco 102. Support patient to change 125. • If HIV-negative and asymptomatic, do a cervical screen from age 30, then 5 yearly if the result is normal till age 49. • If HIV-positive and asymptomatic, do a cervical screen at HIV diagnosis (regardless of age), then 5 yearly if the result is normal. • No screening needed if age ≥ 50, > 30 weeks pregnant or previous total hysterectomy for benign case. Inform patient of symptoms of cervical cancer (abnormal vaginal bleeding, vaginal discharge, postcoital/contact bleeding) and advise her to return should they occur. Manage according to VIA: • If normal: arrange repeat VIA after 5 years. • If VIA abnormal, treat with cryotherapy using double freeze (3 minutes freeze, 5 minutes defrost, 3 minutes freeze) technique. • After treatment, continue screening every year. • If suspicious of cancer, refer same week. Lumps Itchy rash in pubic area Molluscum contagiosum • Papules with central dent • Usually self- limiting and no treatment required. • If HIV positive, should resolve with ART. • If no response to treatment, refer. Pubic lice • Treat patient and partner/s • Apply thin film of permethrin 1% or 5% cream to affected areas and adjacent hairy areas. Wash off after 10 minutes. Avoid mucous membranes, urethral opening and raw areas. Repeat after 7 days if needed. • Wash all clothes, sheets and blankets in very hot water. • Iron all clothing • Shave pubic area Genital warts • Test for syphilis. If positive 41. • Choose treatment based on availability and/or patient choice. • Patient administered: - - Apply imiquimod 5% cream directly to warts. Wash off after 6-10 hours. Apply 3 times weekly for 16 weeks. - - Alternatively, apply podophyllotoxin 0.5% cream BID for 3 days followed by 4 days of no treatment. Repeat cycle up to 4 times. • Provider administered: - - Apply Vaseline® to surrounding normal skin and then apply trichloroacetic acid 30-90% solution directly to warts weekly until wart resolves. - - Alternatively, apply podophyllin resin 10-25% directly to warts. Wash after 1-4 hours. Repeat weekly until wart resolves. • Do cervical screen. © University of Cape Town • If warts > 1cm, multiple, in vagina or on cervix, pregnant or medications not available, refer. • Reassure patient that most warts resolve spontaneously within 2 years. Scabies • Treat patient, partner/s and household contacts • Apply permethrin 5% from the neck down. Wash off after 8-14 hours. Avoid mucous membranes, urethral opening and raw areas. • Repeat after 1 week if needed. © BMJ Best Practice • Wash clothes in hot water or iron clothes after normal wash.
  • 41. Adult 41 Positive syphilis result Approach to the patient with a positive RPR result First assess and advise the patient and his/her partner/s 36. Does patient have a genital ulcer or signs of secondary syphilis1 ? • Treat for late syphilis: - - Give benzathine benzylpenicillin 2.4MU IM weekly for 3 weeks. - - If penicillin allergic and not pregnant/breastfeeding, give instead doxycycline 100mg PO BID for 28 days. - - If penicillin allergic and pregnant/breastfeeding, give instead erythromycin 500mg PO QID for 30 days. • Repeat RPR in 6, 12 and 24 months. If positive RPR at 24 months, refer. • Treat partner/s36. Is there a negative RPR from the last 2 years? • Treat for early syphilis: - - Give single dose benzathine benzylpenicillin 2.4MU IM. - - If penicillin allergic and not pregnant/breastfeeding, give instead doxycycline 100mg PO BID for 14 days. - - If penicillin allergic and pregnant/breastfeeding, give instead ceftriaxone 1g IM daily for 8-10 days. • Repeat RPR in 6 and 12 months. If RPR positive at 12 months, refer. • Treat partner/s 36. • Treat for late syphilis: - - Give benzathine benzylpenicillin 2.4MU IM weekly for 3 weeks. - - If penicillin allergic and not pregnant/breastfeeding, give instead doxycycline 100mg PO BID for 28 days. - - If penicillin allergic and pregnant/breastfeeding, give instead erythromycin 500mg PO QID for 30 days. • Repeat RPR in 6, 12 and 24 months. If RPR positive at 24 months, refer. • Treat partner/s 36. Manage the newborn of the RPR positive mother: • If baby well and mother fully treated > 1 month before delivery: give single dose benzathine benzylpenicillin 50 000 units/kg IM. • If signs of congenital syphilis2 , or mother not fully treated or treated < 1 month before delivery, refer to hospital. Is previous RPR result available? 1 The signs of secondary syphilis occur 4-8 weeks after the primary ulcer and include a generalized rash (including palms and soles), flu-like symptoms, flat wart-like genital lesions, mouth ulcers and patchy hair loss. 2 Signs of congenital syphilis are rash (red/blue spots or bruising especially on soles and palms), jaundice, pallor, distended abdomen, swelling, low birth weight, runny nose/respiratory distress, hypoglycaemia. No No No Yes Yes Yes
  • 42. Adult 42 Abnormal vaginal bleeding (AVB) Give urgent attention to the patient with vaginal bleeding and one or more of: • Pregnant 112 • BP < 90/60 • Postpartum 116. • Following miscarriage/abortion 112 • Pallor with pulse ≥ 100, respiratory rate > 30, dizziness/faintness or chest pain Management: • If BP < 90/60, give normal saline 1L IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • Refer urgently. Approach to the patient with abnormal vaginal bleeding not needing urgent attention • Do a bimanual palpation for pelvic masses, a speculum examination to visualise cervix and a cervical screen 40. If abnormal, refer. • If > 40 years, ask about menopausal symptoms: hot flushes, night sweats, vaginal dryness, mood changes, difficulty sleeping and sexual problems 119. If new bleeding occurs > 1 year after final period, refer same week. • If patient is not menopausal determine the type of bleeding problem: Heavy regular bleeding (interferes with quality of life) or clots or bleeding > 7 days each period Periods have irregular pattern (< 21 days or > 35 days between periods) Bleeding after sex • Assess for STI 36. • If assault or abuse 66. • If weight change, pulse ≥ 100, tremor, weakness/ tiredness, dry skin, constipation or intolerance to cold or heat, refer to hospital. • Give combined oral contraceptive: ethinylestradiol/ levonorgestrel 30/150mcg for 6 months. • If pregnancy desired, refer instead. Refer the patient within 2 weeks if: • Unsure of diagnosis • Bleeding > 1 week after STI treatment, or after diarrhoea/vomiting stop • Bleeding persists after 3 months on treatment. • Abnormal cervix on speculum examination (suspicious of cancer) Oral contraceptive: • Ensure correct use. • If ≥ 2 days diarrhoea/ vomiting, advise condom use (continue for 7 days once diarrhoea/vomiting has resolved). • If on ART, rifampicin or phenytoin, change to injection/IUD. • If on ethinylestradiol/ levonorgestrel 30/150mcg, change to ethinylestradiol/ norethisterone 35mcg/1mg for 3 cycles. Injectable contraceptive or subdermal implant: • Reassure (common in first 3 months). • If bleeding persists, give combined oral contraceptive: ethinylestradiol/ levonorgestrel 30/150mcg for 3 cycles. • If combined oral contraceptive contraindicated (heart disease, thrombo-embolic conditions, liver disease, migraine headache, genital tract cancer), give instead ibuprofen 400mg PO TID with food for 5 days (avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease). Spotting between periods • Assess for STI 36. • If on hormonal contraceptive, manage according to method: Has the patient been bleeding elsewhere (gums, easy bruising, purple rash)? Yes • Check complete blood count. • Refer to hospital same week. No • If Hb ≤ 12g/dL, give ferrous sulphate 200mg (65mg elemental iron) 1 tablet PO TID until 3 months after Hb reaches 12g/dL. • Give combined oral contraceptive: ethinylestradiol/ levonorgestrel 30/150mcg for 3 cycles 110. • If combined oral contraceptive contraindicated (heart disease, thrombo-embolic conditions, liver disease, migraine headache, genital tract cancer), or pregnancy desired, give instead ibuprofen 400mg PO TID with food for 5 days (avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • If on injectable contraceptive or subdermal implant: reassure (common in first 3 months). If bleeding persists, give combined oral contraceptive or ibuprofen as above. • Refer the patient: - - Same week if mass in abdomen - - If no better after 3 months on treatment - - If excessive bleeding after IUD insertion
  • 43. Adult 43 Sexual problems Problems getting or maintaining an erection Does patient often wake with an erection in the morning? No • Assess and manage CVD risk 84. • Review medication: propranolol, atenolol, hydrochlorothiazide, spironolactone, fluphenazine decanoate, fluoxetine and amitriptyline can cause sexual problems. Consider changing medication. • Screen for substance use/ abuse: In the past year, has patient: 1) drunk ≥ 4 drinks1 / session, 2) used khat or illegal drugs or 3) misused prescription or over-the- counter medications? If yes to any 103. • If patient smokes tobacco 102. Support patient to change 125. • Assess and manage stress 65. • If no better once chronic condition/s stable and treatment optimised, refer. Yes • If genital symptoms 36. • If urinary symptoms 44. • Review medication: herbal medication, antidepressants and schizophrenia treatment can cause painful ejaculation. Consider changing medication. • If no cause found or painful ejaculation or erection continues, refer. Superficial pain • If genital symptoms 36. • If urinary symptoms 44. • Ask about vaginal dryness: - - If woman > 40 years, ask about menopausal symptoms: hot flushes, night sweats, mood changes and difficulty sleeping 119. - - Review medication: oral or injectable contraceptive, antidepressants and hypertension treatment can cause vaginal dryness. Consider changing medication. • Advise patient to use lubricant during sex. Ensure it is condom- compatible, avoid using petroleum jelly with condoms. Deep pain • If genital symptoms 36. • Refer if: - - Heavy, painful or prolonged periods - - Infertility - - Abdominal/pelvic mass • Assess and manage stress 65. • Ask about relationship problems, anxiety/ fear about sex, unwanted pregnancy, infertility and performance anxiety. • If sexual assault or abuse 66. • In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. • Discuss condom use. Ensure patient knows how to use condoms correctly. Pain with sex (vaginal) Painful erection orejaculation Loss of libido Ask if pain with sex or if problem with erections. Assess and manage in adjacent columns. • Assess and manage stress 65. • Review medication: phenytoin, metoprolol, hydrochlorothiazide, spironolactone, chlorpromazine, fluphenazine decanoate, risperidone, fluoxetine, amitriptyline and lopinavir/ ritonavir can cause loss of libido. Consider changing medication. • In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. • Screen for substance use/abuse: In the past year, has patient: 1) drunk ≥ 4 drinks1 / session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. • Ask about relationship problems, anxiety/ fear about sex, unwanted pregnancy, infertility and performance anxiety. • If woman > 40 years, screen for menopause 119. • If sexual assault or abuse 66. • Assess the patient’s contraception needs 110. Is the pain superficial or deep? • Assess and manage stress 65. • If sexual assault or abuse 66. Ask about problems getting or maintaining an erection, pain with sex, painful ejaculation or loss of libido: If sexual problems do not improve, refer to hospital. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
  • 44. Adult 44 Urinary symptoms Give urgent attention to the patient with urinary symptoms and one or more of: • Unable to pass urine with lower abdominal discomfort/distention • Flank pain with leucocytes/nitrites on urine dipstick and any of: vomiting, BP < 90/60, pulse ≥ 100, temperature > 39°C, pregnant, ≥ 60 years or chronic illness: complicated pyelonephritis likely. Manage and refer urgently: • If unable to pass urine, insert urinary catheter. • If complicated pyelonephritis likely, give ceftriaxone1 1g IV/IM. If pyelonephritis not complicated, treat below. If unsure about diagnosis or severe pain, refer. If BP < 90/60, give normal saline 250mL IV rapidly, 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 pyelonephritis not complicated: send urine for microscopy. Give ciprofloxacin 500mg PO BID for 10 days and paracetamol 1g PO QID. If no better after 2 days, refer. • Ask about blood in urine, burning urine and flow problem. Check urine dipstick. Blood in urine Has patient been in bilharzia area? Woman Is patient pregnant, catheterised, known with diabetes or urinary tract problem? Flow Problem Check dipstick and microscopy to exclude urinary tract infection. Leakage of urine Urinary incontinence likley • Review use of furosemide • Look for vaginal atrophy 119. • Ask about constipation 35. • Advise patient to cut down alcohol and caffeine and to do pelvic muscle exercises3 . • If patient has vaginal prolapse or no response to above measures, refer. Poor stream or difficulty passing urine Benign Prostatic hyperplasia likely. • Review use of amitriptyline. • Refer for assessment. Man No discharge Are there leucocytes and nitrites on midstream urine? Discharge Burning urine or leucocytes/nitrites on urine dipstick If symptoms do not resolve or recurrent urinary tract infections, refer to hospital. Yes Schistosomiasis likely • Give single dose praziquantel 40mg/kg. • To prevent re- infection advise patient to avoid contact with contaminated water. No Does patient have burning urine? No Leucocytes/nitrites on urine dipstick? No No No No Kidney stone likely Refer for investigation. Yes Yes Yes Yes Simple urinary tract infection likely • Give ciprofloxacin 500mg PO BID for 3 days or norfloxacin 400mg PO BID for 3 days. Acute prostatitis likely • Give ciprofloxacin 500mg PO BID for 21 days. • Give ibuprofen 400mg PO TID with food for up to 5 days (avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease). Urethral discharge syndrome likely 37. Check for tender prostate. Complicated urinary tract infection likely • Give ciprofloxacin 500mg PO BID for 7 days. • If pregnant, give instead cefalexin 500mg PO BID or amoxicillin2 500mg PO TID for 7 days . 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria) and able to take orally, give instead ciprofloxacin 500mg PO (avoid if pregnant). 2 If penicillin allergic give instead co-trimoxazole 960mg PO BID for 7 days. 3 Repeated contraction and relaxation of pelvic floor muscles. If no response to treatment, refer.
  • 45. Adult 45 Body/general pain Approach to the patient who aches all over • Check temperature and weight. • Ask about a sore throat, runny/blocked nose or fever in the past 3 days. • If on ART, check for urgent side effects 80. Normal Screen for a joint problem: 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 temperature ≥ 38°C or fever in the past 3 days 17. • If weight loss ≥ 5% of body weight in past 3 months 16. • If sore throat 27. • If runny/blocked nose 26. Unable to do all actions comfortably Examine the joints. Joints are warm, tender, swollen, have limited movement. Arthritis likely 107 Joints are normal. < 3 months • Give paracetamol 1g PO QID as needed for up to 5 days. • Advise patient to return if no better after 2 weeks. Any result abnormal Refer for further assessment. Results all normal • Assess and manage stress 65. • Consider fibromyalgia 109. • Test for HIV 75. • Assess and manage stress 65. • Review patient's medication. If on simvastatin or lovastatin and muscle pain/cramps and weakness, refer to hospital. • If patient is terminally sick and survival is predicted to be short, give palliative care 120. • Ask about duration of pain: Able to do all actions comfortably ≥ 3 months • Give paracetamol 1g PO QID as needed for up to 5 days. Advise to avoid long term regular use. • Check ESR ,urine protein, blood glucose and Hb. • If weakness/tiredness, weight gain, low mood, dry skin, constipation or cold intolerance: hypothyroidism likely. Refer to hospital.
  • 46. Adult 46 Joint symptoms Give urgent attention to the patient with a joint symptom and: • Short history of single warm, swollen, extremely painful joint with limited range of movement Management: • If recent trauma, immobilise and if available arrange x-ray. • If known with gout, manage as acute gout 108. • Refer urgently. Approach to the patient with a joint symptom not needing urgent attention Check if problem is in the joint: 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. Able to do all actions comfortably Unable to do all actions comfortably Has there been recent trauma? Joint problem unlikely ≥ 6 weeks Chronic arthritis likely 107 No Yes < 6 weeks Recent genital discharge or painless non-itchy skin rash? Musculoskeletal sprain/strain likely • Rest and elevate joint. • Apply ice. • Apply pressure bandage. • Give paracetamol 1g PO QID as needed for up to 5 days. If no response, give ibuprofen 400mg PO TID with food as needed for up to 7 days (avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • Advise patient to mobilise joint after 2-3 days, if not too painful. • Advise to avoid traditional practices like massage. • Review after 1 week: if no better, refer and if available arrange x-ray. Sudden onset of 1-3 warm, extremely painful, red, swollen joints (often big toe or knee)? • If generalised body pain 45. • If back pain 47. • If neck pain 48. • If arm symptoms 48. • If leg symptoms 49. • If foot symptoms 50. Yes No No • Give paracetamol 1g PO QID as needed for up to 5 days. If no response, give ibuprofen 400mg PO TID with food as needed (avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • Test for HIV 75. • Review after 1 month or sooner if joint pain worsens. If worsens, refer. Yes Acute gout likely 108 Gonococcal arthritis likely • Usually involves wrists, ankles, hand and feet. • Refer patient same day. • Treat patient’s partner/s as for cervicitis/male urethritis 36. Ask about duration of joint pain
  • 47. Adult 47 Back pain Approach to the patient with back pain not needing urgent attention • If pyelonephritis not complicated: send urine for microscopy, culture, sensitivity. Give ciprofloxacin 500mg PO BID for 10 days and paracetamol 1g PO QID as needed. If no better after 2 days, refer same day. • Does patient have any of: cough, weight loss, night sweats or fever? Yes Yes Any of: > 50 years, pain progressive or for > 6 weeks, previous cancer, back surgery or trauma, osteoporosis, oral steroid use, HIV, IV drug use or deformity? Exclude TB 71 and • If available, do back x-ray. • Check ESR. • Refer to hospital. Any of: < 40 years, sleep disturbed by pain, pain better with exercise, does not get better with rest? Mechanical back pain likely • Measure waist circumference: if > 80cm (woman) or > 94cm (man) assess CVD risk 84. • Assess and manage stress 65. • Reassure patient that back pain is very common, normally not serious and will get better on its own. • Advise patient to be as active as possible, continue normal activity and avoid resting in bed. • Advise patient that regular exercise may prevent recurrence of back pain. • Give diclofenac2 /misoprostol 50mg/200mg PO BID or ibuprofen2 400mg PO TID with food for up to 5 days or paracetamol 1g PO QID as needed for up to 5 days . • If degenerative disc disease, consider indomethacin1 25mg PO or 100mg PR BID. • If pain persists > 4 weeks or unable to cope with daily activities, refer for physiotherapy. • If pain persists > 6 weeks, do back x-ray if available and refer to hospital. • If bladder/bowel disturbance, numbness or weakness develops, refer urgently. Inflammatory back pain likely Yes No No No • If available, do back x-ray • Check ESR. • Refer to hospital. Unsure 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid ceftriaxone and refer. 2 Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. Give urgent attention to the patient with back pain and one or more of: • Bladder or bowel disturbance - retention or incontinence • Numbness of buttocks, perineum or legs • Leg weakness or difficulty walking • Recent trauma and x-ray unavailable or abnormal • Sudden severe upper abdominal pain with nausea/vomiting: pancreatitis likely • Any palpable abdominal mass • If flank pain or fever, check urine dipstick: - - If leucocytes/nitrites, pyelonephritis likely. If also vomiting, BP < 90/60, pulse ≥ 100, temperature > 39°C, pregnant, ≥ 60 years or chronic illness: complicated pyelonephritis likely - - If blood with sudden, severe, one-sided pain radiating to groin: kidney stone likely Management: • If pancreatitis likely: give Ringer’s lactate 1L IV rapidly regardless of BP, then give 1L 4 hourly. Stop if breathing worsens. • If abdominal mass: if ruptured abdominal aortic aneurysm suspected avoid giving IV fluids as raising blood pressure may worsen rupture even if BP < 90/60 • If complicated pyelonephritis likely: give ceftriaxone1 1g IV/IM. If pyelonephritis not complicated: 44. If unsure about diagnosis or severe pain, refer. If BP < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • If kidney stone likely: give normal saline 1L IV 6 hourly and ibuprofen2 800mg PO. • Refer urgently.
  • 48. Adult 48 Neck pain Arm symptoms Give urgent attention to the patient with neck pain and one or more of: • Neck stiffness/meningism and temperature ≥ 38°C: give ceftriaxone1 2g IV/IM or crystalline penicillin1 4M IU IV with chloramphenicol 500mg IV. • Neurological symptoms in arms/legs: weakness, numbness, clumsiness, stiffness, change in gait or difficulty with co-ordination • Recent trauma and x-ray unavailable/abnormal x-ray, or neurological symptoms: immobilise neck with rigid collar and sandbags/blocks on either side of head. Management • Refer urgently. Approach to the patient with neck pain not needing urgent attention Any of: < 20 years, > 55 years, pain progressive or for > 6 weeks, previous cancer/TB/neck surgery, osteoporosis, oral steroid use, HIV, diabetes, IV drug use or unexplained weight loss/fever? Yes • Arrange cervical spine x-rays if available. • Check ESR and refer to hospital. Painful shoulder Referred pain likely Ask about neck pain (see above), cough/difficulty breathing 29, abdominal pain 32, pregnancy 112. Wrist/hand pain: intermittent, worse at night, relieved by shaking. May be numbness/tingling in 1st, 2nd and 3rd fingers or weakness of hand. Carpal tunnel syndrome likely Refer. Elbow pain with or after elbow flexion/extension. May have decreased grip strength. Tennis or Golfer’s elbow (medial/lateral epicondylitis) likely • Advise patient to apply ice to elbow and rest arm. • Give ibuprofen2 400mg PO TID with food for 10 days. • If no better after 6 weeks or worsens, refer. Pain at base of thumb worsened by thumb or wrist movement or catching/locking of finger Tenosynovitis of hand/wrist likely • Rest and splint joint. • Give ibuprofen2 400mg PO TID with food for up to 14 days. • If no better after 6 weeks or worsens, refer. • Give paracetamol 1g QID PO as needed for up to 5 days. • If no arm pain, refer to hospital for physiotherapy. • If no response after 6 weeks, weakness/numbness in arm or hand develops or pain worsens, do cervical spine x-rays if available and refer. No Approach to the patient with arm symptoms not needing urgent attention Give urgent attention to the patient with arm symptoms and one or more of: • Arm pain with chest pain 28. • Recent trauma with pain and limited movement: immobilise, arrange x-ray if available and refer. • If arm/hand cold, pale, decreased pulses or numb or open fracture, refer urgently. • If new sudden weakness of arm, may have difficulty speaking or visual disturbance: consider stroke or TIA 91. Check if problem is in the joint: patient to place hands behind head; then behind back. Bury nails in palm and open hand. Press palms together with elbows lifted. If unable to do all actions comfortably 46. 1 If severe penicillin allergy with previous angioedema, anaphylaxis or urticaria, give chloramphenicol only and refer. 2 Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease.
  • 49. Adult 49 Leg 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 46. • If the problem is also in the foot 50. Approach to the patient with leg symptoms not needing urgent attention • If constant burning pain, pins/needles or numbness of legs and feet that is worse at night, peripheral neuropathy likely 50 • Review patient’s medication. If on simvastatin and muscle pain/cramps and weakness, refer to hospital. • Is there leg swelling? No Yes 1 Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. Yes Yes Pain in buttock radiating down back of lower leg Muscle pain in legs or buttocks on exercise that is relieved by rest No No No No Both legs swollen Is there difficulty breathing worse on lying flat? One leg swollen Has there been a recent injury? Irritation of sciatic nerve likely • Give paracetamol 1g PO BID and ibuprofen1 400mg PO TID with food only as needed for up to 1 month (avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • Advise patient to be as active as possible, continue normal activity and avoid resting in bed. • Advise patient to return and refer same day if: - - Retention or incontinence of urine or stool - - Numbness of buttocks, perineum or legs - - Leg weakness - - Difficulty walking • If no better after 1 month, refer. Musculoskeletal sprain/strain likely • Ensure patient can bear weight on leg, otherwise refer same day. • Rest and elevate leg. • Apply ice. • Apply pressure bandage. • Advise patient to mobilise leg after 2-3 days, if not too painful. • Give paracetamol 1g PO QID for up to 5 days or give ibuprofen1 400mg PO TID with food up to 7 days (avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • Review after 1 week: if no better, refer to hospital. Heart failure likely 91. Examine skin: are there any painful areas, ulcers, lumps or changes in skin colour? • If pregnant 112. • Check for kidney disease on urine dipstick: if blood or protein, refer to hospital. • If weight loss and MUAC < 21cm, malnutrition likely 70. • If none of the above or unsure, refer to hospital. Yes Yes 53 18 Check for groin lump/s. Refer same week. Peripheral vascular disease likely 96. Give urgent attention to the patient with leg symptoms and one or more of: • Unable to bear weight following injury 14. • Swelling and pain in one calf: deep venous thrombosis likely, especially if BMI > 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 Management: • Refer same day.
  • 50. Adult 50 Foot symptoms Give urgent attention to the patient with foot symptoms and one or more of: • Unable to bear weight following injury 14. • 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, gangrene or ulceration: critical limb ischaemia likely • On ART and symptoms rapidly worsening over a few weeks, sensation decreased, and/or arms involved: stop ART Management: • Refer same day. 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 46. In the patient with diabetes or PVD, identify the foot at risk. Review more frequently the patient with diabetes or PVD and one or more of: • Skin: callus, corns, cracks, wet soft skin between toes 55, ulcers 59. • Foot deformity: check for bunions (see above). If foot deformity, refer to hospital. • Sensation: light prick sensation abnormal after 2 attempts • Circulation: absent or reduced foot pulses Advise the 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. • Moisten dry cracked feet daily with Vaseline®. Avoid moisturising between toes. • Tell your health worker at once if you have any cuts, blisters or sores on the feet. • Avoid walking barefoot or wearing shoes without socks. Change socks/stockings daily. Inspect inside shoes daily. • Clip nails straight, file sharp edges. Avoid cutting corns/calluses yourself or chemicals/plasters to remove them. • Avoid testing water temperature with feet or using hot water bottles or heaters near feet. Approach to the patient with foot symptoms not needing urgent attention Generalised foot pain Constant burning pain, pins/needles or numbness of feet worse at night Peripheral neuropathy likely • Test for HIV 75. If HIV positive, give routine care 76. • Exclude diabetes 86. • Give amitriptyline 10-75mg at night and paracetamol 1g PO QID. If no response, add ibuprofen 400mg PO TID with food up to 5 days (avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • Refer same week if one-sided, other neurological signs or loss of function. • Check if patient is on IPT, TB treatment or ART: - - If on IPT or TB treatment: give pyridoxine 75mg daily. Localised pain Ensure that shoes fit properly. Heel pain, worse on starting walking Foot deformity Foot pain with muscle pain in legs or buttocks Bony lump at base of big toe; may have callus, redness or ulcer Bunion likely • Advise pain relief as needed: apply ice, give paracetamol 1g PO QID or ibuprofen 400mg PO TID with food for up to 5 days (avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • Advise to wear comfortableshoes when possible. • If severe pain, ulcer or other foot deformity refer. Plantar fasciitis likely • Advise patient to avoid bare feet and to apply ice. • If BMI > 25, assess CVD risk 84. • Give as needed: paracetamol 1g PO QID or ibuprofen 400mg PO TID with food for up to 5 days (avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure or kidney disease). • Refer to hospital for physiotherapy. Peripheral vascular disease likely 96.
  • 51. Adult 51 Burn/s Give urgent attention to the patient with burn/s: Give facemask oxygen if: • Burns to face, neck or upper chest • Cough, difficulty/noisy breathing or hoarse voice: inhalation burn likely • Patient drowsy or confused • Oxygen saturation < 90% • Percentage total body surface area (%TBSA burnt) > 15% Remove any sources of heat: • Remove burnt or hot clothing. Immerse burnt skin in cool water or apply cool, wet towels for 30 minutes. • Cover patient with clean, dry sheet to prevent hypothermia. Calculate size and depth of burn: • Calculate percentage total body surface area (%TBSA) burnt using adjacent guide. • If red, blistered, painful, wet: partial thickness burn likely • If white/black leathery, painless, dry: full thickness burn likely Assess and manage fluid needs if %TBSA burnt >10%: • Insert a large-bore IV line in area away from burned skin. If > 15 %TBSA or deep/electrical , insert a second IV line. • Give Ringer’s lactate IV: - - Calculate total volume needed over next 24 hours (mL) = %TBSA burnt x weight(kg) x 4 - - Give half this volume in the first 8 hours after burn. Calculate the hourly volume (mL) = total volume ÷ 2 ÷ 8 • Insert a urine catheter and document urine output every hour. Give medication: • If pain severe, give tramadol 100mg IV/IM. If pain not severe, give paracetamol 1g PO QID. • Give tetanus toxoid 0.5mL IM if none in past 5 years. If unavailable, check for tetanus antitoxin (TAT) hypersensitivity1 : if no reaction, give single dose TAT 3000U SC. If < 3 tetanus vaccine doses in lifetime, also give tetanus immunoglobulin 250 units IM at different site to toxoid with separate syringe. If unavailable, refer to hospital. Give wound care: • Do not rupture blisters. • Cover burn with a non-adherent dressing or wrap in clean, dry sheet and blanket. Keep as sterile as possible. Refer same day the patient with any of: Calculate % total body surface area (TBSA): • Head 9% • Neck 1% • Front 18% • Back 18% • Each arm 9% • Each leg 18% 9% 9% 9% 1% 18% 18% Front 18% Back 18% - - Burn covering > 10% TBSA - - Full-thickness burn of any size - - Burn involves face/neck/hands/feet/genitals/joint - - Circumferential burn of limbs/chest - - Inhalation/electric/chemical burn - - Other injuries • While awaiting transport, monitor vital signs: BP, pulse, respiratory rate, oxygen saturation, level of consciousness and urine output. • Write a referral letter and include details of how burn occurred, vital signs, fluid calculation, details of fluid and other medications given. • Review daily below if not needing same day referral. Review daily the patient with a burn not needing same day referral: • Clean with water and mild soap. Dress wound daily: apply silver sulfadiazine 1% cream and cover with non-adherent dressing. Check for infection (red, warm, painful, swollen, smelly or pus). • Give paracetamol 1g PO QID as needed for up to 5 days. If increased pain/anxiety with dressing changes, give tramadol 100mg IM while changing dressing. • Refer if signs of infection, pain despite medication or burn not healed within 2 weeks. 1 Inject 0.1mL TAT SC and 0.1mL normal saline at separate site as control: if wheal with redness develops around TAT site, skin test positive. Refer to hospital.
  • 52. Adult 52 Bites and stings Approach to the patient with a bite/sting not needing urgent attention Give tetanus toxoid 0.5mL IM if none in past 5 years. If unavailable, check for tetanus antitoxin (TAT) hypersensitivity1 : if no reaction, give single dose TAT 3000U SC. If < 3 tetanus vaccine doses in lifetime, also give tetanus immunoglobulin 250 units IM at different site to toxoid with separate syringe. If unavailable, refer to hospital. Human or animal bite/s • Remove loose/dead skin and clean wound with soap and water. Irrigate under pressure with normal saline for 15 minutes. Avoid suturing the wound. • Consider rabies risk if bite/scratch or licking of eyes/mouth/broken skin by a dog, feral cat, hyena, rat or other animal or any contact with bat: - - Clean wound thoroughly with povidone iodine or hydrogen peroxide or chlorhexidine solution. - - Give rabies vaccine 1 ampoule IM into shoulder/upper arm muscle immediately and repeat on day 3. If patient unimmunised or unsure, repeat vaccine on day 7 and 14 and if impaired immunity1 , also give a 5th dose on day 28. If unavailable, refer to hospital. - - If patient unimmunised, also give rabies immunoglobulin 20 units/kg immediately. Inject most into wound, and the rest IM at a distant site. • If impaired immunity2 or bite is deep, infected, involves hand/head/neck/genitals or bite from cat or human: give amoxicillin/clavulanate3 500/125mg PO TID and metronidazole4 500mg PO TID for 7 days. • If human bite has broken the skin, also assess need for HIV and hepatitis B post-exposure prophylaxis 68. • Give paracetamol 1g PO QID as needed for up to 5 days. • If bite infected and no response to antibiotics, refer. Insect/spider/scorpion bite or sting • Remove stinger. Clean wound with soap and water. Apply ice pack for pain/swelling. • If itch and rash, give loratadine 10mg PO daily and ranitidine 150mg PO daily for 3 days. If no response, give prednisolone 60mg PO daily for 5 days. • If pain, give ibuprofen5 400mg PO TID with food for up to 5 days. • If very painful scorpion sting, inject lidocaine 2% 2mL around site. 1 Inject 0.1mL TAT SC and 0.1mL normal saline at separate site as control: if wheal with redness develops around TAT site, skin test positive. Refer to hospital. 2 Known with HIV, diabetes, cancer,pregnancy or receiving chemotheraphy or corticosterroid. 3 If penicillin allergy give instead clindamycin 300mg QID and cotrimoxazole 160/800mg BID for 7 days. 4 Advise no alcohol until 24 hours after last dose of metronidazole. 5 Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. Give urgent attention to the patient with a bite/sting and one or more of: • Snake bite (even if bite marks not seen) • Sudden diffuse rash or face/tongue swelling with difficulty breathing, BP < 90/60 or collapse: anaphylaxis likely • 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 Management: • If snake bite: - - Reassure patient. - - Remove jewellery and immobilise bitten limb. Avoid applying tourniquet or trying to suck out venom. - - Discuss anti venom with doctor if available. • If anaphylaxis likely: - - Raise legs and give face mask oxygen. - - Give immediately adrenaline 0.5mL (1:1000 solution) IM into mid outer thigh. Repeat every 5-15 minutes if needed. If no response, give hydrocortisone 100mg IV and promethazine 50mg IM. - - Give normal saline 1-2L IV rapidly, regardless of BP. Then if BP < 90/60, also give fluids as below. - - Remove stinger. • If BP < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • If excessive or pulsatile bleeding, apply direct pressure and elevate limb. If bleeding severe and persists, apply tourniquet above injury. • Remove loose/dead skin and clean wound with soap and water. Irrigate under pressure with normal saline for 15 minutes. Avoid suturing the wound. • Give tetanus toxoid 0.5mL IM if none in past 5 years. If unavailable, check for tetanus antitoxin (TAT) hypersensitivity1 : if no reaction, give single dose TAT 3000U SC. If < 3 tetanus vaccine doses in lifetime, also give tetanus immunoglobulin 250 units IM at different site to toxoid with separate syringe. If unavailable, refer to hospital. • Refer urgently.
  • 53. Adult 53 No rash Localised Generalised 56 Pain 54 Lump/s 58 Generalised, non-itchy rash 57 Ulcers 59 Crusts 59 Changes in skin colour 60 Skin symptoms 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), give chloramphenicol only and refer. Give urgent attention to the patient with skin symptoms and one or more of: • Sudden diffuse rash or face/tongue swelling with difficulty breathing, BP < 90/60 or collapse: anaphylaxis likely • Purple rash with fever, headache, neck stiffness/meningism, nausea/vomiting or confusion: meningococcal disease likely • Extensive blisters • If on abacavir, check for abacavir hypersensitivity reaction 80. • Serious drug reaction likely if on any medication and one or more of: - - Temperature ≥ 38°C - - BP < 90/60 - - Jaundice - - Vomiting/abdominal pain/diarrhoea - - Involves mouth, eyes or genitals - - Blisters, peeling or raw areas © St. Paul's Hospital Millennium Medical College © University of Cape Town Management: • Anaphylaxis likely: - - Raise legs and give face mask oxygen. - - Give immediately adrenaline 0.5mL (1:1000 solution) IM into mid outer thigh. Repeat every 5-15 minutes if needed. If no response, give hydrocortisone 100mg IV and promethazine 50mg IM. - - Give normal saline 1-2L IV rapidly, regardless of BP. • Meningococcal disease likely: give ceftriaxone1 2g IV or crystalline penicillin1 4M IU IV with chloramphenicol 500mg IV. • Serious drug reaction likely: stop all medication and refer urgently. If peeling or raw skin, also manage as for burns before referral 51. • If BP < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • Refer urgently. Approach to the patient with skin symptom/s not needing urgent attention If rash is extensive, recurrent or difficult to treat, test for HIV 75. Itch 55 Rash
  • 54. Adult 54 Painful skin Furuncle/carbuncle/boil/abscess likely • Advise patient to wash with soap and water, keep nails short, and avoid sharing clothing or towels. • If fluctuant, incise and drain. • If multiple lesions, extensive surrounding infection or impaired immunity1 , give cloxacillin 500mg PO QID for 7 days. If penicillin allergic, give instead erythromycin 500mg PO QID for 7 days. • Give paracetamol 1g PO QID as needed for up to 5 days. • If recurrent boils or abscesses: - - Test for HIV 75 and diabetes 86. - - Wash once with chlorhexidine 5% solution from neck down. • Refer if: - - Difficult area to drain (face, genitals, hands) - - No response to treatment within 2 days Cellulitis likely • Give cloxacillin 500mg PO QID for 7 days. If penicillin allergic, give instead erythromycin 500mg PO QID for 7 days. • Give paracetamol 1g PO QID as needed for up to 5 days. Sudden swelling of skin with redness, pain and warmth Are borders poorly or clearly defined? • Refer if: - - Temperature ≥ 38°C - - BP < 90/60 or pulse > 100 - - Confused - - Face or eye involvement - - Blisters or grey/black skin - - Poorly controlled diabetes or stage 4 HIV - - No response to treatment within 2 days Erysipelas likely • Give cloxacillin 500mg PO QID for 5 days. If penicillin allergic, give instead erythromycin 500mg PO QID for 5 days. • Give paracetamol 1g PO QID as needed for up to 5 days. Herpes zoster (shingles) likely • Test for HIV 75. • Advise to keep lesions clean and dry, and avoid skin contact with others until crusts have formed. • Apply calamine lotion to rash 4 times a day as needed. • Give aciclovir 800mg 5 times a day for 7 days if ≤ 3 days since onset of rash (or if ≤ 1 week since onset of rash if impaired immunity1 ). • For pain: - - Give paracetamol 1g PO QID for up to 5 days. - - If needed add tramadol 50mg PO BID for 5 days. - - If poor response or pain persists after rash has healed, give amitriptyline 25mg at night. Increase by 25mg every week to 75mg if needed. • If infected, give cloxacillin 500mg PO QID for 7 days. If penicillin allergic, give instead erythromycin 500mg PO QID for 7 days. • Refer same day if: - - Eye, ear or nose involvement - - Signs of meningitis (headache, temperature ≥ 38°C, neck stiffness/meningism) - - Rash involves more than one region Firm, red, warm lump which softens in the centre to discharge pus © University of Cape Town Poorly-defined borders © University of Cape Town Painful blisters in a band along one side © University of Cape Town Clearly-defined borders CDC Public Health Image Library 1 Known with HIV, diabetes or cancer or receiving chemotherapy or corticosteroids.
  • 55. Adult 55 Itch with localised rash Itch with no rash Intense itch on scalp or in pubic area Tinea (ringworm) likely • If extensive or involves nails, test for HIV 75. If HIV positive, give routine care 76. • Advise to keep skin clean and dry and avoid sharing towels/clothes. • Apply clotrimazole or ketoconazole cream twice a day. Use for 1 week after rash has cleared. • If rash on scalp or no response to terbinafine, give griseofulvin 500mg daily until cured (up to 8 weeks) or fluconazole 200mg PO daily for 2-4 weeks. Tinea pedis (Athlete's foot) likely • Apply clotrimazole or ketoconazole cream twice a day. Continue for 1 week after rash has cleared. • Advise to wash and dry feet well. • Encourage open shoes/sandals. Lichen Planus likely • Apply liquid paraffin once daily. • Apply betamethasone ointment over the lesion once daily for 1-2 weeks. Pityriasis rosae likely • Apply liquid paraffin once daily. • Reassure patient that it should resolve within 3 weeks. • If persists after 3 weeks, apply momethason ointment once daily for 1 to 2 weeks. Confirm there is no rash, especially scabies, lice or other insect bites. Is the skin very dry? No Did the patient start any new medications in the weeks before the itch started? Yes Medication side-effect likely • Continue the medication only if no rash and treatment still necessary. • For itch, give loratadine 10mg or cetirizine 10mg PO daily for 5 days. • Advise patient to return immediately if rash develops. No • Advise to avoid hot baths and soap (wash with aqueous cream instead). • Moisturise skin twice a day. • Give loratadine 10mg or cetirizine 10mg PO daily for 5 days. • If itch persists, refer Yes Dry skin (xeroderma) likely • Advise to avoid soap (wash with aqueous cream instead). • Moisturise skin twice a day. • For itch, give loratadine 10mg or cetirizine 10mg PO daily. Lice likely Look for lice or eggs in hair and small red dots from bites. • Apply malathion 1% lotion to scalp. Rinse after 2 hours. Repeat after 1 week. • Soak all combs and brushes in permethrin for at least 2 hours. • Wash clothes and linen in very hot water. • Treat household contacts if infected or share a bed. If pubic lice, also treat sexual partners. Psoriasis likely • Apply betamethasone 0.1% ointment twice a day. For face, use hydrocortisone 1% cream only. Reduce to once a day when improvement seen. Stop as soon as better. • Advise to avoid using soap and to moisturise skin 3 times a day. • If extensive or no better after 1 month, refer. Slow-growing ring-like patch/es with raised edge © University of Cape Town Scaling moist lesions between toes or on soles of feet CDC Public Health Image Library Itchy flat purple papules/plaques © St. Paul's Hospital Millennium Medical College Oval shaped plaques with scales at the edges over trunk, arms and thighs © St. Paul's Hospital Millennium Medical College Well demarcated, pink, raised plaques covered with silvery scales, usually on elbows, knees, trunk and scalp © St. Paul's Hospital Millennium Medical College
  • 56. Adult 56 Generalised itchy rash Scabies likely • Apply permethrin 5% cream or benzyl benzoate 25% lotion or sulphur 5-10% ointment. Avoid eyes and mouth. Wash off after 12 hours. Repeat for 3 consecutive nights. • Treat all household contacts and sexual partners at the same time, even if asymptomatic. • Wash linen and clothing in very hot water and dry well. • For itch, give loratadine 10mg or diphenhydramine 25-50mg PO daily until itch subsides. Papular pruritic eruption (PPE) likely • Test for HIV 75. If HIV positive, give routine care 76. • May temporarily worsen when starting ART. • First treat for scabies in adjacent column. • Moisturise skin twice a day. • Apply betamethasone 0.1% cream twice a day. For face, use instead hydrocortisone 1% cream. • For itch, give loratadine 10mg or cetirizine 10mg or diphenhydramine 25-50mg PO daily until itch subsides. Eczema likely • Moisturise skin twice a day and immediately after bathing. • Avoid frequent bath with soap. • Apply hydrocortisone 1% cream twice a day until improved (up to 4 weeks). If poor response, apply betamethasone 0.1% cream twice a day (avoid face). • For itch, give loratadine 10mg or cetirizine 10mg or diphenhydramine 25-50mg PO daily until itch subsides. • If infected, treat with cloxacillin 500mg PO QID for 7 days. If penicillin allergic, give instead erythromycin 500mg PO QID for 7 days. • If patient also has asthma, give routine asthma care 82. Urticaria likely Commonly due to allergy to food/medication/insect sting If sudden rash with difficulty breathing, BP < 90/60 or collapse, anaphylaxis likely 53. Approach to the patient not needing urgent attention: • Identify and remove cause. • Give loratadine 10mg or cetirizine 10mg PO daily until rash resolved. • If no response after 24 hours, give prednisolone 40mg PO daily for 5 days. • Advise patient to return immediately if any symptoms of anaphylaxis occur. • If recently started new medication, check for drug reaction 57. • If no response to treatment, refer. Widespread, very itchy rash with burrows, in web-spaces of hands/feet, axillae and genitals. Especially itchy at night. © University of Cape Town Itchy bumps on extremities or lower trunk. Skin often remains hyperpigmented. © University of Cape Town Itchy, thickened, hyperpigmented rash with associated allergic rhinitis, allergic conjunctivitis and other allergies. © St. Paul's Hospital Millennium Medical College © Very itchy, red, raised wheals that appear suddenly and usually disappear within 24 hours © St. Paul's Hospital Millennium Medical College
  • 57. Adult 57 Generalised non-itchy red rash Is patient taking any medication? Yes No • Check patient does not need urgent attention 53. • If bleeding from gums or purple rash, do complete blood count and refer immediately. • Patient may have fever, headache, lymphadenopathy, muscle pain. • If pain or fever, give paracetamol 1g PO QID as needed for up to 5 days. • Test for syphilis and HIV 75. Yes No Is patient taking ART, TB treatment, co-trimoxazole or IPT? Rash may be part of HIV seroconversion illness. HIV negative HIV positive No • If itchy, give loratadine 10mg or cetirizine 10mg PO daily and and apply hydrocortisone 1% cream to rash twice a day. • Refer if: - - Any markers of severity develop. - - Rash does not improve within 2 weeks of stopping/ changing medication. Yes • If on abacavir, check for hypersensitivity reaction 80. If likely, stop ART and refer same day. • If itchy, give loratadine 10mg PO daily and apply hydrocortisone 1% cream to rash twice a day. • Check ALT and review result within 24 hours: Treat patient for early syphilis 41. If no better after 1 week, refer. ALT ≥ 100U/L or patient unwell Manage as serious drug reaction Stop all drugs and refer same day 53. ALT < 100U/L and patient well • Continue medication. • If on nevirapine: - - If on once daily dose, avoid increasing until rash resolved. - - Repeat ALT after 1 week. If ≥ 100U/L, refer same day. - - If rash persists > 4 weeks after starting nevirapine, switch medication 79. • If on co-trimoxazole prophylaxis1 : stop it until rash resolved. Consider re-starting co-trimoxazole or changing instead to dapsone 100mg daily. • Review patient within 2 days. • Advise patient to return urgently if markers of severity develop. • If rash no better after 2 weeks, refer to hospital. Secondary syphilis likely Rash often on palms and soles. May have wart-like lesions on genitals and patchy hair loss. Syphilis test positive If generalised non-itchy rash and no obvious cause, refer. • If risk of HIV infection in past 4 weeks, repeat HIV test after 4 weeks. • Encourage patient to follow safe sex practices. Give routine HIV care 76. Are there any markers of severity? • Temperature ≥ 38°C • BP < 90/60 • Difficulty breathing • Face or tongue swelling • Abdominal pain • Vomiting or diarrhoea • Involves mouth, eyes or genitals • Blisters, peeling or raw areas • Severe rash • Jaundice Drug reaction likely • Rash may be mild, patchy spots or widespread (like burns). • Can be caused by any medication. Common causes are antibiotics, anticonvulsants, antiretrovirals (especially nevirapine), TB medication, co-trimoxazole and NSAIDs (e.g. ibuprofen). © University of Cape Town 1 If on co-trimoxazole treatment for pneumocystis pneumonia (PJP), toxoplasmosis or Isospora belli diarrhoea, refer to hospital. © University of Cape Town
  • 58. Adult 58 Refer same week the patient with a mole that: • Is irregular in shape or colour • Changed in size, shape or colour • Differs from surrounding moles • Is > 6mm wide • Bleeds easily • Itches Warts likely • Usually on hands, knees or elbows but can occur anywhere. • Plantar warts on the soles of the feet are thick and hard with black dot/s. • Reassure patient that warts often disappear spontaneously. • If treatment desired, apply salicylic acid 5% 1-2 drops to wart every night and cover with a plaster. • Advise patient to soak in warm water for 5 minutes then scrape wart with nail file between treatments. • Continue to apply salicylic acid for a week after wart has come off. • If warts are extensive, refer. Molluscum contagiosum likely May be extensive in HIV. • Test for HIV 75. • Reassure patient that lesions may resolve spontaneously after several years or with ART. • If intolerable, remove with curettage or apply podophyllum 15% for 4 hours, then wash off. Repeat podophyllum weekly for up to 6 weeks. • If podophyllum not available, protect surrounding skin with petroleum jelly and apply KOH 5-10% solution with cotton tip applicator daily for 2-3 weeks. • If extensive or no resolution after 4 years and intolerable for patient, refer. Kaposi’s sarcoma likely Lesions vary from isolated lumps to large ulcerating tumours and may also appear in mouth and on genitals. • Test for HIV 75. If HIV positive, give routine care and ART 76. • Refer for biopsy to confirm diagnosis and for further management. Rosacea likely • Advise to avoid aggravating factors. • Apply zinc oxide ointment every morning. • Give doxycycline1 100mg PO daily for 1 month or azithromycin 250mg PO 3 times a week for 6 weeks. • Refer if no improvement or diagnosis uncertain. Acne likely May involve chest, back and upper arms • Advise patient to wash skin with mild soap twice a day and to avoid picking, squeezing and scratching. • Apply benzoyl peroxide 5% cream twice a day after washing. Continue for 2 weeks after lesions have gone. Avoid in pregnancy. • If benzoyl peroxide not available, apply clindamycin 1% gel and tretinoin 0.025- 0.05% cream once daily. • If red, swollen and extensive lesions over chest and back, also give doxycycline 100mg PO daily for at least 3 months. Doxycycline may interfere with oral contraceptive. Advise patient to use condoms as well. Avoid in pregnancy. • In woman needing contraception, advise combined oral contraceptive 110. • Advise patient that response may take several weeks to months. • If severe or no response after 6 months of treatment, refer. Round, raised papules with rough surfaces © University of Cape Town Small, skin-coloured bumps with pearly central dimples © University of Cape Town Painless, purple/brown lumps on skin © BMJ Best Practice Painless lumps on face and extremities with overlying scales or central ulcer © St. Paul's Hospital Millennium Medical College Oily skin with white/blackheads © University of Cape Town Red lumps on face If painful, firm, red, warm lump which softens in the centre to discharge pus, boil/abscess likely 54. Dry skin with redness and visible vessels on face Cutaneous leish- maniasis likely Do slit skin smear microscopy and refer to leishmaniasis treatment center. Skin lump/s 1 Avoid if pregnant.
  • 59. Adult 59 Ulcers and crusts Ulcer/s Is patient usually in bed and is ulcer in common bedsore site (see below)? No No • If genital ulcer 39. • If elsewhere on body and no obvious cause like trauma, refer to exclude skin cancer. Pulses reduced or muscle pain in legs/buttocks on exercise that is relieved by rest Bedsore likely • Relieve pressure on ulcer and reposition patient every 2 hours. • Clean ulcer daily and cover with non- adherent dressing. • If infected (skin red, warm or tender), apply silver sulfadiazine 1% cream to ulcer until infection better. • Give paracetamol 1g PO QID as needed for up to 5 days. If needed, add tramadol 50mg PO BID for 5 days. • Refer to dietician to ensure adequate calorie and protein intake. • Refer if: - - Fat, bone, muscle or tendon visible - - Yellow/grey/black tissue - - Extensive or worsening infection - - Ulcer not healing with treatment • If patient is terminally sick and survival is predicted to be short, also give palliative care 120. Does patient have diabetes 86? Yes No • If cough ≥ 2 weeks, weight loss, night sweats or fever ≥ 2 weeks, exclude TB 71. • Refer for further assessment. Diabetic ulcer likely • Avoid pressure/weight-bearing on ulcer. • Give foot care advice 50. • Clean ulcer daily and cover with non-adherent dressing. • If infected (skin red, warm, painful), give erythromycin 500mg PO QID and ciprofloxacin1 500mg PO BID for 10 days. • Give diabetes routine care 86. • Refer if - - Fever, pus or extensive infection - - Ulcer > 2cm, or tendon or bone visible - - Ulcer no better after 2 weeks of treatment Venous stasis ulcer likely • Encourage exercise. • Advise elevating leg when possible and to avoid prolonged standing. • Apply compression bandage from foot to knee. • Assess and manage CVD risk 84. • Clean ulcer daily and cover with non-adherent dressing. • Refer if: - - Recurrent ulcers - - No better after 3 months Peripheral vascular disease (PVD) likely • Clean ulcer daily and cover with non-adherent dressing. • Avoid compression bandage. • Give PVD routine care 96, and refer to hospital. If sudden severe leg pain at rest with numbness, weakness, pallor or no pulse, refer urgently. Yes Yes No Yes Pulses normal and no muscle pain in legs or buttocks on exercise Is there red/brown darkening of skin around ulcer, spidery veins? Check leg and foot pulses and if patient has muscle pain in legs or buttocks on exercise. Is ulcer on the leg or foot? Impetigo likely Often around mouth or nose. May complicate insect bites, scabies or skin trauma. • Test for HIV 75. • Impetigo is contagious: - - Advise patient to avoid close contact with others and to wash with soap and water twice a day. - - Advise contacts to avoid sharing towels and to add a spoon of potassium permanganate solution (1:10 000) to bathwater 2-3 times a week. • Apply fusidic acid cream to lesions and nostrils 3 times a day for 7 days. • If extensive or no response to above treatment, add cloxacillin 500mg PO QID for 7 days. If penicillin allergic, give instead erythromycin 500mg PO QID for 7 days. • Refer if: - - Cellulitis or abscess - - Temperature ≥ 38°C - - No response to antibiotic Blisters which dry to form honey coloured crusts © St. Paul's Hospital Millennium Medical College © BMJ Best Practice 1 Avoid if pregnant.
  • 60. Adult 60 Changes in skin colour Melasma likely • Hormones and sunlight will worsen melasma: - - Advise patient to apply sunscreen daily and avoid sun exposure. - - Avoid oral contraceptive, rather use alternative contraception 110. - - If pregnant, advise patient lesions may resolve up to 1 year after pregnancy. • Avoid facial products other than bland emollients. • Often difficult to treat. If not responding to above and intolerable for patient, refer. Tinea versicolor likely • Apply selenium sulfide 2% or ketoconazole 2% shampoo to neck, trunk, arms and legs. Leave for 10 minutes, then wash off. Repeat daily for 1 week. • Advise that colour may take months to return to normal. • If scale persists or frequent relapses, give single dose fluconazole 400mg PO. • Recurrence is common and the patient may need frequent treatment. If diagnosis is uncertain, refer. Yellow skin Lightening of skin Is skin smooth or scaly? Is skin smooth or scaly? Smooth Smooth Is there decreased sensation on the skin lesion? No Vitiligo likely • Advise patient to use camouflage cosmetics. • If patient requests treatment and lesions are limited, apply betamethasone 0.1% cream twice a day for at least 3 months (avoid face). Stop if skin thinning, stretch marks or bruising occur. • If extensive or no response to treatment, refer to hospital. • If distressing to patient, refer for psychological support. Yes © St. Paul's Hospital Millennium Medical College Leprosy likely Do baciliary index, morphology index and manage accordingly. Scaly Jaundice likely Refer urgently the patient with jaundice and one or more of: • Temperature ≥ 38°C • Hb < 11g/dL • BP < 90/60 • Severe abdominal pain • Drowsy or confused • Easy bruising or bleeding • Pregnant • Alcohol dependent 103 or recent alcohol binge (≥ 5 drinks1 / session) • Using any medication or illegal drugs Approach to the patient with jaundice not needing urgent referral: • Send blood for ALT, AST, GGT, ALP, complete blood count. • Advise patient to return immediately if any above markers of severity develop. • Review patient with results within 2 days. If ALT/AST raised, send blood for hepatitis serology and refer. Refer. Yes No No Flat, brown patches on cheeks, forehead and upper lip © University of Cape Town Light or dark patches with fine scale. Usually on trunk. © University of Cape Town © University of Cape Town 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. Is ALP/GGT predominantly raised? Red-brown discolouration. May have breaks in skin/ ulcers, spidery veins. © BMJ Best Practice Yes Venous stasis likely • Encourage exercise. • Advise elevating leg when possible and to avoid prolonged standing. • Apply compression bandage from foot to knee. • Assess and manage CVD risk 84. • If ulcer: - - Clean daily and cover with non- adherent dressing. - - If no better after 3 months or recurrent ulcers, refer. Darkening of skin Is darkened area only on lower leg/s?
  • 61. Adult 61 Nail symptoms Pain, redness and swelling of nail folds, there may be pus. © BMJ Best Practice Chronic paronychia likely Usually associated with excessive exposure to water and irritants like nail cosmetics, soaps and chemicals. • Advise patient to avoid water and irritants and to wear gloves if unavoidable. • Apply betamethasone 0.1% cream to swollen nail beds twice a day for 3 weeks. • If no response, apply miconazole 2% cream twice a day for 4 weeks. • If no response, refer. Acute paronychia likely Often with history of trauma, such as nail biting or pushing the cuticle. • Advise patient to stop trauma to nail. • If any pus, incise and drain. • Advise warm saline soaks for 20 minutes twice a day. • Apply fusidic acid 1% cream after soaking. • If severe pain, pus, infection beyond nail fold or temperature ≥ 38°C, give cloxacillin 500mg PO QID for 7 days. If penicillin allergic, give instead erythromycin 500mg PO QID for 7 days. • If no response, refer. Fungal infection likely • Test for HIV 75. • Fungal nail infection is difficult to treat. • Treat if: - - Previous cellulitis on affected limb - - Diabetes - - Painful nail - - Cosmetic concerns • Send nail clippings for microscopy to confirm diagnosis before starting treatment. • If fungal infection confirmed, give fluconazole 400mg PO once weekly for 6-9 months for finger nails and 12-18 months for toe nails. Has there been recent trauma to nail? Yes Haematoma likely • Treat if injury < 2 days old and painful: - - Clean nail with povidone iodine solution. - - Hold finger secure and gently twist a large bore needle into nail over centre of haematoma. Stop when blood drains through hole. - - Cover with sterile gauze dressing. • Review medication: chloroquine, fluconazole, ibuprofen, lamivudine, phenytoin and zidovudine can cause discolouration of nails. Consider changing medication. • Refer same week to exclude melanoma (picture above) if: - - New dark spot on 1 nail which is getting bigger quickly and no recent trauma - - Discolouration extends into nail folds - - Band on nail that is: • > 4mm wide • Getting darker or bigger • Has blurred edges • Nail is damaged. No Disfigured nail with swollen nail bed and loss of cuticle © University of Cape Town White/yellow disfigured nails © University of Cape Town Blue/brown/black discolouration of nail CDC Public Health Image Library If nails long and dirty and patient unkempt, screen for mental health problem and abuse/neglect 66.
  • 62. Adult 62 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? No: does patient have current thoughts or plans to commit suicide? Yes Yes Yes: is patient agitated, violent, distressed or uncommunicative? No No No: has patient had thoughts or plans of self-harm or suicide in past month or performed act of self-harm or suicide in past year? High risk of self-harm or suicide Low risk of self-harm or suicide Manage patient as below. • Remove any possible means of self-harm (firearms, knives, pills). • If aggressive or violent, ensure safety: assess patient with other staff, use security personnel or police if needed. Sedate only if necessary 63. • Refer urgently. - - While awaiting transport, monitor closely. Avoid leaving patient alone. If patient refuses admission, consider involuntary admission 98. Yes • First assess and manage airway, breathing, circulation and level of consciousness 12. • If oral overdose or harmful substance in past 1 hour and patient fully conscious, give activated charcoal 100g in 500mL water via nasogastric tube. Avoid if paraffin, petrol, corrosive poisons, iron, lithium or alcohol. • If opioid (morphine/codeine) overdose and respiratory rate < 12: give 100% face mask oxygen and naloxone 0.4mg IV immediately. Repeat every 2-3 minutes, increasing dose by 0.4mg each time until respiratory rate > 12, maximum 10mg. • If exposed to carbon monoxide (exhaust fumes): give 100% face mask oxygen. • If no response, or overdose/poisoning with other or unknown substance, refer to hospital. 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. Assess the patient whose risk of self-harm or suicide is low Assess When to assess Note Depression Every visit • If known depression 100. • In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. Substance use/abuse Every visit In the past year has the patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Other mental illness Every visit If hallucinations, delusions, disorganised speech, disorganised or catatonic behaviour, refer to mental health professional same day. Stressors Every visit • Assess and manage stress 65. • Help identify psychosocial stressors. Ask about trauma, sexual abuse/violence 66, family or relationship problems, financial difficulty, bereavement, chronic ill-health. Chronic condition Every visit • If chronic pain, assess and manage pain 45 and underlying condition. • If patient is terminally sick and survival is predicted to be short, also give palliative care 120. • Discharge into care of family, if possible. Review patient at least weekly for 2 months. 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 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
  • 63. Adult 63 Give urgent attention to the aggressive/disruptive patient with one or more of: • Angry behaviour • Loud, aggressive speech • Challenging, insulting or provocative behaviour • Frequently changing body position, pacing • Tense posturing like gripping arm rails tightly, clenching fists • 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 or a potentially harmful object (e.g.: stick, stone etc). Assess with other staff in a safe spacious room with at least two doors for entry and exit. 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. - - 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 64, especially if patient disorientated/confused as sedatives may worsen the condition. • 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 98. If needed, sedate the aggressive/disruptive patient: Try to avoid IM or IV medication, especially if > 65 years. Will patient accept oral medication? • Monitor and record temperature, BP, respiratory rate and pulse rate and level of consciousness every 15 minutes for the first hour and every 30 minutes until patient alert and walking. • If haloperidol used and painful muscle spasms, acute dystonic reaction likely, give benzhexol 2-5mg, if needed can be given PO TID. • Once patient is calmer, reassess for underlying cause and manage further 64. No Yes Patient calm Exact cause unknown Patient calm Give haloperidol 2-5mg (2mg if elderly) IM or diazepam 10mg IV slowly (avoid IM). If confused (without alcohol withdrawal), avoid diazepam if possible. Give haloperidol 2-5mg (2mg if elderly) IM. Alcohol/drug withdrawal Partial response Repeat same dose of IM medication used above. No response • If diazepam used above, give haloperidol 2-5mg (2mg if > 65 years) IM. • If haloperidol used above, give diazepam 10mg IV slowly (avoid IM). Stimulant drug intoxication Alcohol intoxication Psychosis Patient still aggressive/disruptive after 30 minutes Decide which medication to sedate patient according to likely cause: Assess after 30 minutes: • Give diazepam 5mg PO or haloperidol 2-5mg (2mg if > 65 years) PO. • Assess response after 30 minutes: Patient refuses oral medication Refer the mentally ill aggressive patient same day to hospital: document history, details of involuntary admission, and time and dose of medication given. Aggressive/disruptive patient
  • 64. Adult 64 Abnormal thoughts or behaviour 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 106. • If unsure of diagnosis, refer for further assessment. 1 Add 10 vials of glucose 40% in 1L dextrose in normal saline solution at 30 drops per minute. 2 If severe penicillin allergy with previous angioedema, anaphylaxis or urticaria, give chloramphenicol only and refer. 3 Test for malaria with parasite slide microscopy or if unavailable, rapid diagnostic test. Give urgent attention to the patient with abnormal thoughts or behaviour and one or more of: • Sudden onset of abnormal thoughts or behaviour • Recent onset of abnormal thoughts or behaviour Management: • If aggressive/disruptive, assess and manage 63. Sedate only if absolutely needed: if patient confused sedatives may worsen the condition. • If new sudden asymmetric weakness or numbness of face, arm or leg; difficulty speaking or visual disturbance: consider stroke or TIA 93. • Just had a convulsion 15. • If difficulty breathing, respiratory rate > 30, oxygen saturation < 90% or oxygen saturation machine not available, give face mask oxygen. • If glucose < 70mg/dL or unable to measure, give oral glucose 20g. If unable to take orally, give instead glucose 40% 50mL IV over 2-3 minutes. Repeat if glucose still < 70mg/dL after 15 minutes. Maintain with 10% glucose solution1 . • If known alcohol user, give thiamine 100mg IV before glucose. If glucose ≥ 200mg/dL 86. • If thirst, dry mouth, poor skin turgor, sunken eyes, decreased urine: give oral rehydration solution. If unable to drink or BP < 90/60, give normal saline 250mL IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • If suicidal thoughts or behaviour 62. • 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 98. • Look for delirium, mania, psychosis, intoxication, withdrawal or poisoning and manage before referral: Varying levels of consciousness over hours/days and/or temperature ≥ 38°C Abnormally happy, energetic, talkative, irritable or reckless Mania likely Lack of insight with ≥ 1 of: • Hallucinations (seeing/ hearing things which are not there for others around the patient) • Delusions (unusual/ bizarre beliefs) • Disorganised speech or behaviour Dilated pupils, restlessness, paranoia, nausea, sweating or pulse ≥ 100, BP ≥ 140/90 Smells of alcohol, slurred speech, incoordination, unsteady gait Known alcohol/drug user who has stopped/reduced intake with tremor, sweating, nausea, severe restlessness/ agitation or hallucinations Exposure via ingestion/ inhalation/ absorption of medication/ unknown substance Psychosis likely Stimulant drug intoxication likely If pulse irregular, chest pain or BP ≥ 140/90, refer urgently to hospital. If aggressive 63. Alcohol intoxication likely • Give thiamine 100mg IV/IM. • Give normal saline 1L 6 hourly. • Check for head injury. Alcohol/drug withdrawal likely • If no other sedation given, give diazepam 10mg PO or IV. • If alcohol withdrawal, also give thiamine 100mg PO or IV/IM and oral rehydration solution. • If ≥ 8 hours since last alcohol, refer to hospital for detoxification. Poisoning Refer to hospital. Delirium likely • Give single dose ceftriaxone2 2g IV/IM or crystalline penicillin2 4M IU IV with chloramphenicol 500mg IV. • If malaria test3 positive, also give artesunate 2.4mg/kg IM or artemether 3.2mg/kg IM. Refer urgently unless: • Patient with known chronic psychosis who is otherwise well: give routine psychosis care 104. • Patient with known diabetes and low glucose, not on glicazide or insulin: if abnormal thoughts/behaviour resolve following oral or IV glucose, no need to refer, give routine diabetes care 87. • Patient with known alcohol use who is otherwise well: if abnormal thoughts/behaviour resolve once sober, no need to refer 103.
  • 65. Adult 65 Stressed or distressed patient Give urgent attention to the stressed or distressed patient with: • Suicidal thoughts or behaviour 62. Assess the stressed or distressed patient: if known with depression, give routine care 100. Assess Note Symptoms Manage symptoms on symptom pages. If patient has multiple physical complaints consider depression 99. Stressors • Help identify psychosocial stressors. Ask about family or relationship problems, financial difficulty, bereavement, chronic ill-health. Ask about loneliness in older person. • If patient is terminally sick and survival is predicted to be short, also give palliative care 120. Trauma/abuse 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 66. If patient being abused 66. Anxiety • If excessive worry causes impaired function/distress for at least 6 months with ≥ 3 of: muscle tension, restless, irritable, difficulty sleeping, poor concentration, tired: generalised anxiety likely 100. • If anxiety impairs function and is induced by a particular situation/object (phobia) or has no obvious cause with repeated sudden fear with physical symptoms (panic) 100. Depression In the past month, has patient felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. Substance abuse In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Women’s health • If recent delivery, give postnatal care 116. • If woman > 40 years, ask about menopausal symptoms: hot flushes, night sweats, vaginal dryness, mood changes, difficulty sleeping and sexual problems 119. Medication Review medication: prednisolone, efavirenz, metoprolol, metoclopramide, theophylline and estrogen containing oral contraceptives can cause mood changes. Consider changing medication or alternative contraceptive and antihypertensive. If persistent symptoms on efavirenz for > 6 weeks, change ART 79. Advise the stressed or distressed patient • 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 If patient has difficulty sleeping 67. Access support Encourage patient to connect with friends, family, spiritual leaders and community groups like Edir, Mahber, Senbete. Get active Advise regular exercise. Do a relaxing breathing exercise each day. Spend time with supportive friends or family. Encourage patient to do activities s/he enjoyed previously. Encourage patient to take time to relax: • Do relaxing breathing in a quiet place for 10 minutes everyday: sit comfortably, breathing slow, steady breaths through nose. Time breathing with counting: 1, 2, 3 in; 1, 2, 3 pause; 1, 2, 3 out. • Support problem solving: List main problems and identify an important but solvable problem. Support the patient to identify steps to solving the problem. Agree on specific steps that the patient will try in the next week. At follow-up, review, trouble-shoot and set new goals. • 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. • For tips on how to communicate effectively 124. Offer to review the patient in 1 month. If no better, refer to available counsellor, psychiatric nurse/psychologist or social worker. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
  • 66. Adult 66 Traumatised/abused patient Review the traumatised/abused patient • If sexually assaulted, review within 3 days 69. Also check syphilis after 1 month. • Offer to review the traumatised/abused patient who has not been sexually assaulted in 3 months. 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. • Encourage patient to report case to the police and to apply for protection order. Respect patient’s wishes if s/he declines to do so. 1 Advise no alcohol until 24 hours after metronidazole. 2 If patient taking ART, rifampicin or phenytoin, offer copper intrauterine device instead or increase single dose levonorgestrel to 3mg. 3 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. Give urgent attention to the traumatised/abused patient with one or more of: • Injuries needing attention 14 • Immediate risk of being harmed and in need of shelter • Suicidal thoughts or behaviour 62 • Recent sexual assault: - - If severe vaginal or anal bleeding, refer urgently. - - Aim to prevent HIV, hepatitis B, STIs and pregnancy urgently: Prevent STIs • Give single doses of ceftriaxone 250mg IM, metronidazole1 2g PO and doxycycline 100mg PO BID for 7 days. • If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), omit ceftriaxone and give instead single dose spectinomycin 2g IM. Prevent HIV and hepatitis B 68. Prevent pregnancy • Do pregnancy test. If pregnant 112. • If not pregnant, not on reliable contraception and ≤ 5 days since rape, give emergency contraception: - - Give single dose levonorgestrel 1.5mg2 PO. If patient vomits < 2 hours after taking, repeat dose or - - Insert copper intrauterine device instead 110. • If > 5 days since rape and emergency contraception not given, repeat pregnancy test 6 – 8 weeks after last menses. If pregnant 112. Also assess and support the patient needing urgent attention 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 sexual assault 36. Family planning Every visit Assess patient’s contraception needs 110. If pregnant 112. Mental health Every visit • Assess and manage stress 65. • In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. • In the past year, has patient: 1) drunk ≥ 4 drinks3 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. • 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. HIV First visit Test for HIV 75. Syphilis (if sexual assault) If negative: repeat after1 month If positive 41.
  • 67. Adult 67 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 patient has a chronic condition, give routine care. • Ask about snoring or restless legs. If present, refer for assessment. • If pulse ≥ 100, weight loss, palpitations, tremor, dislike of hot weather or thyroid enlargement, thyrotoxicosis likely, refer to hospital. • If patient is terminally sick and survival is predicted to be short, also give palliative care 120. Review medication: • Over-the-counter decongestants, salbutamol, theophylline, fluoxetine and efavirenz can cause difficulty sleeping. Consider changing medication. • Reassure patient that difficulty sleeping from efavirenz is usually self-limiting and resolves within 4 weeks on ART. If > 4 weeks, refer to hospital. Assess substance use/abuse: • In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Screen for possible stressors and mental health problem: • Screen for mental health problem (depression, anxiety, post-traumatic stress disorder and phobias) and manage stress 65. • If abnormal thoughts or behaviour 64. • 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 106. Ask about menopausal symptoms: • If woman > 40 years, ask about menopausal symptoms: hot flushes, night sweats, vaginal dryness, mood changes and sexual problems 119. 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. If very tired, nap for no longer than 30 minutes. - - Encourage routine: get up at the same time every day (even if tired) and go to bed at 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, get out of bed and 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 clinician and patient can help. If still no better after 1 month on medication, refer patient for further assessment. Treat the patient with difficulty sleeping: If problems with daytime functioning, daytime sleepiness, irritability, anxiety or headaches that do not improve with 1 month of sensible sleep habits: reassess for mental health and substance use problems and consider promethazine 25mg or amitriptyline 12.5-25mg PO at night for short-term symptom-relief. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
  • 68. Adult 68 Exposed to infectious fluid: post-exposure prophylaxis Fluids transmit infection through 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. Give urgent attention to the patient exposed to infectious fluid: Does patient have one or more of the following? • Exposure to blood, blood-stained fluid/tissue, pleural/pericardial/peritoneal/amniotic/synovial/cerebrospinal fluid, vaginal secretions, semen or breast milk • Human bite that broke the skin Yes No No Yes • Give immediate attention: - - 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 or normal saline. - - If sexual assault 66. • Assess need for HIV post-exposure prophylaxis: • Reassure that HIV and hepatitis B transmission is unlikely. • Avoid giving HIV or hepatitis B post-exposure prophylaxis. • If unsure, refer to hospital. Patient known HIV positive Positive • Send blood for HBsAg, hepatitis C antibody. If sexual exposure, also check syphilis. • Avoid giving HIV post-exposure prophylaxis, give routine HIV care 76. Yes Reassure that hepatitis B transmission is unlikely. No or not sure Give 1st dose of hepatitis B vaccine 1mL IM. • Give HIV post-exposure prophylaxis (PEP) only if ≤ 72 hours since exposure (ideally within 1 hour): • Give tenofovir/lamivudine 300/300mg and efavirenz 600mg PO daily for 28 days. • If known kidney disease, give zidovudine/lamivudine 300/150mg PO BID instead of tenofovir/lamivudine . • If source on ART, start PEP as above and refer to hospital to adjust PEP if needed. • Send blood for HBsAg, hepatitis C antibody and creatinine1 . If sexual exposure, also check syphilis. Assess need for hepatitis B post-exposure prophylaxis: has patient received 3 doses of hepatitis B vaccine? Assess source: if s/he agrees, test for HIV 75, HBsAg and hepatitis C antibody. If sexual exposure, check syphilis. Review patient and blood results within 3 days 69. Negative, one positive and one negative or patient refuses HIV test Patient HIV negative or unknown: do HIV test 75. Was there sexual contact, sharps injury, splash to eye, mouth, nose or broken skin? 1 If giving zidovudine, check complete blood count instead of creatinine.
  • 69. Adult 69 Review the patient on post-exposure prophylaxis Review patient within 3 days, at 2 weeks, 6 weeks, 3 months and 6 months. • Check adherence and ask about side effects from HIV post-exposure prophylaxis 80. Advise patient to report side effects promptly if they occur. • Advise patient to use condoms for 3 months until results confirmed. • If assault or abuse 66. • Check bloods according to table and review results as below: Assess When to assess Note HIV If negative: at 6 weeks, 3 months Test for HIV 75. If positive, stop HIV post-exposure prophylaxis and give routine HIV care 76. HBsAg If negative: at 6 months If positive, refer. Hepatitis C antibody If negative: at 6 weeks, 3 months If positive, refer. Syphilis (if sexual exposure) If negative: repeat after 1 month If positive 41. eGFR1 (by referral to hospital) If on tenofovir: at 2 weeks, 6 weeks • If initial eGFR < 50mL/min/1.73m3 : stop tenofovir/lamivudine, give instead zidovudine/lamivudine 300/150mg PO BID and check complete blood count. • If repeat eGFR < 50mL/min/1.73m3 : refer. Complete blood count If on zidovudine: at 2 weeks, 6 weeks If Hb < 7g/dL or neutrophils < 0.75 x 109 /L, refer. Source blood results (if done) - • If HIV negative, discontinue HIV post-exposure prophylaxis. • If HIV positive, give source routine HIV care 76. Continue HIV post-exposure prophylaxis. • If HBsAg or hepatitis C antibody positive, refer source and patient to hospital. • If syphilis positive 41. 1 Calculate eGFR = [(140 - age) x weight (kg)]/[72x creatinine (mg/dL)]. If patient is a woman, multiply by 0.85. Approach to the patient who is HBsAg negative Has patient received 3 doses of hepatitis B vaccine? Yes No or not sure Reassure that hepatitis B transmission is unlikely. Source HBsAg positive or not known Source HBsAg negative If not already given, give 1st dose of hepatitis B vaccine 1mL IM. • At 4 weeks: Give patient 2nd dose of hepatitis B vaccine 1mL IM. • At 8 weeks: Give patient 3rd dose of hepatitis B vaccine 1mL IM. Refer to hospital. Check source HBsAg result.
  • 70. Adult 70 Malnutrition: routine care Assess the patient with malnutrition Assess When to assess Note Symptoms Every visit Manage symptoms as on symptom page. Ask about diarrhoea 34 and vomiting 33 and manage on symptom pages. Diet At diagnosis Check variety and quantity of food. If patient not getting at least 2 meals a day or eating a balanced diet, refer to nutrition support programme. TB screening Every visit Exclude TB 71. Family At diagnosis Ensure that patient’s family and children are screened for malnutrition. Oedema Every visit If swelling of feet, hands or face develops or does not resolve with feeding, refer. Weight/BMI Every visit If not gaining weight or losing weight, refer. Discharge the non-pregnant patient when BMI > 17.5. MUAC Monthly Discharge the pregnant/breastfeeding patient when MUAC is > 23. Substance use At diagnosis In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Pallor At diagnosis Look for pallor and if possible check Hb. If < 7gdL, refer. HIV At diagnosis Test for HIV 75. If HIV positive, give routine HIV care 76. Family planning Every visit Assess patient’s contraception needs 110. If pregnant 112. Diagnose malnutrition The patient has malnutrition if not pregnant and BMI < 17.5 or MUAC < 21 or if pregnant/breastfeeding and MUAC < 23 or if oedema of both feet with no other cause. Advise the patient with malnutrition • Provide nutrition counselling: advise the patient to eat a healthy balanced diet and about preparing food and water in a hygienic way. • Advise the patient not to share Plumpy nut® with others, how to open packets, to store it in a cool place and avoid keeping it once opened. • How to link to other services, programs or initiatives as appropriate. Treat the patient with malnutrition • Give single dose mebendazole 500mg PO or single dose albendazole 400mg PO. • Give Ready to Use Therapeutic Food (RUTF) (Plumpy nut®) two 100g sachets three times a day. Review the patient with malnutrition monthly until BMI and MUAC are normal stop RUTF. Ensure ongoing follow-up from available nutrition support programme. Give urgent attention to the patient with malnutrition and one or more of: • Hb < 7g/dL • Respiratory rate ≥ 30 29 • BP < 90/60 • Jaundice • Extensive skin lesions • Very weak, lethargic or unconscious Management • If BP < 90/60, give normal saline 250mL IV. Avoid or stop if breathless. • Refer urgently. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela
  • 71. Adult 71 Tuberculosis (TB): diagnosis Check for TB in the patient with any of the following: cough ≥ 2 weeks, weight loss, drenching night sweats, fever ≥ 2 weeks, chest pain on breathing, blood-stained sputum. Approach to presumed TB patient not requiring urgent attention: • Test for HIV 75. • Assess risk factors for drug resistant (DR) TB: previously treated for TB, close contact with another DR-TB patient or known high risk MDR settings (correctional facilities, military barracks, homeless shelters, refugee camps, dormitories or nursing homes). • Decide which test the patient needs: Does patient have abdominal pain, swelling, diarrhoea, headache or lymph node ≥ 2cm? Send 2 spot sputum samples for AFB Both sputum AFB negative • Give doxycycline4 100mg PO BID for 7 to 10 days or clarithromycin 500mg PO BID for 5 to 7 days. • If antibiotic use in last 3 months, add amoxicillin 1g PO TID for 5 to 7 days. • Advise patient to return if no better or symptoms worsen. At least one sputum positive for AFB Send single sputum sample for Xpert MTB/RIF assay Review Xpert MTB/RIF assay results3 MTB detected Rifampicin sensitive Diagnose drug-sensitive TB Give routine DS-TB care and start DS-TB treatment same day 72: Diagnose rifampicin-resistant TB Refer to hospital. Rifampicin resistant MTB not detected Presumed Pulmonary TB (PTB) Any of: risk factors for DR TB, HIV positive or recent 2 sputum samples negative2 ? No No Yes Yes Presumed Extra-pulmonary TB (EPTB) 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid and refer. 2 If patient previously tested negative for AFB and no better after antibiotic therapy. 3 If unsuccessful or error result seen, repeat with new sample. 4 Avoid if pregnant. Give urgent attention to the presumed TB patient with one or more of: • Respiratory rate > 30 • Breathless at rest or while talking • Confusion or agitation • Coughs ≥ 1 tablespoon fresh blood Management: • Give ceftriaxone1 1g IV/IM. If unavailable, give amoxicillin1 1g PO. • Give face mask oxygen. • Refer same day. TB TB MALNUTRITION
  • 72. Adult 72 Drug-sensitive (DS) TB: routine care Assess the patient with DS-TB at diagnosis, at 2 weeks and then once a month throughout DS-TB treatment. Assess When to assess Note Symptoms Every visit • If respiratory rate > 30, breathless at rest or while talking, or confused/agitated, give urgent attention 71. • Expect gradual improvement on TB treatment. If symptoms worsen or do not improve after 1 month of treatment, refer to hospital. Contacts At diagnosis and if contact symptomatic • Trace and screen symptomatic contacts, HIV positive contacts and contacts < 5 years of age for TB. • Exclude TB and administer 6 months IPT to asymptomatic contacts < 5 years of age and to HIV positive contacts. Family planning Every visit Assess contraception needs to avoid pregnancy during TB treatment 110. If oral contraceptive, give higher estrogen dose (50 mcg). If on subdermal implant, advise consistent condom use. Alternatively, offer switch to intrauterine contraceptive device (IUCD). Adherence Every visit Review adherence on the TB treatment card. Manage the patient who interrupts TB treatment 74. Side effects Every visit Ask about side effects on treatment 73. Substance use/abuse At diagnosis; if adherence poor In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Weight Every visit Expect weight gain on treatment and adjust TB treatment dose accordingly 73. If losing weight, refer same week to hospital. BMI/MUAC At diagnosis and week 8 • BMI = weight (kg) ÷ height (m) ÷ height (m). • If pregnant/breastfeeding and MUAC < 23cm or if not pregnant/breastfeeding and BMI < 17.5 or MUAC < 21cm, malnutrition likely 70. Glucose At diagnosis Check glucose 86. HIV At diagnosis or if status unknown Test for HIV 75. If HIV positive and not already on ART, start ART once tolerating TB treatment 76: • If CD4 ≤ 50 cells/mm3 or stage 4, start ART within 2 weeks. If TB meningitis, start ART after 4-6 weeks of TB treatment. • If CD4 > 50 cells/mm3 and not stage 4, start ART between 2-8 weeks of TB treatment. Sputum specimen for microscopy, if smear positive at diagnosis End of month 2, month 5 and month 6 • IIf smear negative at end of month 2, change to continuation phase. • If smear positive at end of month 2, manage as on month 2 smear positive algorithm 74. Sputum specimen for Xpert MTB/RIF, if HIV positive, smear negative or EPTB End of month 2, month 5 and month 6 • If drug sensitive, continue treatment. • If drug resistant, diagnose DR-TB, stop DS-TB treatment and refer to hospital for DR-TB treatment. Treatment outcome End of treatment Manage according to smear status at diagnosis: • Smear positive at diagnosis: - - If AFB negative at month 5 and month 6, assign“Cure”outcome. - - If AFB positive at either month 5 or month 6, assign“Treatment failure”outcome and refer to hospital. - - If smear result does not fit any of the criteria above, assign“Treatment completed”outcome. • Smear negative at diagnosis or patient with extrapulmonary TB: If patient completed full course of TB treatment, assign“Treatment completed”outcome. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. Advise and treat the patient with TB 73.
  • 73. Adult 73 Advise the patient with TB • Arrange TB/HIV education and refer for community or workplace adherence support. • Support the patient with poor adherence. Educate on adherence and the dangers of resistance and arrange adherence support. If treatment interrupted 74. • Educate patient about TB treatment side effects below and to report these promptly if they occur. • Advise patient s/he will no more be infectious after 2 weeks of effective treatment. • Advise the patient misusing alcohol, khat and/or using illegal or misusing prescription or over-the-counter medication to stop. • Alcohol, khat and drug misuse interferes with recovery and adherence 103. If patient smokes tobacco 102. Support patient to change 125. Review the patient with DS-TB at diagnosis, at 2 weeks and then once a month throughout DS-TB treatment. Treat the patient with TB • Treat the patient with TB 7 days a week for 6 months: - - Give intensive phase RHZE for 8 weeks. - - Change to continuation phase RH at 8 weeks to complete 6 months of TB treatment. If sputum smear positive at end of 2 months, manage further 74. • If TB meningitis, TB spine or TB of hip or knee, extend continuation phase to 10 months. • If TB meningitis or TB pericarditis, also give prednisolone 60mg PO daily for first 4 weeks, then gradually taper off over the next 4 weeks. • Give pyridoxine 25mg PO daily until treatment completed. Intensive phase: 8 weeks Continuation phase: 4 months Weight RHZE (150/75/400/275) RH 30-37kg 2 tablets 2 tablets (150/75) 38-54kg 3 tablets 3 tablets (150/75) 55-70kg 4 tablets 2 tablets (300/150) ≥ 71kg 5 tablets 2 tablets (300/150) R - rifampicin H - isoniazid Z - pyrazinamide E - ethambutol Manage the TB/HIV co-infected patient: • If TB diagnosed while patient on IPT, stop IPT and start TB treatment. • Avoid starting nevirapine with DS-TB treatment. If already on nevirapine, consider switching medication 79. Look for and manage TB treatment side effects Jaundice and vomiting Most TB medications Stop all medications and refer same day. Skin rash/itch Most TB medications Assess and manage 53. Loss of colour vision Ethambutol Refer same day. Nausea/poor appetite Rifampicin Take treatment at night. Give metoclopramide 10mg PO TID up to 5 days. Joint pain Pyrazinamide Give ibuprofen 400mg PO TID up to 5 days (avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease). Orange urine Rifampicin Reassure. Burning feet Isoniazid Increase pyridoxine to 75mg PO daily.
  • 74. Adult 74 Manage the patient with a positive sputum smear at the end of month 2 • Look for explanation for result: ask about alcohol, khat or drug use 103, stress 65 and side effects. Give increased adherence support and educate the patient about the risks of poor adherence 73. • Send 1 sputum specimen for Xpert MTB/RIF. Indicate on the request form that the patient’s sputum at end of month 2 is smear positive. Review results: Rifampicin sensitive or Xpert MTB/RIF not available Manage the patient who interrupts TB treatment • Trace the patient and look for explanation for treatment interruption. Ask about alcohol, khat or drug use 103, stress 65 and side effects. • Give increased adherence support and educate the patient about the risks of poor adherence 73. • Manage treatment interruption according to duration of interruption: Interrupted for < 1 month MTB detected Sensitive Resistant • Continue TB treatment. • Ensure patient makes up missed doses by adding the missed days at the end of treatment. Sensitive Resistant Refer to hospital for DR TB treatment. Rifampicin resistant TB Refer to hospital for treatment Restart full course of DS-TB treatment. MTB not detected Refer to hospital Interrupted for 1-2 months • Send sputum for Xpert MTB/RIF. • Continue treatment while awaiting results. Interrupted for ≥ 2 months • Register patient as lost to follow up. • Send sputum for Xpert MTB/RIF and manage patient according to result: Change to continuation phase. At the end of month 5 and month 6, send sputum specimen for smear. Rifampicin resistant Smear positive Smear negative Assign treatment failure. • Stop treatment • Refer to hospital Assign cured/completed Stop treatment at 6 months. Diagnose rifampicin-resistant TB Refer to hospital for treatment.
  • 75. Adult 75 HIV: diagnosis Decide who to test for HIV • Pregnant woman and her partner/s if HIV status unknown • Patient in labour and her partner/s if HIV status unknown • Postpartum woman and her partner/s if HIV status unknown • Patient seeking contraception and her partner/s if HIV status unknown • Patient whose partner is HIV positive • Patient whose family member is HIV positive • Patient with symptoms of HIV/AIDs • Patient with TB if HIV status unknown • Patient with STI and partner/s if HIV status unknown • MARP1 patient or between patient 15-24 years of age. Obtain informed consent • Educate patient about HIV, modes of HIV transmission, risk factors, benefits of knowing one’s HIV status and treatment. • Offer HIV testing like any other investigation. Unless the patient says no, s/he is tested. • If consent is granted, explain the test procedure and proceed to testing immediately. Test Do rapid HIV test on finger-prick blood using Colloidal Gold®. Support Ensure patient understands test result and knows where and when to access further care. Positive Do a second rapid HIV test on finger-prick blood using Uni Gold®. Positive Positive Negative Do a third rapid HIV test on finger-prick blood using Vikia® HIV test result negative Was patient at risk of HIV infection in the past 4 weeks (new or multiple sexual partners, or unprotected sex)? Yes • Repeat HIV test after 4 weeks. • Encourage patient to follow safe sex practices. No • Patient does not have HIV. • Encourage patient to remain negative and advise when to re-test: - - If sexually active, yearly - - If pregnant: between 28 and 36 weeks • Offer referral for male circumcision to decrease risk of HIV infection. Patient has HIV. Negative Negative Indeterminate/Invalid • Advise patient to practice safe sex and return after 2 weeks for repeat test. • If results are still indeterminate, send blood specimen to laboratory for ELISA test. • Give routine HIV care at this visit 76. • Offer to help disclose status to sexual partner/s. • Encourage HIV testing for sexual partners and children. 1 MARP include commercial sex workers, long distance drivers, university students and community around and workers of Mega projects. HIV
  • 76. Adult 76 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 TB symptoms 71. TB Every visit If any one of: cough, weight loss, night sweats or fever, exclude TB 71. If none of the symptoms are present, start IPT. Start ART after TB has been excluded. STI Every visit If genital symptoms 36. Adherence Every visit Ask patient if s/he is taking medicines regularly. Check adherence with pill count (at pharmacy) and record of attendance. If adherence to IPT or CPT is poor, give adherence counseling before considering starting ART. Side effects Every visit Ask about side effects from ART 80, isoniazid preventive therapy (IPT) 78, co-trimoxazole 78 and fluconazole 78. Mental health Every visit • In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. • In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. • If ≥ 1 of: memory/co-ordination problems, disorientation, language difficulty, less able to cope with daily activities and work/social function: consider dementia 106. CVD risk At diagnosis Assess the patient’s CVD risk 84. Sexual health Every visit Ask about risky behaviour (patient or partner has new or > 1 partner, unreliable condom use or risky alcohol/drug use 103) and sexual problems 43. Family planning Every visit • Advise reliable2 contraception (IUD, injectable or sterilisation plus condoms) 110. • If planning pregnancy, advise patient to use contraception until viral load < 1000copies/mL. eMTCT If pregnant or breastfeeding If not on ART, start ART same day or as soon as possible. If pregnant, give antenatal care 114. Palliative care If deteriorating If patient deteriorating on ART and survival is predicted to be short, also give palliative care 120. Weight (BMI) Every visit • If weight loss ≥ 5% of body weight in 4 weeks 16. • If BMI < 17.5, malnutrition likely 70. BMI = weight (kg) ÷ height (m) ÷ height (m). MUAC Every visit, if pregnant/lactating or unable to stand If pregnant/breastfeeding and MUAC < 23cm or if not pregnant/breastfeeding and MUAC < 21cm, malnutrition likely 70. Stage Every visit • Check weight, mouth, skin, previous and current problems. • If stage 3 or 4 give co-trimoxazole and prioritise patient for ART. If clinical stage worsens while patient on ART, refer to hospital. Stage 1 Stage 2 Stage 3 Stage 4 • No symptoms • Persistent painless swollen glands • Recurrent sinusitis, tonsillitis, otitis media, pharyngitis • Papular pruritic eruption (PPE) • Fungal nail infections • Herpes zoster (shingles) • Recurrent mouth ulcers • Angular cheilitis • Unexplained weight loss < 10% body weight • Pulmonary TB • Oral candida • Oral hairy leukoplakia • Unexplained weight loss ≥ 10% body weight • Unexplained diarrhoea > 1 month • Unexplained fever > 1 month • Severe bacterial infections (pneumonia, meningitis) • Unexplained anaemia < 8g/dL, neutropaenia < 0.5x10/L, or chronic thrombocytopaenia < 50x10/L • Extrapulmonary TB • Weight loss ≥ 10% and diarrhoea or fever > 1 month • Pneumocystis pneumonia (PJP) • Recurrent severe bacterial pneumonia • Herpes simplex of mouth or genital area > 1 month • Oesophageal candida • Kaposi’s sarcoma, lymphoma, invasive cervical cancer • Cytomegalovirus infection • Toxoplasmosis • HIV-associated dementia, encephalopathy • Cryptococcal disease (including meningitis) • Cryptosporidium or Isospora belli diarrhoea Cervical screen (VIA) At diagnosis, then 5 yearly if normal If VIA abnormal 40. Continue to assess the patient with HIV 77. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. 2 The oral contraceptive and implant may be less effective on ART. Advise the patient on ART choosing to continue with oral contraceptive or implant to use condoms as well.
  • 77. Adult 77 Review results of routine blood tests Assess When to assess Note Hepatitis At diagnosis and if changing from TDF • If HBsAg or hepatitis C antibody positive, refer to hospital. • If changing regimen: if HBsAg positive, continue tenofovir as a 4th medication (avoid stopping tenofovir) and refer to hospital. CD4 At diagnosis and 6 monthly • Start ART regardless of CD4 count. • If CD4 ≤ 350cells/mm3, also give co-trimoxazole. • If viral load test available, stop CD4 testing after 1 year on ART and 2 consecutive CD4 counts of >350cells/mm3 or viral load < 1000 copies/mL. • If viral load test not available, continue CD4 6 monthly testing. Cryptococcal antigen At diagnosis if CD4 ≤ 100cells/mm3 • If cryptococcal antigen positive and symptomatic, (headache, confusion), refer same day. • If cryptococcal antigen positive and asymptomatic or test unavailable, give fluconazole 78 for cryptococcal infection and start ART 4 weeks later. eGFR2 (if not pregnant) On TDF: before starting (if available) If eGFR < 50mL/min/1.73m3 : • Avoid tenofovir and start instead zidovudine3 . Adjust doses of other medications. • Check BP, glucose, urine dipstick and arrange kidney ultrasound. Refer to hospital. Creatinine (if pregnant) If creatinine ≥ 85μmol/L, avoid tenofovir and refer. CBC On AZT: before starting, at 4, 8 and 12 weeks • If Hb 7-7.9g/dL or neutrophil ≥ 0.75 x 109 /L or platelet > 50,000/mcL: start/continue ART. • If Hb < 7g/dL or neutrophils < 0.75 x 109 /L or platelet ≤ 50,000/mcL: if starting, avoid zidovudine, refer. If on AZT, switch medication 79. ALT On NVP: before starting, then 6 monthly • At diagnosis: - - If ALT > 200, refer same day. If ALT 100-200, review hepatitis results, medications, alcohol use. Avoid nevirapine. • On ART: - - If ALT > 200, refer same day. If ALT 100-200, continue medication and repeat ALT within 1 week. Viral load At 6 months, 12 months, then 12 monthly • If viral load > 1000 copies/mL for 1st time, give intensified adherence support and repeat viral load after 3 months. • If viral load > 1000 copies/mL for 2nd time, patient has virological failure: refer to hospital. Advise and treat the patient with HIV 78. 1 If not pregnant, check eGFR. If pregnant, check creatinine instead. 2 Calculate eGFR = [(140 - age) x weight (kg)]/[72x creatinine (mg/dL)]. If patient is a woman, multiply by 0.85. 3 If previously on zidovudine, refer to hospital. Continue to assess the patient with HIV Do blood tests at diagnosis, before starting ART and regularly on ART: sending blood samples to respectively assigned referral hospital At diagnosis Starting/changing ART regimen 4 weekss 8 weeks 12 weeks 6 months 1 Year Yearly 6 monthly • CD4 • If available: - - Cryptococcal antigen - - HBsAg and Hepatitis C antibody tests • Starting AZT: CBC • Starting NVP: ALT • Starting TDF: eGFR or creatinine1 • Changing from TDF: HBsAg AZT: CBC AZT: CBC AZT: CBC • Viral load • CD4 • Viral load • CD4 Viral load • CD4: If viral load test available, stop after 1 year on ART and 2 consecutive CD4 counts of >350cells/mm3 or viral load < 1000 copies/mL • NVP: ALT AZT – zidovudine CBC – complete blood count Hb – haemoglobin
  • 78. Adult 78 Advise the patient with HIV • Offer to help disclose status 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 abstinence, being faithful to one partner and 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 prevent resistance. • Explain the benefits of starting ART early, regardless of CD4 or stage but especially if CD4 ≤ 350, stage 3 or 4, pregnant or breastfeeding. If patient chooses not to start ART, advise to attend regularly for routine HIV care and to return immediately if s/he becomes unwell. • Give increased adherence support to the patient with poor adherence/attendance or viral load > 1000copies/mL: - - Educate patient and family on the importance of adherence and dangers of resistance. - - Plan with patient how to take treatment. Consider adherence aids (pillboxes, diaries). - - Refer for support: adherence counsellor, support group, treatment buddy, health extension worker. Treat the patient with HIV • Give prophylaxis: isoniazid preventive therapy (IPT), co-trimoxazole and fluconazole as needed (see below). • Give ART regardless of CD4 or stage 79. • If already on ART and no problems, continue treatment. • If already on ART and contraindication to current ART or intolerable side effect, change ART 79. When to give What to give Side effects When to stop Isoniazid preventive therapy (IPT) • No TB symptoms • If also starting ART, start IPT once tolerating ART. • Avoid if TB symptoms, on TB treatment, peripheral neuropathy, liver disease, alcohol abuse. • Isoniazid 300mg daily • Pyridoxine 25mg daily • Peripheral neuropathy 50 • Rash 53 • Hepatitis - - If jaundice: refer same day. - - If nausea, vomiting, abdominal pain: check ALT and review result within 24 hours 80. Stop IPT after 6 months. Co-trimoxazole • CD4 ≤ 350cells/mm3 • Stage 3 or 4 Co-trimoxazole 960mg PO daily • Nausea/vomiting 33 • Rash 53 • Fatigue, dizziness (if Hb ≤ 7g/dL, refer to hospital) • Easy bruising, bleeding from gums: stop medication and refer same day. • Hepatitis - - If jaundice: refer same day. - - If nausea, vomiting, abdominal pain: check ALT and review result within 24 hours 80. Stop co-trimoxazole after 1 year on ART and 2 consecutive CD4 counts of >350cells/mm3 or viral load < 1000 copies/mL Fluconazole • Cryptococcal antigen positive or • Cryptococcal antigen unavailable with CD4 ≤ 100cells/mm3 • If pregnant, breastfeeding or known liver disease, avoid fluconazole and refer same day. • If symptomatic (headache, confusion), refer same day. • If asymptomatic, give fluconazole 800mg PO daily for 2 weeks, then 400mg daily for 2 months, then 200mg daily to complete at least 1 year. • Nausea/vomiting 33 • Hepatitis - - If jaundice: refer same day. - - If nausea, vomiting, abdominal pain: check ALT and review result within 24 hours 80. Stop after at least 1 year on ART and fluconazole if 2 consecutive CD4s ≥ 100cells/mm3 or viral load < 1000copies/mL. Review the patient with HIV • If starting ART: review 2 weeks after starting ART, then monthly. • Once on ART for ≥ 1 year, 2 consecutive viral loads < 1000 copies/mL, not pregnant or breastfeeding, is adherent and well, review 6 monthly. If unwell or problems with adherence, see more often. • If declines ART: see patient 2 weekly and give repeated counseling; Otherwise advise patient to return if unwell or s/he decides to start ART.
  • 79. Adult 79 Start or change ART in the patient with HIV 1. Decide which ART regimen the patient needs Currently not on ART Currently on ART and contraindication or intolerable side effect. Switch to a medication from the same section 80. Choose 1st line ART Known with kidney disease or uncontrolled hypertension? Never had ART Refer to hospital for 2nd line ART Known with active psychiatric illness? Known with active psychiatric illness? Choose same regimen as before. Choose zidovudine, lamivudine and efavirenz. Choose tenofovir, lamivudine and nevirapine. Choose zidovudine, lamivudine and nevirapine. Choose tenofovir, lamivudine and efavirenz. • Do viral load test. • Is viral load > 1000copies/mL? Previously had ART and interrupted Yes Yes Yes Yes No No No No 2. Check other medications and change if needed • If epilepsy and patient is on phenytoin, monitor closely. If available or affordable, use instead valproic acid 97. • If on oral contraceptive or implant, advise the patient to use condoms as well. • If on TB treatment and starting nevirapine, replace with efavirenz 80. 3. Order blood tests as directed 77 If blood results done accordingly are abnormal, alter regimen choice 80. Discuss if needed. 4. Decide when to start/change ART If starting ART: • If pregnant or breastfeeding: start ART after 2 weeks unless newly diagnosed TB or suspected TB (refer instead to hospital). • If TB, start ART once tolerating TB treatment: - - If CD4 ≤ 50cells/mm3 or stage 4, start ART within 2 weeks. If TB meningitis, start ART after 2-8 weeks of TB treatment. - - If CD4 > 50cells/mm3 and not stage 4, start ART between 2-8 weeks of TB treatment. • If cryptococcal antigen positive: start ART after 4 weeks of fluconazole. If cryptococcal meningitis, start ART after 4-6 weeks of fluconazole. • If none of above: start ART within 2 weeks. If changing ART: • Change as soon as blood results are available. • If contraindication or intolerable side effect: change same day and review blood results as soon as possible.
  • 80. Adult 80 5. Start/change ART • Give a combination of 3 medications (1 from each of the 3 sections in the table below) according to chosen ART regimen and blood results. • Give fixed dose combination tablet if available. Medication Dose Urgent side effects (stop medication and refer same day) Self-limiting side effects (refer to hospital if persist after 6 weeks) Long-term side effects 1 Tenofovir (TDF) • 300mg PO daily • Avoid if eGFR < 50mL/min/1.73m3 Kidney failure Nausea, diarrhoea - Zidovudine (AZT) 300mg PO BID • Lactic acidosis1 • Symptomatic anaemia (pallor with respiratory rate > 30, dizziness/faintness or chest pain) • Headache • Nausea • Muscle pain • Fatigue (if Hb ≤ 7g/dL switch medication 79) Fat loss in face, limbs and buttocks; fat accumulation (central obesity, breast enlargement); switch to tenofovir or abacavir 79. Abacavir (ABC) Avoid if previous Abacavir Hypersensitivity Reaction (AHR) 300mg PO BID or 600mg PO daily Abacavir Hypersensitivity Reaction likely if ≥ 2 of: • Fever • Rash • Fatigue/body pain • Nausea/vomiting/diarrhoea/abdominal pain • Sore throat/cough/difficulty breathing • Nausea • Vomiting • Diarrhoea - 2 Lamivudine (3TC) 150mg PO BID or 300mg PO daily Uncommon Uncommon. Occasional nausea and diarrhoea Uncommon 3 Efavirenz (EFV) Avoid if active psychiatric illness • 400mg PO daily • If pregnant or TB, give 600mg PO daily • Avoid taking drug with fatty meal • Rash 53 • Jaundice/hepatitis2 • Psychosis • Rash 53 • Headache, dizziness, sleep problems, low mood - take dose at night. If on 600mg daily, consider giving 400mg PO daily. • Central obesity, breast enlargement, switch to nevirapine 79. • Dyslipidemia Nevirapine (NVP) Avoid if CD4 > 250cells/mm3 (woman) or > 400cells/mm3 (man) or ALT ≥ 100 200mg PO daily for 2 weeks, then 200mg PO BID • Rash 53 • Jaundice/hepatitis2 • Rash 53 • Nausea - 1 Lactic acidosis likely if 2 or more of: fatigue/weakness, body pain, nausea/vomiting, diarrhoea, weight loss, loss of appetite, abdominal pain, difficulty breathing (more likely if rapid lactate ≥ 2.5mmol/L). 2 If jaundice: refer same day. If nausea, vomiting, abdominal pain: check ALT and review result within 24 hours 77.
  • 81. Adult 81 Asthma and COPD: diagnosis • The patient with chronic cough may have more than one disease. Also consider TB, pneumocystis pneumonia (PJP), lung cancer, bronchitis, heart failure and post-infectious cough 29. • Asthma and chronic obstructive pulmonary disease (COPD) both present with cough, wheeze, tight chest or difficulty breathing. Distinguish asthma from COPD: If unsure of diagnosis, treat as asthma 82 and refer to hospital within 1 month. Asthma likely if several of: • Onset before 20 years of age • Associated allergic rhinitis, eczema, allergic conjunctivitis, other allergies • Symptom severity changes over time with symptom-free periods in between. • Symptoms worse at night, early morning, with cold, stress or common cold • Patient or family have a history of asthma Give routine asthma care 82. COPD likely if several of: • Onset after 40 years of age • Symptoms are persistent and worsen slowly over time • Cough with sputum starts long before difficulty breathing • History of heavy tobacco smoking or indoor smoke exposure • Previous diagnosis of TB • Poor response to inhaled salbutamol Give routine COPD care 83. 1 Adapted from: Zar HJ, Green C, Mann MD, Weinberg EG. A novel method for constructing an alternative spacer for patients with asthma. SAMJ. 1999 January; 89(1): 40-42. 2 If 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. While breathing in, press pump once and keep breathing in slowly. Close mouth and hold breath for 10 seconds. Breathe out. Using inhalers and spacers • If patient unable to use an inhaler correctly, add a spacer to increase drug delivery to the lungs, especially if using inhaled corticosteroids. This may also reduce the risk of oral candida. • Clean the spacer before first use and every second week: remove the canister and wash spacer with soapy water. Allow it to drip dry. Avoid rinsing with water after each use. How to make a spacer from a plastic bottle1 How to use an inhaler with a spacer2 1 • Wash a 500mL plastic cold-drink bottle with soapy water. • Leave to air-dry. • Discard the lid. 2 • Wind a steel wire around the open mouth of inhaler to form a mould. • Keep some wire for a handle. • Heat the mould with a flame until it is red hot. 1 Shake inhaler and insert into spacer. 2 • Stand up and breathe out. • Then form a seal with lips around mouthpiece. 3 Apply the hot mould to the bottom end of the bottle for 10 seconds then rotate 180° and reapply until the plastic melts. 4 • Insert mouth of inhaler immediately to create a tight fit. • Apply quick-setting glue to seal the inhaler permanently to the spacer. 3 Press pump once to release one puff into spacer. 4 • Then take 4 breaths keeping spacer in mouth. • Repeat steps 3 and 4 for each puff. • Rinse mouth after using inhaled corticosteroids. CHRONIC RESPIRATORY DISEASE
  • 82. Adult 82 Asthma: routine care Advise the patient with asthma • Ask about smoking. If patient smokes tobacco 102. Support patient to change 125. • Ensure patient understands medication: beta-agonist (salbutamol) relieves symptoms but does not control asthma. Inhaled corticosteroid (beclomethasone) prevents but does not relieve symptoms and it is the mainstay of asthma control. • Inhaled corticosteroids can cause oral candida: advise patient to rinse and gargle after each dose of beclomethasone. • Advise patient to avoid allergens that worsen/trigger asthma or allergic rhinitis (e.g. animals, dust, chemicals, pollen, grass). Also advise to avoid aspirin, NSAIDs (e.g. ibuprofen) and beta-blockers (e.g. metoprolol). Treat the patient with asthma • Give inhaled salbutamol 200mcg (2 puffs) as needed, up to 4 times a day. If exercise-induced asthma, give patient salbutamol 200mcg (2 puffs) to use before exercise. • If patient received prednisolone or hydrocortisone for an acute exacerbation, give prednisolone 40mg PO daily for 5 days. • If acute exacerbation or asthma is not controlled, step up treatment: - - Before adjusting treatment ensure patient is adherent and can use inhaler and spacer correctly 81. Also check patient is avoiding smoking, allergens and medications (aspirin, NSAIDs, beta-blockers). - - Give inhaled beclomethasone 200mcg BID if not already on it. If already on it, increase beclomethsone to 400mcg BID. If not available start predisolone 2.5 to 5mg daily and refer. • If still not controlled, add theophedrine 120/10mg BID. Increase theophedrine to 240/20mg BID if needed . If not controlled after 1 month, refer to hospital. • If asthma is controlled: continue medication at same dose. If controlled and no acute exacerbations for ≥ 6 months, step down treatment: - - If on theophylline, decrease dose or stop. - - If on beclomethasone, decrease total daily dose by 200mcg. If on 200mcg daily, stop beclomethasone. - - If symptoms worsen while stepping down treatment, step up again to same medication and dose as when the patient was controlled. • If acute exacerbation, only give antibiotic if fever or thick yellow/green sputum: give doxycycline 100mg PO BID for 5 days. Avoid doxycycline if pregnant. • If > 2 courses of prednisolone given in past 6 months or acute exacerbation occurs on maximum treatment, refer to hospital. • Review the patient with controlled asthma 3 monthly, the patient with asthma that is not controlled monthly, and the patient with an acute exacerbation after 1 week. • Advise patient to return before next appointment if no better or symptoms worsen. Assess the patient with asthma Assess When to assess Note Symptom control Every visit • If patient has wheeze/tight chest and is breathless at rest or while talking or respiratory rate > 30, manage acute exacerbation 30. • Any of the following indicate that the patient’s asthma is not controlled: - - Daytime cough, difficulty breathing, tight chest or wheeze > 2 times a week - - Night-time or early morning waking due to asthma symptoms - - Limitation of daily activities due to asthma symptoms - - Need to use salbutamol inhaler > 2 times a week - - frequent exacerbations > 2 in past 12 months • If none of the above then asthma is controlled. Other symptoms Every visit • Manage symptoms as on symptom pages. Ask about and manage allergic rhinitis 26 and dyspepsia 32. • Ask the patient using inhaled corticosteroids about a sore mouth. Check for oral candida 27. Medication use Every visit Check adherence and that patient can use inhaler and spacer correctly 81. If not adherent, refer for health extension worker support.
  • 83. Adult 83 Chronic obstructive pulmonary disease (COPD): routine care Advise the patient with COPD • Ask about smoking. If patient smokes tobacco 102. Support patient to change 125. Stopping smoking is the mainstay of COPD care. • Encourage the patient to take a walk daily and to increase activities of daily living like gardening, housework and using stairs instead of lifts. • Help the patient to manage his/her CVD risk 85. • Inhaled corticosteroids can cause oral candida: advise patient to rinse and gargle after each dose of beclomethasone. Treat the patient with COPD • Give inhaled salbutamol 200mcg (2 puffs) when needed, up to 4 times a day. • If patient received prednisolone or hydrocortisone for acute exacerbation at this visit, give prednisolone 40mg PO daily for 5 days. • If sputum increases in amount or changes in color to yellow/green and worsening of cough or dyspnea, treat for chest infection: - - Give doxycycline 100mg PO BID for 7 days. Avoid if pregnant. - - If increased breathlessness, also give prednisolone 40mg PO daily for 5 days if not already on it. • Before referring for treatment adjustment, ensure patient is adherent and can use inhaler and spacer correctly 81 • If moderate or severe COPD and ≥ 2 exacerbations in 1 year, add inhaled beclomethasone 200mcg BID, if available. • If severe COPD, add theophedrine 120/10mg BID. Increase theophedrine to 240/20mg BID if needed. If no better after 1 month, refer to hospital. • If ≥ 2 courses of prednisolone given in 6 months, refer to hospital for review and spirometry. If stable and mild COPD review 6 monthly. If moderate/severe COPD or frequent/recent exacerbation review monthly. Assess the patient with COPD Assess When to assess Note COPD symptoms: cough and difficulty breathing Every visit • If patient has wheeze/tight chest and breathless at rest or while talking or respiratory rate > 30, manage acute exacerbation 30. • Assess disease severity: If difficulty breathing with activities of daily living (like dressing) and at rest, COPD is severe. If unable to walk at same pace as others of same age, COPD is moderate. If difficulty breathing only when walking fast/up a hill, COPD is mild. • Investigate for TB only if patient has other TB symptoms like weight loss, night sweats, blood-stained sputum 71. Other symptoms Every visit • Manage symptoms as on symptom pages. • Ask the patient using inhaled corticosteroids about a sore mouth. Check for oral candida 27. • If swelling in both legs, and unable to lie flat, consider heart failure. Refer to hospital. BMI/MUAC Every visit If pregnant/breastfeeding and MUAC < 23cm or if not pregnant/breastfeeding and BMI < 17.5 or MUAC < 21cm, malnutrition likely 70 Medication use Every visit Check adherence and that patient can use inhaler and spacer correctly 81. If not adherent, refer for health extension worker support. Depression Every visit In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. Palliative care Every visit If severe COPD, > 3 hospital admissions for COPD in 1 year or heart failure and survival is predicted to be short, also give palliative care 120. CVD risk At diagnosis, then depending on risk • Assess CVD risk 84. • If <10%, reassess after 1 year. If 10% to < 20%, reassess after 6 months.
  • 84. Adult 84 Cardiovascular disease (CVD) risk: diagnosis CVD risk is the chance of having a heart attack or stroke over the next 10 years Identify if the patient has established CVD: • Patient known with any of: previous heart attack, angina pectoris or heart failure, previous stroke or TIA or peripheral vascular disease. • If patient has current/recent chest pain, especially on exertion and relieved by rest, screen for ischaemic heart disease 94. • If patient has current/recent leg pain, especially on walking and relieved by rest, screen for peripheral vascular disease 49. • If new sudden asymmetric weakness or numbness of face, arm or leg; difficulty speaking or visual disturbance: consider stroke or TIA 93. Look for CVD risk factors: • Ask about smoking: consider the patient who quit smoking in the past year a smoker for CVD risk assessment. • Ask about family history: a parent or sibling with premature CVD (man < 55 years or woman < 65 years) is a risk factor. • Calculate Body Mass Index (BMI): weight (kg) ÷ height (m) ÷ height (m). A BMI > 25 is a risk factor. • Measure waist circumference over no/light clothing, at the end of a normal breath 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 89. • Look for diabetes: check glucose 86. Calculate the patient’s CVD risk: • Plot patient’s risk on charts1 below using diabetes status, age, sex, systolic BP (SBP) and smoking status. Show the patient what his/her risk of heart attack or stroke might be over next 10 years. • Avoid using these charts to decide treatment if patient has established CVD or kidney disease. Treat as if the patient has a CVD risk > 30%. CVD risk1 : > 30% 20-30% 10-20% < 10% 1 Adapted from WHO/ISH Cardiovascular Risk Prediction Chart for WHO epidemiological sub-regions AFR E. From: Prevention of Cardiovascular Disease. Pocket Guidelines for Assessment and Management of Cardiovascular Risk. World Health Organization. Geneva, 2007. Diabetic man Diabetic woman Non-diabetic man Non-diabetic woman Non smoker Smoker Non smoker Smoker SBP (mm Hg) Non smoker Smoker Non smoker Smoker SBP (mm Hg) ≥ 70 years ≥ 180 160-179 140-159 < 140 ≥ 70 years ≥ 180 160-179 140-159 < 140 60-69 years ≥ 180 160-179 140-159 < 140 60-69 years ≥ 180 160-179 140-159 < 140 50-59 years ≥ 180 160-179 140-159 < 140 50-59 years ≥ 180 160-179 140-159 < 140 40-49 years ≥ 180 160-179 140-159 < 140 40-49 years ≥ 180 160-179 140-159 < 140 • If CVD risk factors or CVD risk ≥ 10% or established CVD, manage the CVD risk 85. • If CVD risk < 10% and no CVD risk factors, reassess CVD risk after 5 years.
  • 85. Adult 85 Cardiovascular disease (CVD) risk: routine care Assess the patient with CVD risk factors or CVD risk ≥ 10% or established CVD Assess When to assess Note Symptoms Every visit Ask about chest pain 28, difficulty breathing 29, leg pain 49, or new sudden asymmetric weakness or numbness of face, arm or leg; difficulty speaking or visual disturbance 93. Modifiable risk factors Every visit Ask about smoking, diet, substance use and exercise or activities of daily living. Manage as below. BMI Every visit BMI = weight (kg) ÷ height (m) ÷ height (m). Aim for < 25. Waist circumference Every visit 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 Check BP 89. If known hypertension 90. CVD risk At diagnosis, then depending on risk If < 10% with CVD risk factors or 10-20% reassess after 1 year. If > 20%, refer to hospital for investigation if not already done. Blood glucose At diagnosis, then depending on result Check glucose 86. If known diabetes 87. Random total cholesterol (by referral to hospital) At baseline if no CVD or diabetes within 3 months of diagnosis. • If no CVD or diabetes no need to repeat cholesterol or adjust simvastatin. • If CVD or diabetes, increase simvastatin based on repeat cholesterol on relevant page. Treat the patient with CVD risk • If no diabetes, give simvastatin 20mg PO daily if patient has established CVD, cholesterol > 300mg/dL or CVD risk ≥ 30%. • If diabetes, decide if patient needs simvastatin 87. If CVD risk remains > 30% after 6 months, refer. 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. • Invite patient to address 1 lifestyle 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. Stress Assess and manage stress 65. Physical activity • Aim for at least 30 minutes of moderate exercise (e.g. brisk walking) on most days of the week. • Increase activities of daily living like gardening, housework, walking instead of taking transport, using stairs instead of lifts. • Exercise with arms if unable to use legs. Smoking • Encourage patient not to start • If patient smokes tobacco 102. Diet • Eat a variety of foods in moderation. Reduce portion sizes. • Increase fruit and vegetables. • Reduce fatty foods: eat low fat food, cut off animal fat. Use liquid oils instead of solid or semisolid oils • Avoid adding salt to food. • Avoid/use less sugar and sugary foods/drinks. Screen for substance abuse • Limit alcohol intake ≤ 2 drinks1 /day and avoid alcohol on most days of the week. • In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the- counter medications? If yes to any 103. Weight • Aim for BMI < 25, and waist circumference < 80cm (woman) and < 94cm (man). • Any weight reduction is beneficial, even if targets are not met. • Identify support to maintain lifestyle change: health care worker, friend, partner or relative to attend clinic visits, a healthy lifestyle group. • 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 124. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. CHRONIC DISEASES OF LIFESTYLE
  • 86. Adult 86 Diabetes: diagnosis Decide which glucose test to do • If patient is well and able to return for screening, check fasting plasma glucose after an 8-hour overnight fast. • Only check finger prick random glucose if patient is unwell or has symptoms of diabetes (thirst, urinary frequency, weight loss) or is unable to return easily for fasting glucose. Random glucose < 140mg/dL Random glucose 140-199mg/dL < 126mg/dL • Assess and manage CVD risk 84. • Repeat fasting plasma glucose after 1 year. Diagnose diabetes • Classify diabetes: - - Type 1 diabetes more likely if: <30 years, not overweight, no family history of diabetes, presents with DKA. - - Type 2 diabetes more likely if: >30 years, overweight, hypertension or family history of diabetes • Give routine diabetes care 87. ≥ 126mg/dL 100-125mg/dL 100-125mg/dL • Patient has impaired fasting glucose. • Repeat fasting plasma glucose within one week. No ketones Check urine for ketones. Check for symptoms of diabetes: thirst, urinary frequency, weight loss Check fasting plasma glucose after an 8-hour fast. Ketones present Random glucose > 200mg/dL No No No < 100mg/dL < 100mg/dL ≥ 126mg/dL Confirm with another fasting plasma glucose within one week. • Assess and manage CVD risk 84. • Repeat fasting plasma glucose after 3 years, or if CVD or hypertension, 1 year. ≥ 126mg/dL Recheck glucose 3 yearly from 45 years. Yes Yes Yes Check if patient has risk factors: BMI ≥ 25 and one or more of: • Hypertension • Cardiovascular disease • Physical inactivity • Family history of diabetes • Previous gestational diabetes or big baby • Previous impaired glucose tolerance or impaired fasting glucose • Give normal saline 1L IV over 2 hours then 1L 4 hourly. • Refer urgently. Check if patient needs urgent attention: • Unconsciousness 13 • Chest pain 28 • Convulsions 15 • Drowsiness • Confusion • Rapid deep breathing • Nausea or vomiting • Abdominal pain • Temperature ≥ 38o C • Severe dehydration: BP < 90/60, pulse ≥ 100
  • 87. Adult 87 Diabetes: routine care Assess the patient with diabetes Assess When to assess Note Symptoms Every visit • Manage symptoms as on symptom pages. • If frequent urination, thirst or hunger, check random glucose. • Ask about chest pain 28 and leg pain 49. Family planning Every visit Assess patient’s contraception needs 110. If pregnant or planning pregnancy, refer to hospital. CVD risk At diagnosis, then yearly Assess CVD risk 84. Start simvastatin if CVD risk > 20% or patient is > 40 years old 88. BP Every visit Check BP 89. If known hypertension 90. BMI At diagnosis and yearly BMI = weight (kg) ÷ height (m) ÷ height (m). Aim for BMI < 25kg/m2 . Waist circumference Every visit Aim for < 80cm in woman and < 94cm in man. Eyes for retinopathy At diagnosis, yearly and if visual problems If visual problems, cataracts or new retinopathy, refer to hospital. Feet 50 • Visual: every visit • Comprehensive: at diagnosis then yearly, more often if problems • Visual assessment: look for ulcers, calluses, redness, warmth, deformity. • Comprehensive assessment: visual assessment as above, foot pulses, reflexes, sensation in toes and feet • If ulcers 59. If severe infection or other abnormalities, refer to hospital. Random glucose Only if symptoms or adjusting glucose-lowering medication If random glucose < 70mg/dl or > 200mg/dl give urgent attention above. Urine protein At diagnosis, then yearly if not on enalapril If urine protein > 1+, start enalapril 5mg PO daily and increase to a maximum of 10mg PO BID. Refer to hospital for annual check up. eGFR (by referral to hospital) At diagnosis, then yearly If eGFR < 60mL/min/1.73m3 , refer to hospital. Random total cholesterol (by referral to hospital) • Baseline if < 40 years or if CVD risk < 20% • 3 months after starting simvastatin and then after 3 months if ≥ 190mg/dL • If baseline cholesterol > 300mg/dL, start simvastatin. • If cholesterol ≥ 190mg/dL: increase simvastatin to 40mg. If already on 40mg daily, refer to hospital. • If cholesterol < 190mg/dL, no need to repeat. Give urgent attention to the patient with diabetes and one or more of: • Chest pain 28 • Convulsing 15 • Decreased consciousness, drowsiness • Confusion or unusual behaviour • Weakness or dizziness • Shaking • Sweating • Palpitations • Rapid deep breathing • Nausea or vomiting • Abdominal pain • Thirst or hunger • Temperature ≥ 38°C • Severe d ehydration: decrease urine output, BP < 90/60, pulse ≥ 100 Check random fingerprick glucose: Glucose < 70mg/dL with/without symptoms • Give oral glucose 20g. If unable to take orally, give instead glucose 40% 50mL IV over 2-3 minutes. Repeat if glucose still < 70mg/dL after 15 minutes. Maintain with glucose 10% solution1 . • Give the patient food as soon as s/he can eat safely. • Identify cause and educate about meals and doses 88. • If incomplete recovery, refer same day. • Discuss referral if on gliclazide or insulin. Glucose > 200mg/dL with symptoms No ketones in urine Give routine diabetes care below. • Give normal saline 1L IV over 2 hours then 1L 4 hourly. • Give regular insulin 10IU IM single dose. • Refer urgently. Ketones in urine Glucose > 200mg/dL without symptoms Check urine for ketones. 1 Add 10 vials of glucose 40% in 1L dextrose in normal saline solution at 30 drops per minute.
  • 88. Adult 88 Advise the patient with diabetes • Help the patient to manage his/her CVD risk 85. • Explain importance of adherence and to eat regular meals. If newly diagnosed, poor adherence or attendance, refer local diabetes association branches. • Ensure patient can recognise and manage hypoglycaemia (shaking, sweating, palpitations, weakness, hunger): - - Drink sugar water, sugary soft drink or eat a candy or biscuit. Always carry something sweet. If convulsions, confusion/coma, rub sugar inside mouth. - - Identify and manage the cause: increased exercise, missed meals, inappropriate dosing of glucose-lowering medications, alcohol use, illnesses like infections. • Encourage the patient to eat a healthy, balanced, low-fat diet including lots of vegetables. Eat fewer sweet foods. • Educate the patient to care for his/her feet to prevent ulcers and amputation: avoid walking barefoot or without socks, wash feet in lukewarm water and dry well especially between the toes, avoid cutting calluses or corns, use care when cutting nails. Look at feet every day and see health care worker if any problem or injury. • Educate the patient using insulin: - - Explain injection technique and recommended sites: abdomen, thighs, upper arms. - - Advise patient to store insulin in fridge or a cool dark place. - - Ensure patient can recognise hypoglycaemia and hyperglycaemia. - - Arrange for on sharps disposal at home or clinic. Treat the patient with diabetes • Give simvastatin if ≥ 40 years, CVD risk > 20%, established CVD or cholesterol > 300mg/dL. Start simvastatin1 20mg PO daily. If repeat cholesterol > 190mg/dL increase to 40mg PO daily. If already on 40mg daily, refer to hospital. • Start aspirin 75-150mg PO daily if patient has established CVD or CVD risk >30%. Avoid if known peptic ulcer, dyspepsia, kidney or liver disease. • Give enalapril 5mg PO daily if diabetic kidney disease confirmed with urine albumin even if no hypertension. Increase gradually to 20mg PO daily if systolic BP remains > 100. Avoid in angioedema, stop if severe cough with use. • If type 1 diabetes, start or continue insulin: - - Start with NPH insulin at 0.2-0.4U/kg in two divided doses (2/3 morning, 1/3 evening). - - Increase by 2 units every 3 days until morning fasting blood glucose is 90-130mg/dL. - - If > 30IU needed, episodes of hypoglycemia at night or random glucose >180mg/dL repeatedly after 3 months, refer. • If type 2 diabetes, give glucose-lowering medication in a stepwise fashion below. Ensure patient is adherent before increasing treatment. • If patient using insulin: - - Advise home blood glucose monitoring if available and patient is able to operate glucometer. - - Once stable, patient to check fasting blood glucose on waking once a week. - - If unavailable, monitor fasting blood glucose at health centre (or if not possible random). Step Medication Start dose Maximum dose Note 1 Metformin (take with or after meals) 500mg PO daily 1g BID • Increase by 500mg/day every week if random glucose ≥ 180mg/dL or fasting glucose ≥ 130mg/dL and patient adherent. • Avoid in kidney or liver disease, or heart failure. • If on maximum dose, move to step 2. 2 Add glibenclamide (take with food) 2.5mg PO daily 20mg daily • Continue metformin. • If random glucose ≥ 180mg/dL and patient is adherent, increase every week by 2.5mg/day. • If total daily dose > 5mg then give in 2 divided doses. • Avoid in severe kidney or liver disease. • If on maximum dose, move to step 3. 3 Add basal insulin (NPH insulin) 0.1 units/kg/dose subcutaneously • Take at bedtime. • Continue metformin. Decrease glibenclamide gradually until stopped. • Increase by 2 units every 3 days until morning fasting glucose is between 90 and 130mg/dL. • If > 30IU needed, episodes of hypoglycaemia at night or fasting glucose ≥ 130mg/dL repeatedly after 3 months, refer. Review the patient with diabetes 6 monthly once stable.
  • 89. Adult 89 Hypertension: diagnosis Check blood pressure (BP) • Seat patient with back against chair and arm supported at heart level for 5 minutes. • Use a larger cuff if mid-upper arm circumference is > 34cm. • Record systolic BP (SBP) and diastolic BP (DBP): SBP is the first appearance of sound, DBP is the disappearance of sound. • Check two readings 5 minutes apart. Use the lowest reading to determine the patient’s BP. • If patient is pregnant, interpret reading 112. Give urgent attention to the patient with BP ≥ 180/110 and one or more of: • Visual disturbances • Dizziness • Weakness or numbness • Confusion • Headache • Chest pain 28 • Difficulty breathing worse on lying flat or with leg swelling 91 • BP > 200/120 Management: • Give nifedipine 20mg PO. • Refer urgently. BP < 140/90 Approach to the patient not needing urgent attention BP ≥ 140/90 Repeat BP check on 2 more occasions. Avoid diagnosing hypertension based on one reading alone. Assess CVD risk 84. BP < 140/90 on repeat checks BP < 120/80 BP 120/80-139/89 Patient’s BP is a CVD risk factor. • Manage CVD risk 85. • Recheck BP after 1 year. Recheck BP after 5 years. BP confirmed on 3 occasions ≥ 140/90 Diagnose hypertension • Give routine hypertension care 90. • If < 40 years, refer to exclude secondary hypertension.
  • 90. Adult 90 Hypertension: routine care Assess When to assess Note Symptoms Every visit Manage symptoms on symptom pages. Ask about symptoms of heart failure 91, ischaemic heart disease 94 or stroke/TIA 93. BP • Check 2 readings at every visit. • For correct method 89. • If BP < 140/90 (< 150/90 if ≥ 60 years), BP is controlled: continue current treatment and review 6 monthly. • If BP ≥ 140/90 (≥ 150/90 if ≥ 60 years), BP is not controlled: decide treatment below. If ≥ 180/110: also check if needs urgent attention 89. CVD risk At diagnosis, then depending on risk • Assess CVD risk 84. • If < 10% with CVD risk factors reassess after 1 year. If 10-20% reassess after 6 months. If > 20% refer to hospital. Eyes for retinopathy At diagnosis, then yearly and if visual problems If new retinopathy, visual problems or cataracts, refer. Glucose At diagnosis, then yearly Check glucose 86. If known diabetes 87. eGFR1 (by referral to hospital) At diagnosis, then yearly If eGFR < 60mL/min/1.73m3 , refer to hospital. Urine dipstick At diagnosis, then yearly If blood or protein on dipstick, refer to hospital and repeat dipstick at next visit. If glucose on dipstick, screen for diabetes 86. Random total cholesterol (by referral to hospital) At baseline if no CVD or diabetes within 3 months of diagnosis. • If no CVD or diabetes no need to repeat cholesterol or adjust simvastatin. • If CVD or diabetes, increase simvastatin based on repeat cholesterol on relevant page. Advise the patient with hypertension • Help patient to manage his/her CVD risk 85. Emphasise salt restriction ≤ 1 teaspoon/day, weight reduction and smoking cessation. If patient smokes tobacco 102. • Advise patient to avoid NSAIDs (e.g. ibuprofen) and combined oral contraceptive 110. If pregnant or planning pregnancy, refer to hospital. • Explain importance of adherence and that patient will need lifelong hypertension care to prevent stroke, heart disease and kidney disease. If newly diagnosed, refer for health extension worker support. Treat the patient with hypertension • If no diabetes, give simvastatin 20mg PO daily if patient has established CVD, cholesterol > 300mg/dL or CVD risk ≥ 30%. If diabetes, decide if patient needs simvastatin 87. • Give aspirin 75-150mg PO daily if patient has CVD. Avoid if peptic ulcer, dyspepsia, kidney or liver disease. • If BP is not controlled, decide treatment for hypertension using algorithm and table below: Not yet on hypertension medication Review in 1 month. Already on hypertension medication BP ≥ 160/100 Start treatment with 2 medications. Not adherent • Check patient using medication correctly. • Discuss any side effects. • Refer for health extension worker support. • Review in 1 month. Adherent • Increase current medication or if at maximum dose, add new medication. • Review in 2 weeks. No: Start 1 medication only after trying CVD risk management 85 alone for 3-6 months. Yes: Start treatment with 1 medication. BP 140-159/90-99 Any of: CVD, diabetes, CVD risk ≥ 20%, retinopathy or kidney disease? Medication Decide which medication to use Start dose Maximum dose Side effects Hydrochlorothiazide First-line therapy. Avoid in gout, severe liver/kidney disease. Refer if impaired glucose tolerance, diabetes or raised cholesterol. 12.5mg PO daily in morning 50mg daily or in 2 divided doses Impaired glucose tolerance, gout attack, gastrointestinal disturbances Enalapril Use first if diabetes with proteinuria or kidney disease. Avoid if previous angioedema. Add to hydrochlorothiazide if patient needs > 1 medication. 5mg PO daily or in 2 divided doses 40mg daily in 2 divided doses Cough (common), dizziness, angioedema (swelling tongue, lips, face, difficulty breathing: stop enalapril immediately 24). Amlodipine Use if peripheral vascular disease. Refer if patient has heart failure. 2.5mg PO daily 10mg daily Dizziness, flushing, headache, fatigue Atenolol Use if ischaemic heart disease. Avoid in uncontrolled heart failure, asthma, COPD. 50mg PO daily 100mg daily Tight chest, fatigue, slow pulse, headache, cold hands/feet, impotence 1 Calculate eGFR = [(140 - age) x weight (kg)]/[72x creatinine (mg/dL)]. If patient is a woman, multiply by 0.85.
  • 91. Adult 91 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 for specialist assessment. Advise the patient with heart failure • Advise patient to adhere to treatment even if asymptomatic. • Help the patient to manage his/her CVD risk 85. Emphasize salt restriction to < 1 teaspoon/day and advise regular exercise within limits of symptoms. • Advise patient to restrict fluid intake to 1.5L/day (6 cups) and if possible to monitor weight daily. If s/he gains ≥ 2kg in 2 days, advise to return to clinic. Assess the patient with heart failure Assess When to assess Note Symptoms Every visit Manage symptoms as on symptom pages. If cough or difficulty breathing 29. Refer same day if temperature ≥ 38°C, fever/chills or fainting/blackouts. Family planning Every visit Discuss contraception needs 110. If pregnant or planning pregnancy, refer for specialist care. Substance use/abuse Every visit In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Depression Every visit In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. Weight Every visit Assess changes in fluid balance by comparing with weight when patient least symptomatic. BP and pulse Every visit Check BP 89. If known hypertension 90. If new irregular pulse, refer same day. eGFR2 and potassium At diagnosis, 6 monthly Also check 1-2 weeks after starting/increasing dose of spironolactone/enalapril. If abnormal, refer. If potassium > 5mmol/L, stop spironolactone. Other blood tests At diagnosis Check Hb, glucose (also yearly 86 to interpret results). If abnormal, refer. Test for HIV 75. Treat the patient with heart failure Aim to have patient on steps 1, 2 and 3. Add step 4 if patient has ongoing symptoms on steps 1-3. If uncontrolled on steps 1-4, refer to hospital. Step Medication Dose Note 1 Give furosemide Start: 20-40mg PO daily. Use lowest dose to prevent leg swelling. Use if moderate-severe heart failure or eGFR < 60mL/min/1.73m2 . Expect response within 2-3 days. or hydrochlorothiazide 25-50mg PO daily Use if mild heart failure and eGFR ≥ 60mL/min/1.73m2 . Avoid in gout, liver disease. 2 Add enalapril Start 2.5mg PO BID. Maximum: 20mg BID. • Increase gradually. Continue maximum tolerated dose. • Side effects: cough (common, if troublesome refer), dizziness, angioedema (stop enalapril immediately). 3 Add carvedilol Start 3.125mg PO BID. Maximum: 25mg BID. • Start once on enalapril and no oedema. Double dose 2 weekly. Continue maximum tolerated dose. • Avoid in asthma/COPD, peripheral vascular disease or if pulse < 60. 4 Add spironolactone Start 25mg PO daily. Maximum: 50mg daily Avoid if eGFR < 60mL/min/1.73m2 or potassium > 5mmol/L. Stop potassium supplements. Give urgent attention to the patient with heart failure and one or more of: • Chest pain 28 • Rapid worsening of symptoms • Respiratory rate > 30 at rest • BP < 90/60 • New wheeze • Frothy sputum Management: • Sit patient up and if oxygen saturation < 90% or oxygen saturation machine not available, give face mask oxygen. • If systolic BP > 90: give furosemide 40mg slowly IV. If no response after 30 minutes, give 80mg IV; if still no better after 20 minutes, give a further 40mg IV. If IV furosemide unavailable, give PO. • If systolic BP > 90: give sublingual isosorbide dinitrate 5mg even if there is no chest pain. Repeat 4 hourly. • Refer urgently. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. 2 Calculate eGFR = [(140 - age) x weight (kg)]/[72x creatinine (mg/dL)]. If patient is a woman, multiply by 0.85.
  • 92. Adult 92 • The patient with previous rheumatic fever has had one or more episodes of fever, joint swelling/pain, rash, strange movements and carditis following a sore throat. • Sometimes the carditis can lead to rheumatic heart disease which is damage to the heart valves. Ensure that diagnosis of rheumatic fever and rheumatic heart disease is confirmed at hospital. Advise the patient with rheumatic heart disease/previous rheumatic fever • Explain the cause of rheumatic heart disease: a sore throat infection caused rheumatic fever which damaged the heart valves. • This may cause heart failure. Advise patient to return if symptoms of heart failure develop: difficulty breathing (especially on lying down), fatigue, cough, leg swelling). • Having benzathine penicillin every month will prevent recurrences of rheumatic fever and protect the heart valves. Advise the patient that this must be continued lifelong if heart valve damage, or if no heart valve damage for at least 10 years or up to the age of 25 years. • Educate patient on warfarin that it thins the blood to prevent clots on damaged or mechanical heart valves and protects against stroke. Advise to return urgently if abnormal bleeding occurs: gum/ nose bleeds, easy bruising, heavy menstruation. • Advise patient the patient with rheumatic heart disease to brush teeth regularly and to get antibiotic prophylaxis before dental procedures. Treat the patient with rheumatic heart disease/previous rheumatic fever • Give prophylaxis to protect heart valves and prevent recurrence of rheumatic fever: - - Give benzathine penicillin 1.2MU deep IM every 4 weeks. Observe for 15 minutes after injection for anaphylaxis: If sudden face/tongue swelling with difficulty breathing, collapse, anaphylaxis likely 29. - - If penicillin allergic give instead erythromycin 500mg PO BID continuously. - - Continue for life if rheumatic heart disease. If patient had rheumatic fever, the decision to stop will be made at hospital. • Give warfarin if patient has atrial fibrillation or mechanical heart valve. Start at 2.5mg PO daily and increase to maximum 10mg PO daily based on INR. Target INR is 2.0-3.0. • Give antibiotic prophylaxis 1 hour before dental procedure if rheumatic heart disease and one or more of mechanical valve or previous infective endocarditis: single dose amoxicillin 1g PO. If penicillin allergy, give single dose clarithromycin 500mg PO instead, if unavailable, refer. Advise patient to attend monthly for benzathine penicillin and routine care and refer for hospital review annually if stable. Rheumatic heart disease/previous rheumatic fever: routine care Assess the patient with rheumatic heart disease/previous Assess When to assess Note Symptoms Every visit • If cough/difficulty breathing or leg swelling, heart failure likely 91. • If fever with new joint pain or swelling, rheumatic fever recurrence likely, refer. If fever in patient with known rheumatic heart disease, refer to exclude infective endocarditis. • If weakness or numbness of face, arm or leg, especially on one side, visual disturbance, difficulty speaking or walking, refer. • If patient on warfarin has easy bleeding: gum/nose bleeds, easy bruising, heavy menstruation refer same day for INR. Adherence Every visit Check that patient is receiving monthly prophylaxis and if on warfarin, is taking it reliably. Weight At diagnosis, every visit Assess changes in fluid balance by comparing with weight when patient least symptomatic. BP and pulse At diagnosis, every visit Check BP 89. If known hypertension 90. If new irregular pulse, refer hospital same day. Pallor At diagnosis, every visit If pale, check Hb. If < 11g/dL, refer hospital. Family planning Every visit Discuss contraception needs 110. If pregnant or planning pregnancy, refer hospital. Heart failure Every visit • If cough/difficulty breathing or leg swelling, heart failure likely 91. • If known heart failure also give routine heart failure care 91. Depression Every visit In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. INR If on warfarin Ensure patient on warfarin checks INR on regular basis.
  • 93. Adult 93 Stroke: diagnosis and routine care Sudden onset of one or more of the following suggests a stroke or a transient ischaemic attack (TIA): • Weakness or numbness of the face, arm or leg, especially on one side of the body • Blurred or decreased vision in one/both eyes or double vision • Difficulty speaking or understanding • Difficulty walking, dizziness, loss of balance or co-ordination If patient has one or more of: hypertension , diabetes, heart disease, on warfarin, > 60 years and has no history of head trauma, stroke likely. If not, refer to hospital to confirm the diagnosis of stroke. Advise the patient with stroke/TIA • Advise the patient to seek medical attention immediately should symptoms recur. Quick treatment of a minor stroke/TIA can reduce the risk of major stroke. • Help patient to manage his/her CVD risk 85. • If patient is < 55 years (man) or < 65 years (woman), advise the first degree relatives to have CVD risk assessment 84. • Avoid combined oral contraceptive. Advise other method such as IUD, injectable, progestogen-only pill or subdermal implant 110. Assess the patient with stroke/TIA Assess When to assess Note Symptoms Every visit • Manage symptoms as on symptom pages. • Ask about symptoms of another stroke/TIA. Also ask about chest pain 94 or leg pain 96. Depression Every visit In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. Rehabilitation needs Every visit Refer to physiotherapy for mobility. BP Every visit • Check BP 89. If new hypertension, avoid starting treatment until > 48 hours after a stroke. • If known hypertension 90. Glucose At diagnosis, then yearly Check glucose 86. If known diabetes 87. Random total cholesterol (by referral to hospital) 3 months after starting simvastatin and then after 3 months if ≥ 190mg/dL • If cholesterol ≥ 190mg/dL: increase simvastatin to 40mg. If already on 40mg daily, refer to hospital. • If cholesterol < 190mg/dL, no need to repeat. HIV At diagnosis or if status unknown Test for HIV 75. Give urgent attention to the patient with a stroke/TIA: • If oxygen saturation < 95% or oxygen saturation machine not available, give face mask oxygen. • If glucose < 70mg/dL or unable to measure, give 25mL glucose 40% IV over 1-3 minutes. Repeat if glucose still < 70mg/dL after 15 minutes. • Keep patient nil by mouth until swallowing is formally assessed. • Give normal saline 1L IV 4-6 hourly. If glucose ≥ 70mg/dL, avoid fluids containing glucose/dextrose as raised blood glucose may worsen a stroke. • If BP ≥ 220/120, give single dose of nifedipine 20mg PO. • Refer urgently. Treat the patient with an ischaemic stroke/TIA • Give aspirin 75-150mg PO daily for life. Avoid if haemorrhagic stroke, peptic ulcer, dyspepsia, kidney or liver disease. If heart valve disease or atrial fibrillation, refer for warfarin instead. • Start simvastatin 20mg PO daily. If repeat cholesterol > 190mg/dL increase to 40mg daily. If already on 40mg, refer to hospital.
  • 94. Adult 94 Ischaemic heart disease (IHD): initial assessment Is patient known with ischaemic heart disease (or angina1 )? No Chest pain different to above Assess for other causes of chest pain 28. Stable angina likely • Refer to hospital to confirm diagnosis. • Give routine ischaemic heart disease care 95. Patient has stable angina. Give routine ischaemic heart disease care 95. Is chest pain/discomfort: • Occurs at rest or with minimal effort or • Not relieved by rest or • Lasts ≥ 20 minutes No Yes No Is current or previous chest pain/discomfort any of: • Feels like pressure, heaviness or tightness in centre or left side of chest • Spreads to jaw, neck, arm/s • May be associated with nausea, vomiting, pallor, sweating or shortness of breath Is chest pain/discomfort any of: • Occurs at rest or with minimal effort or • Not relieved by rest or • Lasts ≥ 20 minutes or • Worse/lasts longer than usual or • Occurs more often than usual Yes Yes No Yes Acute coronary syndrome (heart attack or unstable angina) likely • If oxygen saturation < 90% or oxygen saturation machine not available, or respiratory rate ≥ 30, give face mask oxygen. • Give single dose aspirin 300mg chewed. • Establish IV access. • If BP < 90/60, give normal saline 250mL IV. Avoid if breathless. • Refer to hospital urgently. 1 Chest pain caused by ischaemic heart disease.
  • 95. Adult 95 Ischaemic heart disease (IHD): routine care Advise the patient with ischaemic heart disease • Help the patient to manage his/her CVD risk 85. • Patient can resume normal daily and sexual activity 6 weeks after heart attack if symptom free. • Emphasize the importance of lifelong adherence to medication. • Advise patient to avoid NSAIDs (e.g. ibuprofen, diclofenac, indomethacin), as they may precipitate chest pain or a heart attack or heart failure. • If patient is < 55 years (man) or < 65 years (woman), advise first degree relatives to have CVD risk assessment 84. If atenolol and amlodipine contra-indicated/not tolerated or chest pain/discomfort persists on full treatment, refer to hospital. Assess the patient with ischaemic heart disease Assess When to assess Note Symptoms Every visit • Do initial assessment if not already done 94. • Ask about leg pain 49 and symptoms of stroke/TIA 93. Modifiable risk factors Every visit • Ask about smoking, diet, khat and alcohol use and exercise or activities of daily living 85. Depression Every visit In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. BP Every visit Check BP 89. If known hypertension 90. Blood glucose At diagnosis, then yearly Check glucose 86. If known diabetes 87. Random total cholesterol (by referral to hospital) 3 months after starting simvastatin and then after 3 months if ≥ 190mg/dL • If cholesterol ≥ 190mg/dL: increase simvastatin to 40mg. If already on 40mg daily, refer to hospital. • If cholesterol < 190mg/dL, no need to repeat. Treat the patient with ischaemic heart disease • Give aspirin 75-150mg PO daily for life. Avoid if peptic ulcer, dyspepsia, severe kidney or liver desease. • Start simvastatin 20mg PO daily. If repeat cholesterol > 190mg/dL increase to 40mg daily. If already on 40mg, refer to hospital. • Give atenolol (immediate release) 50mg PO daily even if no chest pain/discomfort. Avoid in asthma/COPD uncontrolled heart failure, pulse < 50, systolic BP < 100. • If patient also has hypertension, diabetes or chronic kidney disease, give enalapril 5mg PO daily and increase slowly to 20mg daily. Avoid in angioedema. • If patient has new onset or worsening angina, refer to hospital. If patient known with stable angina continue with treatment as prescribed at hospital: Medication Dose Maximum dose Note Atenolol (immediate release) 50mg PO daily 100mg PO daily Avoid atenolol in asthma/COPD, uncontrolled heart failure, pulse < 50, systolic BP < 100 or side effects (headache, cold hands/feet, impotence, tight chest, fatigue) are intolerable. Use amlodipine instead. Amlodipine 5mg PO in the morning 10mg daily Avoid in heart failure, refer to hospital if unsure.
  • 96. Adult 96 Peripheral vascular disease (PVD): diagnosis and routine care • 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 to hospital for assessment. Advise the patient with peripheral vascular disease • Help the patient to manage his/her CVD risk 85. • Advise the patient to keep legs warm and position legs below heart level (especially at night), and to avoid decongestant medications that may constrict blood vessels. • If patient smokes tobacco 102. Support patient to change 125. • 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 patient is < 55 years (man) or < 65 years (woman), advise the first degree relatives (parents, siblings, children) to have CVD risk assessment 84. Treat the patient with peripheral vascular disease • Advise active brisk exercise for 30 minutes at least 3 times a week (preferably daily). Advise patient to pause and rest whenever claudication develops. • Start simvastatin 20mg PO daily. If repeat cholesterol > 190mg/dL increase to 40mg daily. If already on 40mg, refer to hospital. • Give aspirin 150mg PO daily for life. Avoid if peptic ulcer, dyspepsia, kidney or liver disease. • Refer to hospital at diagnosis (start medications if available 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 6 monthly. Give urgent attention to the patient with peripheral vascular disease and one or more 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 • Chest pain28 Management: • Ruptured abdominal aortic aneurysm likely: avoid giving IV fluids even if BP < 90/60 (raising blood pressure may worsen the rupture). • 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 94 and symptoms of stroke/TIA 93. • Document the walking distance before onset of claudication. BP Every visit • Check BP. If ≥140/90 89. • If known hypertension 90. Legs and feet Every visit Check for pain, pulses, sensation, deformity and skin problems on both legs & feet. For foot screen and foot care education and care 47. Abdomen Every visit If a pulsatile mass felt, refer for assessment for possible abdominal aortic aneurysm. Glucose At diagnosis, then yearly Check glucose 86. If known diabetes 87. Random total cholesterol (by referral to hospital) 3 months after starting simvastatin and then after 3 months if ≥ 190mg/dL • If cholesterol ≥ 190mg/dL: increase simvastatin to 40mg. If already on 40mg daily, refer to hospital. • If cholesterol < 190mg/dL, no need to repeat.
  • 97. Adult 97 Epilepsy: routine care • If the patient is convulsing 15 to control the convulsion. If the patient is not known with epilepsy and has had a convulsion 15 to assess and manage further. • Epilepsy is a chronic seizure disorder diagnosed in a patient who has had at least 2 definite convulsions with no identifiable cause or with one convulsion following meningitis, stroke or head trauma. Advise the patient with epilepsy • Educate patient about epilepsy (cause and prognosis), the medications (including about side effects) ,need for adherence to treatment and to record occurrence and frequency of convulsions. • Advise patient to avoid lack of sleep, asubstance use/abuse, dehydration and flashing lights. • Advise patient on avoiding dangers like heights, fires, swimming alone, cycling on busy roads, operating machinery. Avoid driving until free of convulsions for 1 year. • Advise patient there are many medications that interfere with anti-convulsant treatment (see below) and to discuss with health worker when starting any new medication. • Advise patient to use reliable contraception (like IUD , Injectables and condom) and to seek advice if planning a pregnancy. Assess the patient with epilepsy Assess When to assess Note Symptoms Every visit Manage symptoms as on symptom pages. Frequency of convulsions Every visit Ask patient about frequency of convulsions since last visit. Assess if convulsions prevent patient from leading a normal lifestyle. Adherence Every visit Assess past clinic attendance and pill counts. Side effects Every visit Side effects (see below) may explain poor adherence. Weigh up side effects with control of convulsions or consider changing medication. Other medication At diagnosis, if convulsion occur Check if patient is on other medication like TB treatment, ART or contraceptive. See below for interactions and consider referring the patient. Substance use or abuse At diagnosis, every visit In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Family planning Every visit (for reproductive age women) • Refer same week if patient is pregnant or planning to be, for epilepsy and antenatal care. • Assess family planning needs: avoid oral contraceptives and implants on carbamazepine or phenytoin 110. Treat the patient with epilepsy • Initiate with single medication and review every 2 weeks until no convulsions. • If still convulsing on treatment, increase dose as below if patient is adherent, there is no substance use/abuse and no interactions with other medications. • If still convulsing after 1 month on maximum dose or side effects intolerable, start new medication and increase dose without discontinuation of the first medication to avoid recurrence of convulsions. • After the second medication is increased to optimal dose, the first is gradually tapered and discontinued. Medication Dose Note Phenytoin Start 150mg PO daily. If needed, increase by 50mg weekly to 300mg daily. Maximum dose: 600mg daily. Avoid in pregnancy. Side effects: facial hair , drowsiness, large gums. Toxicity: balance problem, double vision, slurred speech. Drug interactions: anti-TB, ART, furosemide, fluoxetine, fluconazole, theophylline, oral contraceptives and implants. Phenobarbitone Start 30mg PO BID; maximum dose of 180mg per day Side Effects: Sedation, ataxia, sexual dysfunction, depression. Liver failure. Drug interactions: similar to phenytoin, see above. Carbamazepine Start dose 100mg PO BID; and a maximum dose of 1200mg daily in 2 or 3 divided doses Side effects: skin rash, blurred or double vision, ataxia, nausea. Drug interactions: isoniazid, warfarin, fluoxetine, cimetidine, theophylline, amitriptyline, oral contraceptives, Implants and antiretrovirals. Valproic acid Start 600mg PO daily in 2 divided doses. Increase daily dose by 200mg every 3 days to maintenance dose of 1-2 g daily in divided doses. Maximum dose: 2.5g daily. Avoid if liver problem, pregnant or a woman of childbearing age unless on reliable contraception. Use as first choice in patient on ART. Side effects: drowsiness, dizziness, weight gain, temporary hair loss. Drug interactions: zidovudine, aspirin. • If convulsion free, follow up 3 monthly. If convulsions uncontrolled with two medications, refer. • Consider stopping treatment if no convulsion for 2 years. Refer patient to a hospital, for gradual tapering and discontinuation of antiepileptic medications. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. EPILEPSY
  • 98. Adult 98 Admit the mentally ill patient Approach to the mentally ill patient in need of hospital admission: • Before sedating the patient (if needed) fully inform patient in his/her own language about reasons for treatment and consider his/her choice if he/she opts for PO medication. • Assess if the patient can give informed consent: the patient understands that s/he is ill, is needing treatment and can communicate his/her choice to receive treatment: Assess the mentally ill patient first on appropriate symptom or chronic condition pages. Does patient agree to admission? Yes Yes Manage as an outpatient. • Refer to hospital. • Record everything clearly in patient notes and referral letter. • A close relative or a carer must accompany the patient to hospital. • Request police assistance if the patient is too dangerous to be transferred in a staffed vehicle or is likely to abscond. No No No Yes Does patient ≥ 1 of the following? • Severe mental illness or suicidal or • Needs treatment in a hospital or • Danger of harm to self, others, own reputation, financial interest or property or • Severe self neglect and poor social support
  • 99. Adult 99 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 or • Loss of interest or pleasure in activities that are usually pleasurable Depression likely, treat 100. Yes Check for anaemia If pallor, check Hb. If < 11g/dL, refer to hospital. Check for thyroid disease Check TSH. If abnormal, refer to hospital. Screen for substance abuse In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Check for medication side effects Review medication: prednisolone, efavirenz, metoprolol, metoclopramide, theophylline and contraceptives can cause depression. If on any of these, refer to hospital. Yes: does the patient have difficulty carrying out ordinary work, domestic or social activities? Yes 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 • Loss of interest or pleasure in activities that are usually enjoyable • Fatigue or loss of energy • Disturbed sleep, sleeping too much/too little • Change in appetite or weight • Feeling guilty or worthless • Reduced concentration, indecisiveness ,forgetfulness • Agitated/restless or talking/moving more slowly than usual • Ideas, plans or acts of self-harm or suicide One or more of above Yes Refer to hospital. Provide support 65. None of above: does the patient have any psychotic symptoms2 ? No: has patient previously had a diagnosis of bipolar disorder or symptoms of mania: 3 or more of the following, that have lasted at least 1 week and interfered with ordinary work, domestic or social activities? • Elevated mood and/or irritability • Decreased desire to sleep • Inappropriate social behaviour • Easily distracted • Increased activity, feeling of increased energy, talkative, rapid speech • Impulsive/reckless behaviour like excess spending, thoughtless decisions, sexual indiscretion • Inflated self esteem No: has there been a major loss or bereavement within last 6 months? Yes: does patient have ideas of suicide or self-harm, feelings of worthlessness or is s/he talking or moving unusually slowly? Yes Bipolar disorder likely • Refer to a mental health professional. • If aggressive/ disruptive 63. Continue to assess and manage the stressed or distressed patient 65. No No No No No Yes Yes No: has patient had depression in the past? 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. 2 Psychotic 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). MENTAL HEALTH
  • 100. Adult 100 Depression and/or anxiety: routine care Assess the patient with depression and/or 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, 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 suicide. If patient has suicidal thoughts or plans 62. Mania Every visit If abnormally happy, energetic, talkative, irritable or reckless: manage the aggression and disruption 63 and 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 likely. • If anxiety is induced by a particular situation/object, phobia likely. If patient avoids social situations because of phobia, social phobia likely. • If repeated sudden fear with physical symptoms and no obvious cause, panic likely. • If patient had a bad experience causing nightmares, flashbacks, avoidance of people/situations, jumpiness or feeling detached, post-traumatic stress likely. 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 106. Substance use/abuse Every visit In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Side effects Every visit Ask about side effects of antidepressant medication 101. Stressors Every visit Help identify the domestic, social and work factors contributing to depression or anxiety. If patient is being abused 66. If recently bereaved 65. Family planning Every visit • Discuss patient’s contraception needs 110. • If pregnant or breastfeeding, refer to hospital to evaluate risks: the risk to baby from untreated depression may outweigh any risk from antidepressants. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. Advise the patient with depression and/or anxiety • Explain that depression is a very common illness and 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 the 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. Advise not to stop treatment abruptly. • Help the patient to choose strategies to get help and cope: Get enough sleep If patient has difficulty sleeping 67. Access support Encourage patient to connect with friends, family, spiritual leaders and community groups like Edir, Mahber, Senbete. Get active Regular exercise may help. Do a relaxing breathing exercise each day. Spend time with supportive friends or family. Find a creative or fun activity to do. Encourage patient to take time to relax:
  • 101. Adult 101 Review 2 weekly, even if not on antidepressants, until symptoms improve, then monthly. If no better after 8 weeks, refer. Plan when to stop antidepressant Has patient has previous episode/s of depression? Reduce dose gradually over at least 4 weeks. If withdrawal (irritability, dizziness, difficulty sleeping, headache, nausea, fatigue) develops, reduce even more slowly. Does patient have any of: onset in adolescence, severe depression, suicide attempt, sudden onset of symptoms, family history of bipolar disorder? Does patient have generalised anxiety, panic, phobia or post-traumatic stress? Consider long term treatment for at least 3 years. If ≥ 3 episodes, advise lifelong treatment. Consider stopping antidepressant when patient has had no/minimal symptoms and has been able to carry out routine daily activities for > 9 months. Consider stopping antidepressant when patient has had no/minimal symptoms and has been able to carry out routine daily activities for > 1 year. No No No Yes Yes Yes 1 Patient has felt nervous, anxious or panicky or been unable to stop worrying or thinking too much over the past month. Treat the patient with depression and/or anxiety • Give anti-depressants to the patient with any of: depression, generalised anxiety, social phobia, post traumatic stress and panic. Respect the patient’s decision if s/he declines antidepressants. • If patient has phobia, also advise gradual desensitization: - - Start with relaxing breathing exercise. - - When calm, imagine the feared thing at some distance away. Continue breathing exercise. When ready, imagine the thing coming slightly closer. Continue breathing exercise. - - Repeat the above and stop if severe anxiety. When calm, repeat, with the thing at a distance that did not cause anxiety. Advise patient to repeat gradual desensitisation daily. • If generalised anxiety disorder or features of anxiety1 when starting antidepressant, consider diazepam 2-5mg PO daily as needed, for up to 10 days. Avoid if patient is known to use substances. • Start antidepressant and increase dose as needed according to response. Plan to continue antidepressant for at least 9 months: Medication Dose Note Side effects Fluoxetine • Start 20mg PO alternate days for 1 week then increase to 20mg daily in the morning. • If partial or no response after 4 weeks, increase by 20mg every 2 weeks, up to 60mg/day. • Refer to specialist if patient has epilepsy, liver or kidney disease. • Monitor blood glucose more often in diabetes. Changes in appetite and weight, headache, restlessness, difficulty sleeping, nausea, diarrhoea, sexual problems Amitriptyline Start 25mg PO at night. Increase by 25mg every 5 days, up to 150mg/day (or 100mg/day if > 65 years). • Use if fluoxetine contraindicated. • If suicidal thoughts, avoid, or if fluoxetine not an option, supply only a few doses at a time and ensure close supervision by carer (can be fatal in overdose). • Avoid if heart disease, urinary retention, glaucoma, epilepsy. Dry mouth, constipation, difficulty urinating, blurred vision, sedation
  • 102. Adult 102 Tobacco smoking Advise the patient who smokes tobacco • Ask if patient is willing to discuss tobacco smoking. For tips on how to communicate effectively 124. • 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. • Educate patient that nicotine is a very addictive substance and stopping can be difficult, resulting in withdrawal symptoms (see below). Nicotine replacement may help reduce these symptoms. • Advise that most smokers make several attempts to stop before they are successful. If patient is not ready to stop in the next month: • Discuss risks to patient (worsening asthma, infertility, heart attack, stroke, COPD, cancer) to spouse (lung cancer, heart disease) and to children (low birth weight, asthma, respiratory infections). • Help the patient identify benefits of stopping tobacco smoking like saving money, improved health, taste, sense of smell and appearance and being a positive role model for children. • Help the patient identify barriers to stopping tobacco smoking and possible solutions. • Ask if patient is ready to stop smoking tobacco in the next month. If not ready to stop, encourage patient to return. If patient is ready to stop in the next month or recently stopped: • Help the patient plan: set date to stop within 2 weeks, seek support from family and friends, avoid/manage situations associated with smoking and remove cigarettes, matches, and ashtrays. • Help manage cravings: set a time limit before giving in, advise to delay as long as possible, take a deep breath and blow out slowly (repeat 10 times). • Educate about nicotine withdrawal symptoms: increased appetite, mood changes, difficulty sleeping/concentrating, irritability, anxiety, restlessness. These should improve after 2 weeks. Assess the patient who smokes tobacco Assess When to assess Note Symptoms Every visit • Ask about symptoms that might suggest cancer: cough/difficulty breathing 29, urinary symptoms 44 or weight loss 16. • Ask about chest pain 28, leg pain 49, new sudden onset of any of: asymmetric weakness of face, arm or leg; numbness, difficulty speaking or visual disturbance 23. • Manage other symptoms as on symptom pages. Use Every visit • Ask about number of cigarettes/day, activities associated with smoking and previous attempts at stopping. • If recently stopped, ask about challenges and give advice below. Stressors Every visit Help identify the domestic, social and work factors contributing to smoking tobacco. Assess and manage stress 65. COPD At diagnosis If difficulty breathing when walking fast/up a hill, consider COPD 81. If known COPD 83 CVD risk At diagnosis Assess and manage CVD risk 84
  • 103. Adult 103 Alcohol/drug use Assess the patient with unhealthy alcohol use or any drug use Assess Note Symptoms • If recently reduced/stopped use and is restless, agitated, difficulty sleeping, confused, anxious, hallucinating, sweating, tremors, headache or nausea/vomiting, treat for likely withdrawal 64. • If aggressive/violent or disruptive behaviour 63. • If patient has suicidal thoughts or plans 62. Hazardous/ harmful use • Use is harmful if it has caused physical (like injuries, liver disease, stomach ulcer), mental (like depression self harm or harm to others), social (relationship, legal or financial) harm or risky sexual behaviour. • The following is considered hazardous/harmful alcohol/drug use and increases the risk of dependence: - - If drinks ≥ 4 drinks1 /day (if man) or ≥ 2 drinks1 /day (if woman), hazardous drinking likely. - - If drinks ≥ 6 drinks1 /day (if man) or ≥ 4 drinks1 /day (if woman), harmful drinking likely. - - Any use of khat or illicit drugs (e.g. cannabis), misuse of prescription drugs, harmful/hazardous drug use likely. 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 the domestic, social and work factors contributing to alcohol/drug use. Ask about reasons for his/her substance use. If patient is being abused 66. Depression In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. Dementia If chronic alcohol/drug use and at least 6 months ≥ 1 of: memory problems, disorientation, language difficulty, less able to cope with daily activities and work/social function: consider dementia 106. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela Assess the patient who uses any drugs or drinks alcohol in way that that puts him/her at risk of harm/dependence. This may be binge drinking or daily drinking. If patient smokes tobacco 102. Advise the patient with unhealthy alcohol use or any drug use • Assess and manage stress 65. • 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. Refer patient to social worker, psychologist or counsellor. • Discuss risks/harms that using alcohol/drugs may cause. Support and encourage patient to decide for him/herself to stop or cut down. Support the patient to make a change 125. Harmful/hazardous alcohol use without dependence • If pregnant, harmful drinking, previous dependence or contraindication (like liver damage, mental illness), advise to stop alcohol completely. Avoid drinking places and keeping alcohol at home. • If none of above and patient chooses to continue alcohol, advise low-risk use: ≤ 2 drinks1 /day and avoid alcohol at least 2 days/week. Harmful/hazardous drug use without dependence • Advise to stop using illegal or misusing prescription drugs completely. • The patient with harmful/hazardous drug use without dependence can safely cut down on his/her own: encourage the patient to set goals for reducing use and a ‘quit date’. • If patient chooses to continue, advise to reduce harm: avoid injections or use sterile injection technique, test regularly for HIV and hepatitis. Alcohol/drug dependence • Advise that alcohol/drugs need to be stopped slowly. If stopped suddenly, withdrawal effects can be harmful. • If patient wishes to stop, refer to a hospital for detoxification. Ensure patient is motivated to adhere. If harmful/hazardous use, review in 1 month then as needed.
  • 104. Adult 104 Psychosis: diagnosis and routine care 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. Consider psychosis in the patient who has difficulty carrying out ordinary work, domestic or social activities and any of the following: • Delusions: unusual/bizarre beliefs not shared by society. • 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 psychosis Assess When to assess Note Symptoms Every visit • Assess symptoms of psychosis above. If symptoms of psychosis and: - - Aggressive/violent 63. - - Varying levels of consciousness over hours/days or temperature ≥ 38°C, delirium likely 64. - - Patient has interrupted treatment: address reasons like side effects, substance abuse and consider intramuscular treatment if patient still struggles with adherence 104. - - Good adherence to optimal doses of treatment, refer. • Manage other symptoms as on symptom pages. Self-harm Every visit If patient has suicidal thoughts or plans 62. 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 66. Substance use/abuse Every visit In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Family planning Every visit Discuss patient’s contraception needs 110. If patient is pregnant, planning pregnancy or breastfeeding, refer to specialist. Medication Every visit • Ask about treatment side effects 105. • Ask about adherence. If non-adherent, restart medication at same dose, explore reasons for stopping treatment and refer for health extension worker support. • Refer to hospital if patient is on medication that might cause acute psychosis, like prednisolone, efavirenz, moxifloxacin and terizidone. Weight (BMI ) Every visit BMI = weight (kg) ÷ height (m) ÷ height (m). • If gaining weight or BMI > 25, assess and manage CVD risk 84 and discuss with specialist about possible alternative psychosis treatment. • If unintentionally losing weight or BMI <17.5 16. Discuss with patient and carer about the importance of eating regular healthy meals. Glucose • At diagnosis, then yearly • Also 4 monthly if gaining weight Check glucose 86. HIV At diagnosis or if status unknown Test for HIV 75. If HIV positive, avoid efavirenz, refer to hospital. Syphilis At diagnosis If positive, refer. Advise the patient with psychosis and the patient’s carer • Educate carer and patient: the patient with chronic psychosis often lacks insight into illness and may be hostile towards carers. S/he may have difficulty functioning, especially in high stress settings. • 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 substance use/abuse and encourage regular sleep routine. • Advise the patient to continue social/educational/occupational activities if possible. Refer to local NGOs or community organisations to help find educational or employment opportunities. • Emphasize importance of treatment adherence and to return immediately if symptoms of psychosis return/worsen. • Refer patient and carer to support group if available. If not, consider starting one at the health facility.
  • 105. Adult 105 Treat the patient with psychosis • Give medication as in the 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. • If unsure or more than typical effective dose needed, discuss with specialist. Medication Starting dose Typical effective dose Note Haloperidol 1mg PO BID 2-10mg/day Increase by 1mg/dose until psychosis symptoms resolve. If > 60 years, start at a lower dose and increase more slowly. Trifluoperazine 5mg PO daily 15-20mg/day - Chlorpromazine 100mg PO daily in a single or divided dose 100-300mg/day in a single or divided dose • Increase every 2 weeks if needed. Give as a single dose at night once symptoms controlled. • Advise patient to avoid the sun. Fluphenazine decanoate 12.5mg deep IM injection every 2-4 weeks 25mg every 2-4 weeks Expect full response to take 2 months. • Review the patient with psychosis 8 weekly once stable. Advise patient to return immediately if symptoms of psychosis. • If restarting treatment after patient has interrupted treatment, review after 2 weeks, sooner if symptoms worsen. • If first episode psychosis, ensure patient receives 12 months of treatment after symptoms have resolved, then stop treatment. • Review the patient monthly for 6 months after stopping to check for recurrence of psychosis. • If 2 or more episodes, refer for specialist review. Look for and manage psychosis treatment side effects Urinary retention Stop treatment and refer same day. Blurred vision Refer same day. Painful muscle spasms (acute dystonic reaction) Usually within 2 days of starting medication. Give benzhexol 2-5mg PO TID if needed. Refer same day. Breast enlargement, nipple discharge Discuss with specialist whether to change medication. 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 patient to stand up slowly. Dry mouth/eyes Usually self-limiting. Constipation Usually self-limiting. Advise high fibre diet and adequate fluid intake. Extra-pyramidal side effects Abnormal involuntary movements Reduce dose. If no better, stop treatment and refer. Slow movements, tremor or rigidity May occur after weeks or months on treatment, refer. Muscle restlessness Stop treatment and refer same day.
  • 106. Adult 106 Dementia: diagnosis and routine care 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 refer. • If suicidal thoughts or plans 62. • If sudden deterioration in behaviour 64. • If hallucinations (seeing or hearing things), delusions (unusual/bizarre beliefs), agitation or wandering, refer to hospital. • Manage other symptoms as on symptom pages. Side effects If on treatment If abnormal movements or muscle restlessness, stop treatment and refer same day. If painful muscle spasms, manage below. Vision/hearing problems Every visit Refer to hospital for testing and proper devices. Nutritional status Every visit Ask about food and fluid intake. BMI = weight (kg) ÷ height (m) ÷ height (m). If pregnant/breastfeeding and MUAC < 23cm or if not pregnant/breastfeeding and BMI < 17.5 or MUAC < 21cm 70. CVD risk At diagnosis, then depending on risk • Assess CVD risk 84. • If CVD risk < 10% with CVD risk factors or 10-20%, reassess after 1 year; if > 20% reassess after 6 months. Palliative care Every visit If any of: bed-ridden, unable to walk and dress alone, incontinence, unable to talk meaningfully or do activities of daily living, also give palliative care 120. HIV At diagnosis or if status unknown Test for HIV 75. If HIV positive, give routine care 76. If new HIV diagnosis with dementia, refer to hospital. Syphilis At diagnosis If positive, refer. • Consider dementia in the patient who has the following for at least 6 months and 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 church or mosque 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. • Refer to hospital to confirm the diagnosis of dementia and identify treatable causes of dementia. Advise the patient with dementia and his/her care giver • Discuss what can be done to support the patient, carer/s and family. Identify local resources, social worker, counsellor. • Advise the carer/s to: - - Give regular orientation information (day, date, weather, time, names) - - Stimulate memories and give current information with newspaper, radio, TV, photos. - - Use simple short sentences. - - Maintain a routine. - - Remove clutter and potential hazards at home. - - Maintain physical activity and plan recreational activities. Treat the patient with dementia • HIV-associated dementia often responds well to ART 76. • If psychotic symptoms, night-time disturbance, wandering or persistent aggression or anxiety, give haloperidol 0.5mg PO BID. If patient has parkinson’s disease, refer. Review the patient with dementia every 6 months.
  • 107. Adult 107 Chronic arthritis: diagnosis and routine care • If patient has episodes of joint pain and swelling that completely resolve in between, consider gout 108. • The patient with chronic arthritis has had continuous joint pain for at least 6 weeks. Distinguish mechanical osteoarthritis from inflammatory rheumatoid arthritis: Osteoarthritis likely if: • Affects joints only. • Weight-bearing joints and possibly hands and feet • Joints may be swollen but not warm. • Stiffness on waking lasts less than 30 minutes. • Pain is worse with activity and gets better with rest. Inflammatory arthritis likely if: • May be systemic: weight loss, fatigue, poor appetite, muscle wasting. • Hands and feet are mainly involved. • Joints are swollen and warm. • Stiffness on waking lasts more than 30 minutes. • Pain and stiffness get better with activity. If inflammatory arthritis likely or uncertain of diagnosis, refer. Advise the patient with chronic arthritis • If BMI > 25 advise to reduce weight to decrease stress on weight-bearing joints like knees and feet. Help the patient to manage his/her CVD risk 85. • Encourage the patient to be as active as possible, but to rest with acute flare-ups. • Refer patient and care giver for education about chronic arthritis. • Advise the patient with rheumatoid arthritis that it must be treated early with disease modifying anti-rheumatic medication to control symptoms, preserve function, and minimise further damage. • 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 • Refer the patient with inflammatory arthritis for treatment. • If rheumatoid arthritis or difficulty with activities of daily living, refer to physiotherapist. • Give paracetamol 1g PO QID as needed or give ibuprofen1 400mg PO QID with food only as needed for up to 1 month. Assess the patient with chronic arthritis Assess When to assess Note Symptoms Every visit Manage symptoms as on symptom pages. 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. Sleep Every visit If patient has difficulty sleeping 67. Depression Every visit In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. 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. Assess CVD risk 84. ESR/Rheumatoid factor (RF) If inflammatory arthritis likely or unsure If ESR raised or RF positive, refer as inflammatory arthritis is more likely. HIV At diagnosis Test for HIV 75. Review monthly until symptoms controlled, then 3-6 monthly. If poor response to treatment, refer. 1 Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. MUSCULOSKELETAL DISORDERS
  • 108. Adult 108 Gout: diagnosis and routine care • 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. Advise the patient with gout • Help the patient to manage his/her CVD risk 85. • Give dietary advice: - - Reduce alcohol (especially beer), sweetened drinks 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 remind her/his health worker about gout before starting any new medication. Treat the patient with gout Treat the patient with an acute gout attack: • Give ibuprofen 800mg PO TID with food until better, then 400mg PO TID until 1 day after symptoms completely resolved (usually 5-7 days). If pain no better/worsens, refer. • If peptic ulcer, asthma, hypertension, heart failure or kidney disease, give instead prednisolone 40mg PO daily, decrease by 10mg every 3rd day until stopped. If unsure, refer to specialist. • If patient is already using allopurinol, avoid stopping it during an acute attack. Treat the patient with chronic tophaceous gout: • Patient needs allopurinol if: > 3 attacks per year, chronic tophaceous gout, kidney stones/kidney disease caused by gout. • Wait at least 3 weeks after an acute gout attack before starting allopurinol. • Give allopurinol 100mg PO daily. Use smallest dose to keep urate < 6mg/dL: increase monthly by 100mg, maintenance usually 300mg daily; maximum 800mg in divided doses. If no response to treatment or uncertain of diagnosis, refer. Assess the patient with gout Assess When to assess Note Symptoms Every visit Manage symptoms as on symptom pages. Substance use/abuse Every visit In the past year, has patient: 1) drunk ≥ 4 drinks1 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Medication Every visit • Hydrochlorothiazide, furosemide, ethambutol, pyrazinamide and aspirin may induce a gout attack. Refer to hospital to review medication. • Continue aspirin given for CVD risk. Joints Every visit • Recognise the acute gout attack: sudden onset of 1-3 hot, extremely painful, red, swollen joints (often big toe or knee). • Recognise chronic tophaceous gout: deposits appear as painless yellow hard irregular lumps around the joints (picture). CVD risk At diagnosis, then depending on risk • Assess CVD risk 84. If < 10% with CVD risk factors or 10-20% reassess after 1 year, if > 20% reassess after 6 months. • If BMI < 18.5 or patient < 40 years, refer within 1 month to exclude possible cancer cause for gout. eGFR2 (by referral to hospital) At diagnosis, then 6 monthly If eGFR < 60mL/minute/1.73m2 , refer. Urate • At diagnosis • On allopurinol • Wait at least 2 weeks after an acute gout attack before checking urate level. • If on allopurinol, repeat monthly and adjust allopurinol dose until urate level < 6mg/dL, then repeat 6 monthly. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. 2 Calculate eGFR = [(140 - age) x weight (kg)]/[72x creatinine (mg/dL)]. If patient is a woman, multiply by 0.85. © Stellenbosch University
  • 109. Adult 109 Fibromyalgia: diagnosis and routine care • 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 16. - - 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 46. - - Check ESR, Hb, TSH and test for HIV 75. • Consider another diagnosis and refer if joint problem, HIV positive, blood results abnormal or uncertain of diagnosis. • Refer to hospital for confirmation of diagnosis. 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 treatments may help (patients will have good days and bad days), fibromyalgia does not get worse over time and 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 67. Treat the patient with fibromyalgia • If no better with education and exercise, give amitriptyline 12.5mg PO at bedtime. Increase by 5mg every 2 weeks until improvement (maximum dose 75mg). • If no improvement after 3 months of advice, exercise and medication, refer for medical and psychiatric evaluation at hospital. A supportive relationship with the same health practitioner can contain frequent visits for multiple problems. Review patient 6 monthly once stable. Assess the patient with fibromyalgia 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. • Avoid dismissing all symptoms as fibromyalgia: exclude treatable and serious illness. If unsure, refer. Sleep Every visit If patient has difficulty sleeping 67. Stressors Every visit Help identify psychosocial stressors that may exacerbate symptoms. Assess and manage stress 65. Depression Every visit In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. Chronic arthritis Every visit If patient also has chronic arthritis, give routine care 107. Press tender points with the pressure that would blanch a fingernail. Compare with a control site on forehead.
  • 110. Adult 110 Contraception Give emergency contraception if patient had unprotected sex in past 5 days and does not want pregnancy: • If within 72 hours of unprotected sex, give as soon as possible: single dose levonorgestrel 1.5mg PO. - - If patient taking ART (or post-exposure prophylaxis), rifampicin or phenytoin, offer copper intrauterine device instead or increase single dose levonorgestrel to 3mg. - - If patient vomits < 2 hours after taking levonorgestrel, repeat the dose or offer copper intrauterine device instead. - - Offer to start contraceptive at same visit (if intrauterine device not chosen). Use condoms or abstain for next 7 days and check pregnancy test in 3 weeks. • If within 5 days of unprotected sex or patient chooses, insert emergency copper intrauterine device instead. • Consider need for HIV and hepatitis B post-exposure prophylaxis 69. 1 If after day 7 of cycle and patient has had unprotected sex since last period, advise patient to abstain or use condoms until next period. Start contraception when period starts. If period delayed, do pregnancy test. 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 36. If sexual problems 43. • If > 40 years, ask about menopausal symptoms: hot flushes, night sweats, vaginal dryness, mood changes, difficulty sleeping and sexual problems 119. If menopausal, decide how long to continue contraceptive 119. • Manage other symptoms as on symptom pages. Adherence Every visit • If already on contraceptive, ask about concerns and satisfaction with method. • If patient has missed injections or pills, manage 111. Side effects Every visit If already on contraceptive, ask about side effects of method 111. Safe sex Every visit Ask about risky sexual behaviour: patient or regular partner has new or multiple partner/s, uses condoms unreliably or has risky alcohol/drug use 103 Other medication Every visit If on ART, TB or epilepsy treatment, check method is suitable 111. If not suitable, choose/change to IUD or injectable. Vaginal bleeding Every visit If abnormal vaginal bleeding: if already on contraceptive, first exclude pregnancy, then see method to manage 111. If not yet on contraceptive 42. Weight (BMI) First visit, then yearly BMI = weight (kg) ÷ height (m) ÷ height (m). If BMI > 25 assess and manage CVD risk 84. BP First visit, every visit on pill or injectable • Check BP 89. • If known 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 yearly Check for lumps in breasts 31 and axillae 18. Pregnancy Every visit • Before starting contraception, exclude pregnancy1 . If pregnant 112. • If pregnancy suspected (significant nausea/breast tenderness or if patient using IUD/combined oral contraceptive misses period), check pregnancy test. If pregnant 112. HIV Every visit Test for HIV 75. Cervical screen (VIA) When needed • If HIV negative and asymptomatic: screen 5 yearly from age 30-49. • If HIV positive and asymptomatic: screen at HIV diagnosis (regardless of age) then 5 yearly. • If abnormal 40. Advise the patient starting and using contraception • Educate patient to use contraceptive reliably. Advise to discuss concerns/problems with method and find an alternative, rather than just stopping it and risking unwanted pregnancy. • 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 combined oral contraceptive pill and ≥ 72 hours diarrhoea/vomiting, advise to use condoms or abstain (continue for 7 days once resolved). • Demonstrate and give male/female condoms. Recommend dual contraception: one method of contraception plus condoms to protect from STIs and HIV. • Encourage patient to have 1 partner at a time and if HIV negative to test for HIV between partners. Advise partner/s to be tested for HIV. • Educate about the availability of emergency contraception (see above) and abortion 113 to prevent unwanted pregnancy.
  • 111. Adult 111 Treat the patient starting and using contraception If already using contraceptive and patient satisfied with method, check method is still suitable. If starting or changing contraceptive, help patient to choose method: Method Help patient to choose method Instructions for use Side effects Intrauterine device (IUD) • Copper IUD (Cu-IUD) • Effective for 10 - 12 years. • Fertility returns immediately on removal. • Avoid if current STI, unexplained vaginal bleeding, abnormal cervix/uterus. • If inserted after day 12 of cycle, exclude pregnancy first. • Can be inserted within 48 hours of delivery. • Must be inserted/removed by trained staff. • Heavy or painful periods: reassure usually improve within 3-6 months. To assess and manage 42. If excessive bleeding occurs after insertion or if tired and Hb < 11g/dL, refer. • Irritation of partner’s penis during sex: cut IUD strings shorter. Subdermal implant • Implanon: Etonogestrel (one-rod: 3 years) • Lasts for 3 years. • Fertility returns immediately on removal. • Avoid if unexplained vaginal bleeding, previous breast cancer or active liver disease. • Use with caution1 if BMI > 28 or on ART, rifampicin or phenytoin. • Plastic rod just under skin of upper arm. • If inserted after day 5 of cycle, use condoms or abstain for 7 days. • Must be inserted/removed by trained staff. • Amenorrhoea: reassure that this is common. • Abnormal bleeding: common. To assess and manage 42. • Acne: change to combined oral contraceptive or non-hormonal method. • Headaches: if severe, change to non-hormonal method. • Weight gain (less with progesterone-only pill) • Moodiness: reassure that this should resolve. In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any, consider changing method and 99. Progestogen injection • Medroxyprogesterone acetate (DMPA) IM 150mg every 3 months • 3 monthly injection • Fertility can be delayed for up to 1 year after last injection. • Avoid if diabetic complications. • If started after day 5 of cycle, use condoms or abstain for 7 days. • No need to adjust dosing interval for ART, TB or epilepsy treatment. Progestogen-only pill (POP) • Levonorgestrel 30mcg PO (especially if postpartum or breastfeeding) • Must be motivated to take pill reliably every day. • Fertility returns once pill is stopped. • Avoid both if active liver disease or on rifampicin or phenytoin. • Use both with caution2 if on ART. • Also avoid COC if smoker ≥ 35 years, migraines and ≥ 35 years or visual disturbances, postpartum3 , BP ≥ 140/90, hypertension, CVD risk > 10%, current or previous deep vein thrombosis/pulmonary embolus, previous stroke, ischaemic heart disease or diabetic complications. • Must be taken every day at the same time (no more than 3 hours late). • If started after day 5 of cycle, use condoms or abstain for 2 days. Combined oral contraceptive (COC) • Ethinylestradiol/ levonorgestrel 30/150mcg PO • Must be taken every day at the same time. • If started after day 5 of cycle, use condoms or abstain for 7 days. • If ≥ 72 hours diarrhoea/vomiting, advise to use condoms or abstain (continue for 7 days once resolved). • Abnormal bleeding: common in first 3 months. To assess and manage 42. • Breast tenderness, nausea: reassure usually resolve within 3 months. • Headaches: if migraines and ≥ 35 years or visual disturbances, change to non-hormonal method. • Moodiness: reassure that this should resolve.In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any, consider changing method and 99. Sterilisation • Tubal ligation/vasectomy • Permanent contraception • Surgical procedure • Refer for assessment. • Written informed consent is needed. Wound pain, infection or bleeding: refer. Follow up the patient on combined oral contraceptive pill after 3 months, then yearly. Follow up patient with IUD 6 weeks after insertion to check strings. Manage the patient who has missed injections or pills Late injection • If ≤ 2 weeks late for the DMPA: give the injection. • If > 2 weeks late for the DMPA: - - Exclude pregnancy. If pregnant 112. - - If not pregnant: give injection and use condoms or abstain for 7 days. If unprotected sex in past 5 days, also offer emergency contraception 110. Missed progestogen-only pill (> 3 hours late) • Take pill as soon as remembered, continue pack and use condoms or abstain for 2 days. • If unprotected sex in past 5 days, also offer emergency contraception 110. Missed combined oral contraceptive (> 24 hours late) • 1 or 2 active pills missed: take 1 pill immediately and take next pill at usual time. • ≥ 3 active pills missed: take 1 pill immediately and take next pill at usual time. Use condoms or abstain for 7 days: - - If 2 or more pills missed in last 7 active pills of pack: omit inactive pills and start next active pill. - - If 2 or more pills missed in first 7 active pills of pack and patient has had unprotected sex in past 5 days: also offer emergency contraception 110. 1 The subdermal implant may be less effective on ART, rifampicin and phenytoin. Advise patient to use condoms as well. 2 The oral contraceptive may be less effective on ART. Advise patient to use condoms as well. 3 Avoid COC for 6 weeks after delivery and for 6 months if breastfeeding. WOMEN'S HEALTH
  • 112. Adult 112 The pregnant patient Give urgent attention to the pregnant patient with one or more of: • Convulsing or just had a convulsion • BP ≥ 140/90 and persistent headache/blurred vision/abdominal pain: treat as severe pre-eclampsia • BP ≥ 160/110 and ≥ 1+ proteinuria: treat as severe pre-eclampsia • BP ≥ 160/110 without proteinuria: treat as severe hypertension • Temperature ≥ 38°C and headache, weakness, back pain, abdominal pain • Difficulty breathing • Swollen painful calf • Vaginal bleeding • Decreased/absent fetal movements 114 • Painful contractions < 37 weeks: preterm labour likely • Sudden gush of clear or pale fluid from vagina with no contractions: premature rupture of membranes (PROM) likely Management: • If difficulty breathing, give face mask oxygen and refer urgently. • If BP < 90/60, give normal saline 1L IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • If temperature ≥ 38°C, give ceftriaxone1 1g IM/IV or ampicillin1 2g IV/IM and gentamicin 80mg IM and refer urgently. Preterm labour Premature rupture of membranes (PROM) • If < 24 weeks: refer. • If 24-34 weeks: - - Give dexamethasone 6mg IM, record time given in referral letter. - - Give nifedipine 30mg PO, then 10mg 4 hourly until transferred. - - Check BP every 30 minutes. If BP < 90/60, give IV fluids as above. • If > 34 weeks: allow labour to continue. • Refer urgently. • Confirm amniotic fluid with sterile speculum: examination. • Avoid digital vaginal examination. • If chorioamnionitis4 : - - Give ceftriaxone1 1g IV/IM or ampicillin1 2g IV/IM and gentamicin 80mg IM. - - Refer urgently to hospital. • If no chorioamnionitis4 : - - If ≥ 37 weeks: if not in active labour 8 hours after PROM, give ampicillin1 1g IV/IM and refer urgently. - - If < 37 weeks: give erythromycin 250mg 6 hourly. If 24-34 weeks, also give dexamethasone 6mg IM, record time given in referral letter. Refer same day. Vaginal bleeding Early pregnancy < 24 weeks3 Cervical os open/dilated or products of conception in cervical os/vagina? Late pregnancy ≥ 24 weeks3 • Avoid digital vaginal examination. • Give IV fluids as above. • Refer urgently. No Threatened or complete miscarriage likely Refer same day to exclude ectopic pregnancy. Yes Incomplete or inevitable miscarriage likely • If ≥ 12 weeks, refer same day. • If < 12 weeks, do MVA. • If pain, give ibuprofen 400mg PO TID. • If bleeding heavy (pad soaked in < 5 minutes): - - Give IV fluids as above. - - Give single dose misoprostol 800mcg intravaginally. - - Refer same day If temperature ≥ 38°C, pulse ≥ 100 or smelly vaginal discharge, give ceftriaxone1 1g IM/IV or ampicillin1 2g IV/IM and gentamicin 80mg IM. • If BP ≥ 160/110, give hydralazine 5mg IV over 4 minutes. Also give 200mL normal saline IV. If BP still ≥ 150/100, repeat hydralazine 5mg every 30 minutes to a total maximum of 20mg. • Arrange urgent referral after giving the first doses of medications. Severe hypertension Convulsing or just had a convulsion • Give magnesium sulphate 4g in 200mL normal saline IV over 20 minutes. Also give 5g IM mixed with 1mL of lidocaine 2% in each buttock, and then 5g IM 4 hourly. • Continue 1L normal saline IV 12 hourly. • Insert urethral catheter and record urine output every 4 hours. • Stop magnesium sulphate if urine output < 100mL in 4 hours or respiratory rate < 162 or knee reflexes disappear. • If convulsion recurs or does not respond, refer urgently to hospital. • If < 20 weeks 15. • If between 20 weeks and 1 week postpartum, treat for eclampsia: - - Lie patient in left lateral position. - - Avoid placing anything in mouth. - - Give 100% face mask oxygen. - - Give magnesium sulphate: Severe pre- eclampsia If Rh-negative, give anti-D immunoglobulin 250mcg IM. Give routine antenatal care to the pregnant patient not needing urgent attention 113. 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid and refer. 2 If respiratory rate < 16, give calcium gluconate 10% 1g IV slowly over 10 minutes. 3 If gestation not known, manage as late pregnancy if uterus palpable above umbilicus. 4 Temperature ≥ 38°C, maternal pulse ≥ 100, fetal heart rate ≥ 160, painful abdomen or smelly amniotic fluid.
  • 113. Adult 113 Does the patient want the pregnancy? Approach to the newly diagnosed pregnant patient not needing urgent attention. Identify the pregnant patient who needs referral level antenatal care • Current medical problems: diabetes, heart/kidney disease, asthma, epilepsy, on TB treatment, substance use/abuse, hypertension, HIV stage 3 or 4. • Current pregnancy problems: rhesus negative with antibodies, multiple pregnancy, < 18 years old, vaginal bleeding or pelvic mass • Previous pregnancy problems: stillbirth or neonatal loss, ≥ 3 consecutive miscarriages, birth weight < 2500g or > 4500g, admission for hypertension or pre-eclampsia, congenital abnormality • Previous reproductive tract surgery (including caesarean section) If not needing referral level antenatal care, give routine antenatal care in health centre 114. • Discuss the options around continuing with pregnancy, choosing adoption or abortion. Refer to social worker. • Determine gestational age by dates and on examination. If unable to determine gestational age, arrange ultrasound. No or unsure Yes No Yes Patient decides to continue with pregnancy. • Abortion is not an option. • Discuss possibility of adoption. • Give routine antenatal care. • < 12 weeks: do MVA or provide medical abortion. • ≥ 12 weeks: refer to hospital for TOP. • Discuss future contraception 110. Patient requests abortion Any one of < 18 years old, pregnant following incest or rape, severe mental illness or congenital malformation?
  • 114. Adult 114 Routine antenatal care 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela. 2 BMI = weight (kg) ÷ height (m) ÷ height (m). 3 High risk of gestational diabetes if any of: previous gestational diabetes, glucose in urine, family history of diabetes, BMI > 30 or previous large baby > 4.5kg. 4 Oral glucose tolerance test: take fasting blood glucose specimen after overnight fast. Give oral glucose 75g in 250mL water to drink within 5 minutes. Take blood glucose specimen 1 hour and 2 hours later. Assess the pregnant patient at first visit and then at 16, 24–26, 32, 36-38 weeks. Assess When to assess Note Symptoms Every visit Manage symptoms as on symptom pages. Check if patient needs urgent attention 112. Estimated delivery date Every visit Plot on antenatal card. If patient ≥ 41 weeks, confirm EDD and refer for fetal evaluation and possible induction of labour. Fetal movements Every visit from 20 weeks If decreased or absent fetal movements, assess fetal heart rate (FHR): if FHR > 160 or < 110 or absent, refer to hospital. TB Every visit If cough > 2 weeks, weight loss, night sweats or fever, exclude TB 71. Mental health Every visit • In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. • If taking ≥ 14 units of alcohol/week or misusing illicit or prescription drugs, refer for secondary hospital antenatal care. Weight Every visit Expect weight gain of 1-2kg at each visit. If < 1kg gain over 2 visits, refer to hospital. BMI2 First visit • BMI < 18.5: exclude TB 71 and give routine malnutrition care 70. • BMI > 30: refer to hospital for CVD risk assessment and management. Mid upper arm circumference First visit MUAC < 23cm: exclude TB 71, HIV 75 and give routine malnutrition care 70. Abdominal examination Every visit • If mass other than uterus in abdomen or pelvis, refer for assessment. • Plot symphysis-fundal height (SFH) on, antenatal card: measurement in centimeters is roughly gestational age in weeks. If SFH is not within 3cm from expected gestational age, refer to hospital. • If breech or non-cephalic presentation at 37 weeks, refer to hospital. Vaginal discharge Every visit • If abnormal discharge, treat for STI 36. • If sudden gush of clear or pale fluid with no contractions: premature rupture of membranes likely 112. If small amounts of clear/pale fluid, refer. Avoid digital examination. BP (BP is normal if < 140/90) Every visit If BP ≥ 140/90, repeat after 1 hour lying on left side. If 2nd BP normal, repeat after 2 days. If 2nd BP still raised, check urine dipstick for protein: • No proteinuria: start methyldopa 250mg PO TID and refer to hospital. • If BP ≥ 140/90 and ≥ 1+ proteinuria, refer to hospital. If BP ≥ 140/90 and symptoms or BP ≥ 160/110, manage as severe pre-eclampsia 112. Arrange ultrasound First visit Book ultrasound before 24 weeks. Urine dipstick: test clean, midstream urine Every visit • If dipstick normal with dysuria (burning urine) or if leucocytes or nitrites present, treat for complicated urinary tract infection 44. • If proteinuria, check BP: - - BP ≥ 160/110, manage as severe pre-eclampsia 112. - - BP < 140/90 and ≥ 2+ proteinuria, refer to hospital to exclude kidney disease. If BP < 140/90 and < 2+ proteinuria, reassess at next antenatal visit. • If glucose in the urine, check random blood sugar 86. Diabetes screen • 26 weeks • If high risk3 : also at first visit • At 26 weeks, do oral glucose tolerance test4 : if fasting glucose ≥ 120mg/dl or following a 75gm oral glucose lose, 1-hour > 180mg/dl or 2-hour ≥ 140mg/dl, refer to hospital. • If high risk at first visit, check blood glucose 86. If diabetes, refer to hospital. Haemoglobin (Hb) First visit or if patient pale • If Hb < 8g/dL at < 34 weeks or Hb < 10g/dL at > 34 weeks or pallor with respiratory rate > 30, dizziness/faintness or chest pain, refer to hospital same day. • If Hb 8-10g/dL at the first visit , treat 115 and repeat Hb monthly until Hb > 10g/dL. Rh status First visit • If Rh-positive, continue routine care. • If Rh-negative, give anti-D immunoglobulin 250mcg IM at 28 weeks and immediately after delivery. Also give if miscarriage, ectopic or abdominal trauma. Continue to assess the pregnant patient 115.
  • 115. Adult 115 Advise the pregnant patient • Advise to stop smoking, drinking alcohol, using drugs and/or misusing medications. Support patient to change 125. Advise patient not to take medications unless prescribed by clinician. • Advise patient to avoid potentially harmful foods: unpasteurised milk, soft cheeses, raw or undercooked meat, poultry, raw eggs and shellfish. Advise to cut down on caffeine. • Advise patient to reduce indoor pollution (rural setting) and avoid smoking (urban setting). • Discuss safe sex. Advise patient to have only 1 partner at a time. Discuss contraception following delivery 110. • Ensure patient knows the danger signs of a pregnancy 112. • Give patient advice to avoid mosquito-transmitted diseases: - - Avoid travel to malaria areas. - - If in malaria area: Use insect repellent and cover exposed skin with long-sleeved shirt/pants and hat. Stay and sleep in screened or air-conditioned room if possible. Sleep under insecticide dipped net. • Regardless of HIV status, encourage exclusive breastfeeding for 6 months: only breast milk (no formula, water, cereal) and if HIV-exposed, nevirapine and co-trimoxazole prophylaxis. • Refer for support if mental health risk: previous depression/anxiety or family history, < 20 years, unwanted pregnancy, poor social/family support, no/unsupportive partner, violence at home, difficult life event in last year or undisclosed HIV. Treat the pregnant patient • Give iron/folic acid 60mg/400mcg PO daily. Avoid tea/coffee 2 hours after taking tablet. If Hb < 10g/dL, give iron/folic acid 60mg/400mcg PO TID for 3 months and reassess. • Check if tetanus immunisations are up to date (3 doses of tetanus in the past): - - If up to date, give 1 dose of tetanus vaccine at 27-36 weeks gestation. - - If not up to date/unknown, give 3 doses of tetanus vaccine: at first visit , then after 1 month and then after 6 months. • Be cautious of the risk of pre-eclampsia if first pregnancy, hypertension, diabetes, kidney disease, twin pregnancy, BMI > 30, previous pre-eclampsia or family history, < 18 years or > 35 years, > 10 years since last pregnancy. • Prevent malaria in a malaria area: if not on co-trimoxazole, give chloroquine 300mg weekly from 14 weeks. • Treat the HIV positive patient: - - If stage 3 or 4 or CD4 ≤ 350cells/mm3 , give co-trimoxazole 160/800mg PO daily. - - If on ART, continue. If on efavirenz, no need to change regimen. - - If not on ART, start ART within 2 weeks 80. Continue to assess the pregnant patient Syphilis First visit, 32 week If positive 41. HIV First visit and at 36 weeks if negative • Test for HIV 75. If patient refuses, offer test at each visit, even in early labour. • If HIV positive give routine care 76 and start ART same week 115. HIV viral load At first visit if HIV positive; On ART: 6 months, 12 months, then yearly • If viral load > 1000copies/mL for 1st time, give increased adherence support 78 and repeat viral load after 3 months. • If viral load > 1000copies/mL for 2nd time, patient has virological failure: refer to hospital. Give postnatal care to mother and baby 116. Treat the HIV positive patient in labour • If HIV positive on ART, continue ART throughout delivery and breastfeeding. • If newly diagnosed HIV positive or known HIV positive and not on ART, start ART 80. • Ensure mother gets routine HIV care after delivery 76. Treat the HIV-exposed baby immediately after birth • Give the baby born to an HIV positive mother a dose of nevirapine syrup (10mg/mL) as soon as possible after birth 118.
  • 116. Adult 116 Routine postnatal care Give urgent attention to the postnatal patient with one or more of: • Heavy bleeding (soaks pad in < 5 minutes): postpartum haemorrhage likely • Convulsing or just had a convulsion up to 1 week postpartum 112. • BP ≥ 140/90 and persistent headache/blurred vision/abdominal pain: treat as severe pre-eclampsia 112. • Feeling unwell and temperature > 38°C • BP < 90/60 • Pulse ≥ 100 • Tear extending to anus or rectum • Pallor with respiratory rate > 30, dizziness/faintness or chest pain • Pallor with Hb < 7g/dL Management: • If BP < 90/60 or bleeding with pulse ≥ 100, give normal saline 1L IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens. • If postpartum haemorrhage likely: - - Look for and repair any perineal tears. - - Massage uterus and empty bladder (with catheter if needed). - - Give oxytocin 10IU IM, then 30IU in 1L normal saline at 40 drops/minute IV. - - Ensure placenta is delivered. If controlled cord traction fails, try manual delivery and give ampicillin1 2g IV/IM. - - If uterus still soft after this, give ergometrine2 0.2mg IM/IV or misoprostol 400mcg sublingual and continue massaging uterus. - - If still bleeding heavily, apply bimanual3 or external aortic compression4 or non-pneumatic anti-shock garments (if available) during referral. • If feeling unwell and temperature > 38°C: give ceftriaxone1 1g IM/IV or amoxicillin1 1g PO with metronidazole 1g PO. • Refer urgently. Assess the mother and her baby within 24 hours, 2-3 days, 1 week and 6 weeks following delivery Assess When to assess Note Symptoms Every visit • Manage mother’s symptoms as on symptom pages. Manage baby’s symptoms with IMCI guide. • Ask about urinary incontinence (leaking or dribbling urine). If still present at 6 weeks, treat for flow problem 44. Depression Every visit If patient not interacting with baby and 2 or more of: a difficult life event in the last year, unhappy about pregnancy, absent or unsupportive partner, previous depression or anxiety, violence at home 99. Substance use/abuse Every visit In the past year, has patient: 1) drunk ≥ 4 drinks5 /session, 2) used khat or illegal drugs or 3) misused prescription or over-the-counter medications? If yes to any 103. Family planning Every visit Assess patient’s contraception needs 110. Baby feeding Every visit • If breastfeeding: check for breast problems 31. Check that baby latches well and is not mixed feeding. • If formula feeding: ensure correct mixing of formula and water and that it is affordable, feasible, acceptable, safe and sustainable. Baby Every visit Assess and manage the baby according to the IMNCI guide. Ensure baby received immunisations at birth and ensure baby is immunised at 6 week visit. Abdomen and perineum Every visit • If perineal or abdominal wound: check healing. • If painful abdomen, smelly discharge or poorly contracted uterus: check temperature and refer. BP Every visit Check BP. If BP ≥ 140/90, recheck after 1 hour rest. If BP still ≥ 140/90 and ≤ 1 week postpartum, refer urgently. Continue to assess the mother and her baby 117. 1 If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid and refer. 2 Avoid if eclampsia, pre-eclampsia or known hypertension. 3 Bimanual compression: insert clenched fist into vagina, back of hand directed posteriorly, knuckles in anterior fornix. Place other hand on abdomen behind uterus and squeeze uterus firmly between hands. 4 External aortic compression: press down with fist just above umbilicus until femoral pulse not felt. 5 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
  • 117. Adult 117 Assess When to assess Note HIV test in mother • If not done • At 6 weeks • If breastfeeding: 3 monthly • Test for HIV 75. If HIV positive, give routine care 76. If not on ART, start ART 79. • If mother tests HIV positive, do HIV PCR on baby same day and start post-exposure prophylaxis in baby while waiting for PCR result 118. HIV test in HIV-exposed baby • 6 weeks • 9 months if previous test negative • 18 months if previous test negative • Decide which HIV test to do: - - If < 9 months, do PCR. If positive, start ART and confirm result with 2nd PCR. - - If 9 - 17 months, do rapid test. If positive, do PCR. If PCR positive, start ART and confirm result with 2nd PCR. - - If ≥ 18 months 75. • If mother diagnosed with HIV while breastfeeding or baby unwell, do HIV test same day. Haemoglobin (Hb) If pale If Hb < 7g/dL, refer same day. If Hb 7-11g/dL, treat as below. Syphilis If not done Test mother for syphilis: if positive, treat mother and baby 41. Cervical screen (VIA) At 6 weeks if needed • If HIV negative: screen every 5 years if patient between 30-49 years. • If HIV positive: screen at HIV diagnosis (regardless of age) then 5 yearly. • If abnormal 40. Treat the HIV-exposed baby Give eMTCT regimen 118. Advise the mother • Encourage mother to become active soon after delivery, rest frequently and eat well. If mother has little support at home, arrange support. • Advise mother to keep perineum clean and to change pads 4-6 hourly. • Advise to return urgently if heavy bleeding, smelly vaginal discharge, red/smelly/oozing wound, fever, dizziness, severe headache, blurred vision, severe abdominal pain, severe calf pain or baby unwell. • Give feeding advice: - - Encourage exclusive breastfeeding for 6 months: baby gets only breast milk (no formula, water, cereal) and if HIV-exposed, nevirapine and co-trimoxazole prophylaxis. - - Refer to an infant feeding support group. - - If patient chooses to formula feed, ensure it is affordable, feasible, acceptable, safe and sustainable. Check formula is correctly prepared. Discourage mixed feeding before age 6 months. - - From 4-6 months, introduce food while continuing with feeding choice. - - If mother HIV positive, continue breastfeeding until 1 year if mother on ART and until at least 2 years if baby diagnosed HIV positive. - - If mother HIV negative: continue to breastfeed until at least 2 years. Explain importance of regular HIV testing while breastfeeding. • If mother HIV positive: ensure mother knows how to give nevirapine syrup correctly. • Advise that mother and baby sleep under an insecticide dipped bed net if in a malaria area. • Advise mother to reduce indoor pollution (rural setting) and avoid smoking (urban setting). Treat the mother • Continue iron/folic acid 60mg/400mcg PO daily for 6 weeks post partum. If Hb 7-11g/dL, give iron/folic acid 60mg/400mcg PO TID for 3 months and reassess Hb. • Check antenatal Rh-status: if Rh-negative, confirm anti-D immunoglobulin was given at delivery. If not given within 72 hrs of delivery, give anti-D immunoglobulin 250mcg IM. • Check tetanus immunisation is up to date: 5 doses in a lifetime. If not up to date: give 1 dose of tetanus vaccine. Repeat at 4 weeks, then 6, 18 and 30 months after first dose. • If painful perineal or abdominal wound, give paracetamol 1g PO QID as needed for up to 5 days. • If HIV positive and not on ART, start ART 79. If mother is already on ART, continue.
  • 118. Adult 118 Elimination of mother-to-child transmission (eMTCT) of HIV Approach to the HIV-exposed baby (mother is known with HIV1 ) Start post-exposure prophylaxis as soon as possible within 6 hours of birth: Mother on ART Low risk of HIV transmission Give nevirapine PO daily for 6 weeks (see table). High risk of HIV transmission Refer to hospital. Treat the HIV-exposed baby • Give eMTCT: nevirapine. Dose according to weight and age (see table). If ≤ 35 weeks gestation, discuss dose. • Start co-trimoxazole at 6 weeks of age. Dose according to weight (see table). Stop if HIV negative 6 weeks after last breastfeed. Nevirapine syrup (10mg/mL) Birth weight (born > 35 weeks) Age Dose < 2.0kg Birth up to 6 weeks 0.2mL/kg daily 2.0-2.49kg Birth up to 6 weeks 1mL daily ≥ 2.5kg Birth up to 6 weeks 1.5mL daily - 6 weeks to 12 weeks 2mL daily Co-trimoxazole syrup (40/200mg/5mL) Weight Dose 3.0-5.9kg 2.5mL daily 6.0-13.9kg 5mL daily Mother not on ART Start ART in mother same day 79. 1 If mother’s HIV status is unknown and mother not available, do rapid HIV test on baby. If positive, send HIV PCR test and refer to hospital. If negative, there is no need for eMTCT. No No Yes Yes Did mother initially test HIV negative and then became HIV positive during this pregnancy? Was there poor adherence to ART or mother in stage 3 or 4?
  • 119. Adult 119 Menopause Treat the menopausal patient • Give calcium 500-1000mg daily. • If menopausal symptoms interfere with daily function and no history of abnormal vaginal bleeding, cancer of uterus/breast, previous DVT or pulmonary embolism, recent heart attack, uncontrolled hypertension or liver disease, refer to hospital for initiation and routine follow up of hormone therapy. • Exclude pregnancy before diagnosing menopause. If pregnant 112. • Menopause is no menstruation for at least 12 months in a row in a woman above 40 years of age. Most women have menopausal symptoms and irregular periods during perimenopause. • If woman is < 40 years, refer to hospital. 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 67 and sexual problems 43. • If night sweats, ask about other TB symptoms: if cough ≥ 2 weeks, weight loss or fever, exclude TB 71. • Manage other symptoms as on symptom pages. Depression Every visit In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. Thyroid function At diagnosis If weight change, pulse ≥ 100, tremor, weakness/tiredness, dry skin, constipation or intolerance to cold or heat, refer to hospital. Vaginal bleeding Every visit If bleeding between periods, after sex or after being period-free for 1 year, refer to hospital. CVD risk At diagnosis, then depending on risk • Assess CVD risk 84. • If < 10% reassess after 1 year. If 10% to < 20%, reassess after 6 months. Osteoporosis risk At diagnosis Refer for possible treatment if high osteoporosis risk: < 60 years with loss of > 3cm in height and fractures of hip/wrist/spine; previous non-traumatic fractures; corticosteroid treatment > 3 months; onset of menopause < 45 years; BMI < 18.5; > 2 alcoholic drinks/day; smoker. Family planning At diagnosis • If on combined oestrogen/progestogen pill or progestogen injection, change to non-hormonal method or progestogen only pill or subdermal implant when ≥ 50 years. • If on non-hormonal method, continue for 2 years after last period if < 50 years and for 1 year after last period if ≥ 50 years. • If on progestogen only pill or subdermal implant, continue until 55 years, or if still menstruating, until 1 year after last period. Breast check At diagnosis If any lumps found in breasts or axillae, refer same week to hospital. Cervical screen When needed If HIV negative, screen every 5 years if patient between 30-49 years. If HIV positive, screen at HIV diagnosis (regardless of age) then 5 yearly. If abnormal 40. Advise the menopausal patient • To cope with the hot flushes, advise patient to dress in layers and to decrease alcohol, avoid spicy foods, hot drinks and warm environments. • Advise increased weight bearing exercise, such as walking. • If patient smokes tobacco 102. Support patient to change 125. • Help patient to manage CVD risk if present 85. • If patient is having mood changes or not coping as well as in the past, refer to counsellor or support group. • Educate the patient about the risks, contraindications and benefits of hormone therapy and that it can be used to treat menopausal symptoms for up to 5 years. Long term use can increase risk of breast cancer, deep vein thrombosis (DVT) and cardiovascular disease.
  • 120. Adult 120 Life-limiting illness: routine palliative care A patient can be given curative and palliative care at the same time. A doctor should confirm the patient with a life-limiting illness's need for palliative care: • If patient terminally sick and survival is predicted to be short then s/he needs palliative care 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 failure, cancer, dementia, HIV, TB. Advise the patient needing palliative care and his/her carer • Explain about the condition and prognosis. Explaining what is happening relieves fear and anxiety. Support the patient to give as much self care as possible. • Discuss the plan for caring for the patient. Advise whom to contact when pain or other symptoms get severe. • 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. • Refer patient and carer to available palliative carer, support group, counsellor, spiritual counsellor. Deal with bereavement issues 65. • Prevent bedsores if bedridden: 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). • Prevent contractures if bedridden: at least twice a day, gently bend and straighten joints as far as they go. Avoid causing pain. Massage muscles. • Prevent mouth disease: brush teeth and tongue regularly using toothpaste or dilute bicarbonate of soda if available. Rinse mouth with ½ teaspoon of salt in 1 cup of water after eating and at night. • The patient’s appetite will diminish 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. • Emphasize the importance of taking pain medication regularly (not as needed) and if using codeine/morphine to use a laxative daily to prevent constipation. Assess the patient needing palliative care Assess Note Symptoms • Manage on symptom pages: fever, constipation, nausea/vomiting, difficulty swallowing, difficulty breathing/cough, sore mouth, weight loss, incontinence, vaginal discharge. • If patient concerned about appetite loss, reassure that this is normal at the end of life. Consider trying a short course of prednisolone 121. Pain • 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, refer. • Assess the severity of the patient’s pain to help the patient to decide which pain medications s/he needs to start or increase : • Ask the patient to point on the pain scale whether his/her pain is mild, moderate or severe. no pain mild pain moderate pain severe pain worst possible pain 0 1 2 3 4 5 6 7 8 9 10 • Ask patient to describe the pain: muscles spasms, bone pain; if burning or electric like sensations, nerve pain likely; if cramping, colicky pain in abdomen, organ pain likely. Sleep If patient has difficulty sleeping 67. Depression In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99. Side effects Manage side effects on symptom pages. Nausea, confusion and sleepiness on morphine usually resolve after a few days. Chronic care • Assess how much patient and family understands 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. Carer Ask how the carer is coping and what support s/he needs. Assess for stress or distress 65. Mouth Check oral hygiene and look for dry mouth, ulcers and oral candida 27. Bed sores If patient is bedridden, check common areas for damaged skin (change of colour) and bedsores (see picture). If patient has bedsore 59. Smelly wound/discharge If patient has a malignant wound or discharge not responding to treatment that is smelly and causing embarrassment, treat with metronidazole solution to reduce smell 121.
  • 121. Adult 121 • If pain persists/increases, increase dose to maximum and then move to next step. If pain decreases, step down. • Review 2 days after starting or changing medication. If side effects intolerable after decreasing dose, refer. Review the patient needing palliative care and his/her carer regularly. Treat the patient needing palliative care • If smelly wound or discharge not responding to treatment, give metronidazole to control infection and smell: dissolve 5g in 2L normal saline and wash/douche daily. • If poor appetite is distressing the patient at the end of life, give prednisolone 5mg PO daily in the morning to stimulate appetite. Increase up to 15mg if needed. • Treat pain. Aim to have patient pain free at rest and as alert as possible. If the patient has any pain, start pain medication. Does patient have mild, moderate or severe pain? If unsure start at lower step and increase pain medication if needed. Also check if patient needs adjuvant pain medication: does s/he have nerve pain, organ cramps, bone pain or muscle spasms? Is anxiety making pain worse? Mild pain Start pain medication at step 1. Use paracetamol in step 1 and add amitriptyline. Nerve pain Add diazepam. Muscle spasms Use ibuprofen or diclofenac in step 1. Bone pain Add hyoscine. Organ cramps Add diazepam. Anxiety Moderate pain Start pain medication at step 2. Severe pain Start pain medication at step 3. Step Pain medication Start dose Maximum dose Note Step 1 Use one of: Paracetamol 1g PO QID 4g daily NSAIDS are very good for visceral and somatic pain. Start this if mild pain and also use in step 2 or 3 and in neuropathic pain with amitriptyline. Diclofenac 50mg BID or PO TID 150g daily Give with/after food. Avoid if peptic ulcer, dyspepsia, bleeding problem, kidney or liver disease, asthma. Ibuprofen 400mg PO QID 2.4g daily Give with/after food. Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. Step 2 Add one of: Codeine 30mg PO 4 hourly 240mg daily If no diarrhoea , give bisacodyl 5-15mg PO daily to prevent constipation. Tramadol 50mg-100mg PO QID 400mg daily • If no diarrhoea, give bisacodyl 5-15mg PO daily to prevent constipation. • Avoid in epilepsy Step 3 Stop step 2 and add: Morphine oral syrup 2.5mg-5mg PO 4 hourly None. If respiratory rate < 12, skip 1 dose, then halve dose. • If no diarrhoea, give bisacodyl 5-15mg PO daily to prevent constipation. • If pain persists after first 24 hours, increase dose by 1.5-2 times. • If patient has severe nausea, give metoclopramide 10mg PO TID for 1 week only • Dizziness should clear in few days. Advise to avoid driving, heavy machinery. If persists > 1 week, lower dose. Add adjuvant pain medication to any step if needed. Amitriptyline 25-75mg PO 75mg/daily Use at night. Advise it may cause dizziness and sedation and to avoid driving and using heavy machinery. Diazepam 5mg PO TID 15mg/daily Explain about dizziness which will clear in few days but avoid driving, heavy machinery Hyoscine 10-40mg PO TID 120mg /daily - PALLIATIVE CARE
  • 122. Adult 122 Protect yourself from occupational infection Give urgent attention to the health worker who has had a sharps injury or splash to eye, mouth, nose or broken skin with exposure to one or more of: • Blood • Blood-stained fluid/tissue • Pleural/pericardial/peritoneal/amniotic/synovial/cerebrospinal fluid • Vaginal secretions • Semen • Breast milk 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 or normal saline. • If health worker has had contact with viral haemorrhagic fever1 suspect, discuss with specialist2 . • Assess need for HIV and hepatitis B post-exposure prophylaxis 68. Adopt measures to diminish your risk of occupational infection Protect yourself Adopt standard precautions with every patient: • Wash hands with soap/water or use alcohol-based cleaner before and after contact with patients or body fluids. • Do not recap or bend needles • Safely pass sharp instruments • Dispose of sharps correctly in sharps bins. Wear personal protective equipment: • Wear gloves when handling blood, body fluids, secretions or non-intact skin. • Wear face mask if in contact with respiratory virus suspects • Wear N95 respirator if caring for MDR TB patient. • Wear face mask with a visor or glasses if at risk of splashes. • Wear personal protective equipment if in contact with viral haemorrhagic fever1 suspects. Get vaccinated: • Get vaccinated against hepatitis B and yearly against influenza. Know your HIV status: • Test for HIV 75. ART and IPT can decrease the risk of TB. • If HIV positive, you are entitled to work in an area of the facility where exposure to TB is limited. Protect your facility Clean the facility: • Clean frequently touched surfaces (door handles, telephones, keyboards) daily with soap and water. • Disinfect surfaces contaminated with blood/secretions with 70% alcohol or chlorine-based disinfectant. Ensure adequate ventilation: • Leave windows and doors open when possible and use fans to increase air exchange. Organise waiting areas: • Prevent overcrowding in waiting areas. • Fast track influenza and presumed TB patients. Manage sharps and other infectious wastes safely: • Ensure sharps bins are easily accessible and regularly replaced. • Segregate and dispose wastes properly Manage infection control in the facility: • Appoint an infection control officer for the facility to coordinate and monitor infection control policies. Reduce TB risk Identify the presumed TB patient promptly: • The patient with cough ≥ 2 weeks is a presumed TB patient. • Separate presumed TB patient from others in the facility. • Educate about cough hygiene and give face mask/tissues to cover mouth/nose to protect others. Diagnose TB rapidly: • Fast track TB workup and start treatment as soon as diagnosed. Protect yourself from TB: • Wear an N95 respirator (not a face mask) if in contact with an infectious MDR TB patient. Reduce risk of respiratory viruses (including influenza) • Wash hands with soap and water. • Wear a face mask over mouth and nose during procedures on patient. • Encourage patient to cover mouth/ nose with a tissue when coughing/sneezing, to dispose of used tissues correctly and to wash hands regularly with soap/water. • Advise patient to avoid close contact with others. 1 Suspect viral haemorrhagic fever in patient who lived in or travelled to an endemic area or had contact with confirmed viral haemorrhagic fever in past 21 days and has fever and ≥ 1 of: bloody diarrhoea, bleeding from gums, bleeding into skin, eyes. 2 Report to the head of the health centre who will contact the Public Emergency Management unit within the Public health institute. Manage possible occupational exposure promptly
  • 123. Adult 123 Protect yourself from occupational stress Give urgent attention to the health worker with occupational stress and one or more of: • Alcohol or drug intoxication at work • Aggressive or violent behaviour at work • Inappropriate behaviour at work • Suicidal thoughts or behaviour 62 Management: • Arrange assessment same day with mental health practitioner. 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. Identify occupational stress in yourself and your colleagues: Possible alcohol or drug problem • In the past year, have you or your colleague: drunk ≥ 4 drinks1 /session, used khat or illegal drugs, or misused prescription or over-the-counter medications? • Smells of alcohol Change in mood • Indifferent, tense, irritable or angry • In the past month, have you or colleague: felt depressed, sad, hopeless or irritable or worrying a lot, had multiple physical complaints, felt little interest or pleasure in doing things? Recent distressing event • Diagnosis of chronic condition • Bereavement • Needlestick injury • Traumatic event Poor attendance at work • Frequent absenteeism Marked decline in work performance • Reduced concentration • Fatigue Adopt measures to diminish your risk of occupational stress Protect yourself Look after your health: • Get enough sleep. • Exercise, eat sensibly, minimise alcohol and don’t smoke 85. • Get screened for chronic conditions. Look after your chronic condition if you have one: • Adhere to your treatment and your appointments. • Don’t diagnose and treat yourself. • If you can, confide in a trusted colleague/manager. Manage stress: • Delegate tasks as appropriate, develop coping strategies. • Talk to someone (friend, psychologist, mentor). • Do a relaxing breathing exercise each day. • Find a creative or fun activity to do. • Spend time with supportive friends or family. Have healthy work habits: • Manage your time sensibly. • Take scheduled breaks. • Remind yourself of your purpose as a clinician. • Be sure you are clear about your role and responsibilities. Protect your team Decide on an approved way of behaving at work: • Communicate effectively with your patients and colleagues 124. • Treat colleagues and patients with respect. • Support each other. Consider setting up a staff support group. • Instead of complaining, rather focus on finding solutions to problems. Cope with stressful events: • Develop procedures to deal with events like complaints, harassment/bullying, accidents/mistakes, violence or death of patient or staff member. Look at how to make the job less stressful: • Examine the team’s workload to see if it can be better streamlined. • Identify what needs to be changed to make the job easier and frustrations fewer: equipment, drug supply, training, space, décor in work environment. • Discuss each team member’s role. Ensure each one has say in how s/he does his/her work. • Support each other to develop skills to better perform your role. Celebrate: • Acknowledge the achievements of individuals and the team. • Organise or participate in staff social events. If you or your colleagues have any of the above you may have substance abuse, stress, depression/anxiety or burnout. Ensure that you seek help. 1 One drink is 1 shot (25mL) of spirits (whiskey, vodka, areke, gin), or 1 small glass (125mL) of wine/tej or 1 can/bottle (330mL) of beer/tela.
  • 124. Adult 124 Communicate 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 • Give all your attention • Recognise non-verbal behaviour • Be honest, open and warm • Avoid distractions e.g. phones The patient might feel: • ‘I can trust this person’ • ‘I feel respected and valued’ • ‘I feel hopeful’ • ‘I feel heard’ Don’t • Talk too much • Rush the consultation • Give unwanted advice • Interrupt The patient might feel: • ‘I am not being listened to’ • ‘I feel disempowered’ • ‘I am not valued’ • ‘I cannot trust this person’ Discuss Discussing a problem and its solution can help the overwhelmed patient to develop a manageable plan. Do • Use open ended questions • Offer information • Encourage patient to find solutions • Respect the patient’s right to choose The patient might feel: • ‘I choose what I want to deal with’ • ‘I can help myself’’ • ‘I feel supported in my choice’ • ‘I can cope with my problems’ Don’t • Force your ideas onto the patient • Be a ’fix-it’specialist • Let the patient take on too many problems at once The patient might feel: • ‘I am not respected’ • ‘I am unable to make my own decisions’ • ‘I am expected to change too fast’ Empathise Empathy is the ability to imagine and share the patient’s situation and feelings. Do • Listen for, and identify his/her feelings e.g. ‘you sound very upset’ • Allow the patient to express emotion • Be supportive The patient might feel: • ‘I can get through this’ • ‘I can deal with my situation’ • ‘My health worker understands me’ • ‘I feel supported’ Don’t • Judge, criticise or blame the patient • Disagree or argue • Be uncomfortable with high levels of emotions and burden of the problems The patient might feel: • ‘I am being judged’ • ‘I am too much to deal with’ • ‘I can’t cope’ • ‘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 • Get the patient to summarise • Agree on a plan • Offer to write a list of his/her options • Offer a follow-up appointment The patient might feel: • ‘I can make changes in my life’ • ‘I have something to work on’ • ‘I feel supported’ • ‘I can come back when I need to’ Don’t • Direct the decisions • Be abrupt • Force a decision The patient might feel: • My health worker disapproves of my decisions’ • ‘I feel resentful’ • ‘I feel misunderstood’
  • 125. Adult 125 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 or 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 and not lower. 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: • Assist the patient to set a realistic change goal. • Explore the factors that may help the patient to change or may make it difficult. • Help the patient plan how s/he will fit the change into the routine of the day. Encourage patient to use strategies s/he used successfully in the past. If the patient is not ready to change: • Respect the patient's decision. • Invite patient to identify the pros and cons of change. • Acknowledge patient’s concerns about change. • 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, health extension worker). • 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.
  • 126. Child 126 Child contents Long-term health conditions A Abdominal symptoms 143 B Breathing difficulty, child 140 Burns 133 C Cardiac arrest 128 Cardiopulmonary resuscitation (CPR) 128 Coma 131 Confusion 131 Convulsions 130 Cough 140 Cough, recurrent 142 D Dehydrated child 129 Diarrhoea 144 E Ear symptoms 138 Emergency child 127 F Fever 134 H Headache 135 Head injury 127 Hearing problems 138 I Injured child 132 L Leg symptoms 146 Limp 146 Lymphadenopathy 136 M Mouth symptoms 139 P Pallor 137 R Rash, generalised 147 Rash, localised 148 Respiratory arrest 128 Resuscitation, child 128 S Seizures 130 Shock 129 T Throat symptoms 139 U Unconscious child 131 Underweight 150 Urinary symptoms 145 W Walking problems 146 Wheeze 141 Wheeze, recurrent 142 Symptoms Malnutrition 153 Epilepsy 154 Quick reference chart 155
  • 127. Child 127 The emergency child Give urgent attention to the emergency child Does child respond to voice or physical stimulation? Assess and manage airway, breathing, circulation and level of consciousness: No Feel for pulse for maximum of 10 seconds: feel carotid pulse. No pulse felt or no signs of life. Pulse felt Call for help and start CPR 128. Yes Child breathing well Pulse rate < 60 Child gasping or not breathing • Check airway clear and give 1 breath with bag valve mask attached to oxygen every 4 seconds. • Recheck pulse every 2 minutes. Pulse rate ≥ 60 Airway • If noisy breathing, position in ‘sniffing position’. If injured, keep neck stable, use instead jaw-thrust1 only. • Check for foreign body in mouth: if easy-to-reach, remove. Suction secretions. • If unresponsive, insert an oropharyngeal airway2 . Breathing • If difficulty breathing or oxygen saturation ≤ 92%, give facemask oxygen 140. • If respiratory rate decreased, or blue lips/tongue, assist each breath with bag valve mask attached to oxygen (at least every 4 seconds). Circulation • Establish IV access: try 3 times for < 90 seconds each, if unsuccessful and trained to do so, insert external jugular or intra-osseous line3 . • If ≥ 2 of: 1) cold hands/feet, 2) weak/fast pulse, 3) capillary refill3 > 3 seconds, 4) decreased level of consciousness 5) decreased urine output: shock likely 129. • If actively bleeding or enlarging/ pulsating swelling, elevate and apply direct pressure. If unsuccessful, compress the nearest large artery. Glucose/level of consciousness • Check fingerprick glucose: - - If glucose if < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose4 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose4 bolus. • Determine AVPU: - - A: alert - - V: responds to voice - - P: responds to pain - - U: unresponsive • If decreased level of consciousness 131. Check breathing: Manage further according to disability and symptoms and refer urgently: • If injured: - - If head injury, neck/spine tenderness, decreased level of consciousness or weak/numb limb, immobilise head with tape and sandbags/bags of IV fluid on either side of head. Use spine board if needing to move patient. - - Identify all injuries: undress child fully and assess front and back using log-roll to turn. Then cover and keep warm. Manage injuries 132. • If pupils unequal or respond poorly to light, tilt bed to raise head by 30 degrees. If injured, avoid bending spine: keep body straight with head/neck in midline. • Manage further according to symptoms: if covulsing 130, if just had convulsion 130, if unconscious 131, if burn 133. • Keep child warm. 3 If trained, insert an intraosseous line: Clean with antiseptic, locate site on medial surface of tibia, 2 finger breadths below tibial tuberosity, stabilize thigh/knee, insert 15-18 gauge intraosseous needle 90o angle to bone with bevel towards foot. Advance with twisting motion, stop when sudden decrease in resistance (needle should be fixed in bone). Remove stylet (if present) and confirm position by aspirating 1mL of blood/marrow with 5mL syringe. Flush with 5mL IV fluid. Apply dressing and secure. Monitor for calf swelling. 1 Lift chin forward with fingers under bony tips of jaw. 2 Size oropharyngeal airway: flat rim at middle of mouth (front incisors), laid on side of face, tip at angle of jaw. If child resists, coughs or gags, likely too alert to tolerate airway. 3 Capillary refill time: hold hand/foot higher than level of heart. Press soft pad of finger/toe until it turns pale, then release pressure and take note of time taken for colour to return. 4 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline). CHILD
  • 128. Child 128 Cardio-pulmonary resuscitation (CPR) of the child Decide when to stop CPR: Return of pulse ≥ 60 127. No return of pulse after 20 minutes • If hypothermia, near drowning or poisoning, continue prolonged CPR and transfer urgently. • If no pulse and fixed dilated pupils after 20 minutes of effective CPR, stop CPR and pronounce dead. • Arrange bereavement counselling for family. In the unresponsive child with no pulse or pulse < 60, start chest compressions: • Note start time. • Give cycles of 15 compressions and 2 breaths with bag valve mask attached to oxygen at a flow rate of 10-15L/min. If only one rescuer, give 30 compressions and 2 breaths. Ensure correct CPR technique: - - For chest compressions: • Find correct hand position: palpate xiphoid process and place hands directly above this area on the sternum. Place one hand on top of the other and push down onto the chest, making sure to keep your shoulders directly over your hands and elbows locked. • Push hard (≥ ⅓ of depth of chest) and fast (100/minute). • Allow full chest recoil (chest to return to normal shape in between compressions). • Minimise interruptions in compressions. - - For breaths: • Check airway clear and head and neck in the‘sniffing position’. If injured, keep neck stable, use instead jaw thrust1 • Give adrenaline 1:10 000, which is 1mL adrenaline (1:1000) diluted in 9mL normal saline, 0.1mL/kg IV/IO every 3 minutes (for quick reference, use the table below): Dose IV/IO adrenaline (1:10 000) according to age 1:10 000 concentration: dilute 1mL adrenaline (1:1000) diluted in 9mL normal saline. Age Volume 5-7 years 2mL 7-11 years 3mL 11-15 years 5mL • If glucose if < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose2 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose2 bolus. • Treat for likely shock 129. • Warm child. • Check for pulse after every 2 minutes of CPR. 1 Lift chin forward with fingers under bony tips of jaw. 2 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline). Use heel of hand/s.
  • 129. Child 129 Assess and manage child’s fluid needs 1 Capillary refill time (CRT): hold hand/foot higher than level of heart. Press soft pad of finger/toe until it turns pale, then release pressure and note time taken for colour to return. 2 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline). 3 Pinch skin on abdomen between 2 fingers. Release. Skin usually snaps rapidly back to its normal position. A slow skin pinch takes longer. 4 Severe acute malnutrition: BMI below -3 line or very low MUAC (< 13cm in a child 5-9 years old or < 16cm in a child 10-14 years old). Yes: shock likely • Establish IV access: try 3 times for < 90 seconds each, if unsuccessful, insert external jugular or intra-osseous (IO) line. If IV access not possible, refer urgently with ORS 20mL/kg/hour NGT or orally if NGT not possible. • Is there ≥ 1 of: 1) severe acute malnutrition4 2) difficulty breathing 3) suspected meningitis? No • Give normal saline 20mL/kg bolus IV/IO rapidly. • Then assess response: feel hands, check pulse and CRT. Good response: hands warmer, CRT faster, pulse slower and stronger Yes Stop IV fluids, give oxygen 2L/minute via nasal prongs, and refer urgently to hospital. Refer urgently. While awaiting transfer: • If not already done, check finger prick glucose: if < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose2 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose2 bolus. • If not due to watery diarrhoea or trauma, or if child has severe acute malnutrition4 , give ceftriaxone 100mg/kg (up to 2g) IV/IM. • Reassess fluid status hourly and keep warm: cover with blanket. Good response: hands warmer, CRT faster, pulse slower and stronger Give 2nd bolus: normal saline 20mL/kg bolus IV/IO and urgently refer to hospital. Continue with normal saline 30mL/kg over 30 minutes, then give 70mL/kg for 2½ hours. No longer shocked. No longer shocked. Give 2nd bolus: DNS 15mL/kg IV/IO over 1 hour and urgently refer to hospital. Continue ORS 10mL/kg/hour orally (or NGT if vomiting). Poor response: hands still cold or pulse weak or not felt, CRT > 3 seconds Poor response: hands still cold or pulse weak or not felt, CRT > 3 seconds Still shocked Are eyelids puffy, leg swelling worse, is pulse rate up by 25 beats/minute or respiratory rate up by 5 breaths/minute? Still shocked Is pulse rate up by 25 beats/ minute or respiratory rate up by 5 breaths/minute or eyelids puffy? Yes • Give DNS 10mL/kg IV/IO over 20 minutes. • Then assess response: feel hands, check pulse and CRT. No • If lethargic, check finger prick glucose if < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose2 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose2 bolus. • Is there ≥ 2 of: 1) sunken eyes, 2) drinking poorly, 3) lethargic, 4) very slow skin pinch3 (≥ 2 seconds) 5) decreased urine output? Yes Moderate dehydration (5%) likely Is there ≥ 1 of: 1) severe acute malnutrition4 , 2) difficulty breathing, 3) suspected meningitis? • Record weight. • If child vomits, wait 10 minutes, then continue more slowly. • If refusing to drink, give via NGT. • Give more ORS if child wants it. • Check fingerprick glucose and manage as above, if necessary. Reassess after 4 hours: • If still dehydrated or weight not up, refer to hospital. • If no longer dehydrated and child has diarrhoea 144. • Address other symptoms on symptom page. No Is there ≥ 2 of: 1) sunken eyes, 2) thirsty/drinks eagerly, 3) restless/irritable, 4) slow skin pinch3 ? No Child not dehydrated No Give ORS 20mL/kg/ hour orally, using small frequent sips, for 4 hours. Yes Give ORS 10mL/kg/ hour orally using small frequent sips, for 4 hours. Return to relevant symptom page to assess and manage symptom/s. Yes Severe dehydration (10%) likely Is there ≥ 1 of: 1) severe acute malnutrition4 , 2) difficulty breathing, 3) suspected meningitis? No No No Give normal saline 30mL/kg IV over 30 minutes, then give 70mL/kg for 2½ hours. Yes Give ReSoMal 5mL/kg orally/NGT every 30 minutes for the first 2 hours. Then 5-10mL/kg/ hour orally/ NGT for the next 4 hours. Assess the child’s fluid needs: Is there ≥ 2 of 1) cold hands/feet, 2) weak/fast pulse, 3) capillary refill time (CRT)1 > 3 seconds, 4) decreased level of consciousness 5) decreased urine output?
  • 130. Child 130 Seizures/convulsions Give urgent attention to the child who is unconscious and convulsing: Give medication to stop the convulsion whilst giving supportive treatment. Then treat possible causes. Stop the convulsion that has lasted > 5 minutes • Give rectal1 diazepam 0.1mL/kg PR or if IV line already inserted, give diazepam 0.05mL/kg IV slowly (see table below). • Expect a response within 5 minutes. Monitor breathing: if decreased respiratory rate, breathing stops or gasping, ventilate with bag-valve mask (1 breath every 3-5 seconds) 127. • If child still convulsing after 5-10 minutes, give a 2nd dose of diazepam. If child still convulsing 5-10 minutes after this, give a 3rd dose of diazepam. Weight/age Rectal1 diazepam (10mg/2mL) 0.1mL/kg IV diazepam (10mg/2mL) 0.05ml/kg 18-25kg (5-8 years) 1.5mL 0.9mL ≥ 25kg (≥ 8 years) 2mL 1mL • If child still convulsing or repeated convulsions without regaining consciousness despite diazepam: give phenytoin 20mg/kg PO via nasogastric tube (NGT) or phenobarbitone 20mg/kg (up to 1g) PO via NGT. • Refer to hospital urgently. Give supportive treatment and treat possible causes • Open airway: clear mouth, stabilise neck if trauma patient and suction secretions. • If not trauma patient, place in recovery position2 . Avoid placing anything in mouth. • Give facemask oxygen 5 L/minute. • Check fingerprick glucose: if < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose3 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose3 bolus. • If meningitis4 likely, give ceftriaxone 100mg/kg (up to 2g) IV. • If malaria is suspected/confirmed5 : give artesunate 3mg/kg IM or artemether 3.2mg/kg IM. 1 Rectal administration: draw up correct dose, remove needle and connect to an NGT that has been cut to a length of 5cm (length of baby finger). Insert into rectum, inject diazepam solution and hold buttocks together. 2 Recovery position: turn onto left side, place left hand under cheek with neck slightly extended and bend the right leg to stabilise position (see picture above). 3 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline). 4 Meningitis likely if: temperature ≥ 38°C, neck stiffness, headache and/or vomiting. 5 Test for malaria with parasite slide microscopy or if unavailable, rapid diagnostic test. 6 Dehydration: ≥ 2 of: 1) sunken eyes, 2) thirsty/drinks eagerly, 3) restless/irritable, 4) slow skin pinch. 7 Family history of epilepsy refers to a parent or sibling with childhood onset epilepsy. Has child had ≥ 2 convulsions in the last year on 2 different days? Refer patient same day if one or more of: • Temperature ≥ 38°C • Convulsion > 15 minutes • Unresponsive to voice > 1 hour after convulsion • > 1 convulsion in 24 hours • Convulsion occurs only on one side • Neck stiffness/ meningism • Weakness of arm/leg/face, even if resolved • Dehydration6 • Suscpted/confirmed malaria5 • Ingestion of medication/potentially harmful substance • Previous birth trauma, head injury, meningitis • Family history of epilepsy7 • HIV positive • Head injury within past week • Close TB contact Approach to the child who is not convulsing now: • If child known with epilepsy, give routine epilepsy care 154. • If not know with epilepsy: confirm that child indeed had a convulsion: jerking movements, loss of consciousness, eyes open during convulsion, incontinence, post-convulsion drowsiness and confusion. If not, refer to hospital. Yes Refer to hospital. No • If talking/understanding problems, refer to hospital. • If otherwise well, review in 3 months for further convulsions, new symptoms or delayed milestones. Advise the caretaker on what to do if child has a convulsion at home • Place child in safe place (on floor or bed) away from objects that may cause injury. • Lie child on left side in recovery position2 . Avoid placing anything in his/her mouth. Wipe away secretions. • Time convulsion: get help if convulstion continues for more than 3 minutes or child does not wake up properly between convulsions. • Encourage caretaker/s to have a plan ready if medical attention needed urgently: know where nearest clinic is, have reliable transport plan.
  • 131. Child 131 Decreased level of consciousness 1 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline). 2 Test for malaria with parasite slide microscopy or if unavailable, rapid diagnostic test. 3 Capillary refill time: hold hand/foot higher than level of heart. Press soft pad of finger/toe until it turns pale, then release pressure and note time taken for colour to return. Give urgent attention to the child with a decreased level of consciousness • If not already done, assess and manage airway, breathing and circulation 127. • If no history of trauma, place child in recovery position: turn left side, place left hand under cheek with neck slightly extended and bend the right leg to stabilise position. • Ask about possible causes and manage symptoms: trauma or injury 132, ulsing or just had a convulsion 130, burns 133. • If known allergy with exposure to allergen, manage as anaphylaxis below. • If poisoning likely, refer to hospital urgently. • Check fingerprick glucose, temperature, pupils and skin: Glucose • If glucose < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose1 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose1 bolus. • If glucose ≥ 200mg/ dL, DKA likely. Assess fluids needs 129. ≤ 35.5° C • Clothe including head and cover with warmed blankets. Place near heater. • Give ceftriaxone 100mg/kg (up to 2g) IV/IM. Treat for likely infection: • Give ceftriaxone 100mg/kg (up to 2g) IV/IM. • If malaria is suspected/ confirmed2 : give artesunate 3mg/kg IM or artemether 3.2mg/kg IM. ≥ 38°C Purple/red rash that does not disappear with pressure. Meningococcal disease likely • Establish IV/IO. • If ≥ 2 of: 1) cold hands/ feet, 2) weak/fast pulse, 3) capillary refill time3 > 3 seconds, 4) decreased level of consciousness 5) decreased urine output: shock likely 129. • Give ceftriaxone 100mg/ kg (up to 2g) IV/IM. Both pupils dilated or pinpoint Poisoning likely • If pinpoint pupils, excessive drooling/ sweating, coughing up or choking on secretions, slow pulse, organo-phosphate poisoning likely: give atropine 0.05mg/ kg IV. If no response, double the dose every 3 minutes until improving. Tilt bed to raise head by 30 degrees. If injured, avoid bending spine: keep body straight with head and neck in midline. Sudden rash There may be swelling of face/tongue or wheezing. Anaphylaxis likely • Lie child flat and give 100% facemask oxygen at 5L/minute. • Give adrenaline (1mg/mL, 1:1000) 0.3mL IM into mid- outer thigh. If no better, repeat every 5 minutes. Give normal saline 20mL/kg IV bolus. Also give diphenhydramine 1mg/kg IM/IV (up to 50mg). Unequal or respond poorly to light Temperature Pupils Skin rash • Consider child abuse if any of: history inconsistent with examination, delay in presentation, skull fracture, old and new scars on body, unusual or patterned wounds, burns, wounds around ano- genital region, refer to hospital. • If child aggressive or violent: ensure safety, assess child with help of other staff, use security personnel if needed. Discuss with hospital doctor before sedating. • Refer urgently with advanced life support ambulance. While waiting for transport: - - Check pulse, respiratory rate, oxygen saturation (if available) and capillary refill time3 every 15 minutes. - - If pulse/respiratory rate abnormal, oxygen saturation drop ≤ 92%, or capillary refill time3 > 3 seconds, reassess airway, breathing and circulation 127. Assess the AVPU scale. The child with a decreased level of consciousness is not alert and does not responds voice, s/he only responds to pain or is unresponsive.
  • 132. Child 132 The injured child Give urgent attention to the injured child with any of: • Decreased level of consciousness • Difficulty breathing: abnormal respiratory rate, grunting, nasal flaring or chest indrawing • Distended abdomen • Bleeding despite direct pressure • Pulsatile or growing swelling • Burns 133 • Weak/numb limb • Multiple injuries • Poor perfusion below injury: cold, pale, numb, no pulse • Weak/numb limb • Stab or gunshot wound • Severe mechanism: high speed collision, car accident, fall from height Also give urgent attention to the child with a head injury and any of: • Lethargy or decreased level of consciousness • History of loss of consciousness • Strange behaviour or memory loss since injury • Suspected skull fracture • Vomiting ≥ 2 episodes • Severe headache • Pupils unequal or respond poorly to light • Blurry/double vision • Blood or clear fluid leaking from ear/nose • Bruising around eyes or behind ears • Blood behind eardrum • Drug or alcohol intoxication Management: • Assess and manage airway, breathing, circulation 127. Establish IV access and assess and manage fluid needs 129. • If actively bleeding or enlarging/pulsating swelling, apply direct pressure while arranging urgent ambulance transfer to hospital. • If severe head injury, neck/spine tenderness, decreased level of consciousness or weak/numb limb, immobilise head with tape and sandbags/bags of IV fluid. Use spine board if moving child. • If pupils unequal/respond poorly to light, keep body straight, raise head by 30 degrees (do not bend spine) and keep head in midline. • Identify all injuries: undress child fully and assess front and back using log-roll to turn. Then cover and keep warm. • While awaiting transport, monitor every 15 minutes: pulse, respiratory rate, oxygen saturation (if available). If deteriorates, reassess and manage airway, breathing and circulation 127. • Refer urgently to hospital. Approach to the injured child not needing urgent attention Consider child abuse, if any of: clear history of abuse, history inconsistent with exam, delayed presentation, skull fracture, old and new scars, burns, unusual or patterned wounds, grasp marks on arms/chest/face, bruises on trunk, different colour bruises, wounds around anus/genital region. Wound • Apply direct pressure to stop bleeding. • If open wound, give tetanus toxoid 0.5mL IM if none in past 5 years. If unavailable, check for tetanus antitoxin (TAT) hypersensitivity1 : if no hypersensitivity, give single dose TAT 3000U SC. • Remove foreign material, loose/dead skin. Irrigate with normal saline or if dirty, dilute povidone iodine solution. • If sutures needed: suture and apply non-adherent dressing for 24 hours. Plan to remove sutures after 5 days (face), 4 days (neck), 10 days (leg) or 7 days (rest of body). • Avoid suturing if wound > 12 hours old (or > 24 hours on head/neck), infected, remaining foreign material or deep puncture, instead: - - Pack wound with saline-soaked gauze and - - Give cloxacillin2 25mg/kg QID PO plus metronidazole 7.5mg/kg (up to 400mg) TID PO for 7-10 days. - - Review in 2 days. If no infection, suture now if still needed, unless deep puncture (irrigate and dress every 2 days instead). • Advise to return if skin red, warm, painful: infection likely. • If unable to close wound easily, cosmetic concerns or child needs sedation to suture, refer to hospital. Head injury • Advise caretaker to observe child carefully for 24 hours and limit activity for at least 48 hours. • Advise to return immediately if any of: blurred vision, vomiting, headache despite paracetamol, difficult to wake, balance problem. Painful limb • Give single dose paracetamol 15mg/kg (up to 1g) PO. • Apply firm, supportive bandage, refer to hospital. 1 Inject 0.1mL TAT SC and 0.1mL normal saline at separate site as control: if wheal with redness develops around TAT site, child has TAT hypersensitivity. Refer to hospital. 2 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give instead erythromycin 12.5mg/kg (up to 500mg) QID PO for 7-10 days.
  • 133. Child 133 Burns Calculate percentage total body surface area (%TBSA) burnt using below figure. Approach to the child with burn/s not needing urgent attention: • Cool burnt area < 3 hours old with cold tap water for 30 minutes. Give paracetamol 15mg/kg (up to 1g) QID PO as needed for up to 5 days. • Clean with water or normal saline, apply thin film of silver sulfadiazine 1% or fusidic acid 2% cream and cover with vaseline gauze dressing. • Give tetanus toxoid 0.5mL IM if none in past 5 years. If unavailable, check for tetanus antitoxin (TAT) hypersensitivity3 : if no hypersensitivity, give single dose TAT 3000U SC. • If cigarette burn, glove and stocking type burn or history given inconsistent with burn, consider child abuse, refer to hospital. • Review daily the child with burn/s not needing urgent attention: - - Dress wound daily with vaseline® gauze dressing. If pain/anxiety with dressing changes, give paracetamol 15mg/kg (up to 1g) PO 1 hour before changing dressing. - - Refer if infection likely (skin red, warm, painful), rash develops, pain despite medication or burn not healing. Decide on maintenance fluid2 rate Weight 24 hour fluid need 10-20kg 1000mL + (50mL for every kg body weight over 10kg) e.g.: if 14kg: 1000mL + (50 x 4) = 1200mL/24 hours ≥ 20kg 1500mL + (20mL for every kg body weight over 20kg) Up to 2000mL in girls and 2500mL in boys e.g.: if 23kg: 1500mL + (20 x 3) = 1560mL/24 hours Give urgent attention to the child with burn/s and any of: • Electric/chemical burn • Full-thickness burn (white/black, painless, leathery, dry) • Partial thickness burn (pink/red, blisters, painful, wet) > 10% TBSA • Likely inhalation burn (burns to face/neck, hoarse, stridor or black sputum) • Circumferential burn of chest/limbs • Temperature ≥38°C • Sudden skin swelling with redness, pain or warmth • Burn of face, hand, foot, genitals, joint • ≥ 2 of: 1) cold hands/ feet, 2) weak/fast pulse, 3) capillary refill time1 > 3 seconds, 4) decreased level of consciousness: shock likely Management: • Remove burnt/hot and tight clothing. Cool burn with water or wet towel for 30 minutes unless ≥ 20% TBSA burn. Avoid hypothermia. • If burn > 10% TBSA, inhalational burn, oxygen saturation ≤ 92%, drowsy/confused, give face mask oxygen 5L/minute. • Give IV fluid: - - If shock likely, assess and manage child's fluid needs 129. If TBSA ≥ 20%, give normal saline 20mL/kg IV bolus. - - If > 10% TBSA: give normal saline IV 4mL x weight(kg) x %TBSA over first 24 hours. Give half this volume in first 8 hours from time of burn. If delay in transfer > 8 hours from time of burn: give the second half of the fluid volume over the next 16 hours. - - In addition, begin maintenance fluids2 according to table below. • Give paracetamol 20mg/kg (up to 1g) and then 15mg/kg 4 hourly PO. If severe pain, give morphine sulphate 0.4mg/kg PO 4 hourly as needed. Monitor breathing, if respiratory rate decreases or oxygen saturation < 92%, give face mask oxygen 5L/minute. • Clean burn with water or normal saline, remove loose/dead skin and apply thin film of silver sulfadiazine 1% or fusidic acid 2% cream. - - If hospital transfer within 12 hours, no need to apply dressing. Wrap child in clean dry sheets and keep warm. - - If delayed > 12 hours, apply vaseline® gauze and cover with dry gauze. - - If full thickness/>10%TBSA burn, cover with vaseline® gauze occlusive dressing and cover with plastic wrap (cling film). • Give tetanus toxoid 0.5mL IM if none in past 5 years. If unavailable, check for tetanus antitoxin (TAT) hypersensitivity3 : if no hypersensitivity, give single dose TAT 3000U SC. • Reassess airway, breathing and circulation hourly 127. • If other injuries, manage 132. • Check fingerprick glucose: if < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose4 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose4 bolus. • Refer urgently. How to calculate %TBSA of burn Front Back 4.5% 4.5% 7% 8% 8% 18% 4.5% 4.5% 7% 8% 8% 18% Child's open hand (area of palm) represents is 1% TBSA. Do not include simple erythema (redness) in calculation. 1 Capillary refill time: hold hand/foot higher than level of heart. Press soft pad of finger/toe until it turns pale, then release pressure and note time taken for colour to return. 2 To make 1000mL: mix 500mL 5% DW + 500mL DNS + 5 vials of 40% glucose (or mix 500mL 5% DW + 500mL NS + 9 vials of 40% glucose). 3 Inject 0.1mL TAT SC and 0.1mL normal saline at separate site as control: if wheal with redness develops around TAT site, child has TAT hypersensitivity. Refer to hospital. 4 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline).
  • 134. Child 134 Fever Approach to the child with fever (temperature ≥ 38°C now or in the past 3 days) not needing urgent attention • If lumps/swellings in neck, axilla or groin 136, ear pain 138, sore throat 139, cough 140], abdominal pain/swelling 143, diarrhoea 144, urinary symptoms 145, limping/difficulty moving limb 146. • Give paracetamol 15mg/kg QID PO as needed for up to 5 days. Do a peripheral blood film examination or a malaria rapid diagnostic test Plasmodium vivax Give chloroquine: 16.6mg/kg (up to 1g) PO initially, then 8.3mg/kg (up to 500mg) at 6, 24 and 48 hours (total of 4 doses) and primaquine 0.25mg/kg daily PO for 14 days. • Give artemether/lumefantrine 20/120mg BID PO for 3 days according to weight: - - 15-24kg: 2 tablets; - - 25-34kg: 3 tablets; - - ≥ 35kg: 4 tablets - - Also give single dose primaquine 0.25mg/kg PO. Advise patient to return if no better. Plasmodium falciparum Both Plasmodium falciparum and Plasmodium vivax • Report. Delouse, shave hair and change clothes. • First insert IV line, then give procaine penicillin5 200 000-400 000IU IM. Monitor for reaction every 15 minutes for next 2 hours, then every 30 minutes for next 4 hours: if drop in BP, increased pulse rate, collapse, give 20mL/kg normal saline bolus. • Repeat peripheral blood film after 12 hours: - - If negative: give tetracycline 250mg TID PO for 3 days or erythromycin 10mg/kg TID PO for 3 days. - - If positive: repeat procaine penicillin5 and monitoring as above, every 12 hours until blood film negative. • Advise family members to wash well, reduce crowding and wash clothes. • If no overnight facilities, refer to hospital. • If none of above, advise cold compresses and review after 2 days. • If cause uncertain, refer. Positive for malaria Manage according to type of parasite/s seen: Positive for Borrelia (relapsing fever) If intermittent fever with any of: headache, lives in overcrowded setting, poor personal hygiene or body lice, typhus fever likely: • Give doxycycline for 7-10 days according to weight: - - < 45Kg: 2.2mg/kg (up to 200mg) BID PO - - ≥ 45kg: 100mg BID PO • Or give chloramphenicol 25mg/kg QID PO for 7 days. If persistent fever with any of: diarrhoea followed by constipation or poor food hygiene, typhoid fever likely: give ciprofloxacin 25mg/kg BID PO for 10-14 days or amoxicillin 10mg/ kg TID PO for 14 days. If fever ≥ 2 weeks, exclude TB and test for HIV. Negative for malaria & Borrelia6 Ask about pattern of fever, personal hygiene, headache, diarrhoea/constipation and look for lice on body: Give urgent attention to the child with a fever (temperature ≥ 38°C now or in the past 3 days) and any of: • Just had convulsion 130 • Decreased level of consciousness • Headache • Neck stiffness • Purple/red rash that does not disappear with pressure • Increased respiratory rate and/or difficulty breathing 140 • Tenderness right lower abdomen, appendicitis likely • Jaundice • Little or no urine 145 • Features of rheumatic fever1 • Previous rheumatic fever or known with rheumatic heart disease Manage and refer urgently: • If decreased level of consciousness, assess and manage airway, breathing and circulation 127. • Assess and manage child’s fluid needs 129. • Check fingerprick glucose: if glucose if < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose2 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose2 bolus. • If headache, decreased level of consciousness, neck stiffness, and/or purple/red rash, meningitis likely, give ceftriaxone 100mg/kg (up to 2g) IV/IM. • If appendicitis likely, give ceftriaxone 100mg/kg (up to 2g) IV/IM. • If malaria is suspected/confirmed3 : give artesunate 3mg/kg IM or artemether 3.2mg/kg IM. • If rheumatic fever likely, give benzathine benzylpenicillin4 IM according to weight: < 20kg, 600 000 units and if ≥ 20kg, 1.2 million units and report as a reportable disease. • Give paracetamol 15mg/kg (up to 1g) PO. 1 ≥ 2 of: joint pain/swelling that moves from joint to joint, strange movements of limbs/face, lumps over joints/tendons, rash (round pink lesions with pale centre. 2 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline). 3 Do a peripheral blood film examination or a malaria rapid diagnostic test. 4 If penicillin allergy, refer to hospital for doctor decision. 5 If penicillin allergy (anaphylaxis, urticaria, angioedema), give instead single dose tetracycline 250mg PO or single dose erythromycin 10mg/ kg PO. 6 Widal and Weil felix tests not recommended, as not specific and do not show new infection.
  • 135. Child 135 Headache Give urgent attention to the child with headache and any of: • Sudden severe headache • Headache/vomiting on awakening or waking from sleep • Headache getting worse and more frequent • Temperature ≥ 38°C • Decreased level of consciousness • Neck stiffness/meningism • Head tilted to one side (torticollis) • Pupils different size • Weakness of arm or leg • Vision problems (e.g. double vision) • Head trauma in last week 132 • Abnormally large head • Elevated BP1 Manage and refer urgently: • If neck stiffness/meningism or decreased level of consciousness, meningitis likely: give ceftriaxone 100mg/kg (up to 2g) IV/IM. • If malaria is suspected/confirmed1 : give artesunate 3mg/kg IM or artemether 3.2mg/kg IM. • If temperature ≥ 38°C 134. • Give paracetamol 15mg/kg (up to 1g) PO. Approach to child with headache not needing urgent attention Is headache throbbing, disabling and recurrent with nausea/vomiting or light/noise sensitivity, that resolves completely within 72 hours? Migraine likely • Give immediately and then as needed: paracetamol 15mg/kg (up to 1g) QID PO or if ≥ 20kg and able to swallow tablet, ibuprofen2 200mg TID PO with meals. Advise to return if no better after 24 hours and refer to hospital. • Advise child/caretaker with migraine: - - Recognise migraine early and rest in dark, quiet room. - - Draw up a headache calendar to identify and avoid triggers like lack of sleep, stress, prolonged screen time, hunger and some food or drink. - - Migraine may occur at start of menstrual period. Reassure. - - Give letter with advice on care if migraine occurs at school. • If ≥ 2 attacks/month or no response to treatment, refer to hospital. Sinusitis likely • Give paracetamol 15mg/kg (up to 1g) QID PO as needed for up to 5 days. • Give normal saline drops into nostrils as needed. • If no better, give oxymetazoline 0.025% 2 drops TID into each nostril for up to 5 days. • If symptoms > 10 days: give amoxicillin3 50mg/kg (up to 1g) BID PO for 10 days. • If > 1 episode, test for HIV. • If poor response to antibiotic or > 4 episodes per year, refer to hospital. • If swelling around sinus/eye or tooth infection, refer same day to hospital. Consider tension headache and muscular neck pain Tightness around head or generalised pressure-like pain Tension headache likely • Give paracetamol 15mg/kg (up to 1g) QID PO as needed for up to 5 days. • Do vision test, if problem, refer to hospital. Constant aching neck pain, tender neck muscles Muscular neck pain likely • Give paracetamol 15mg/kg (up to 1g) QID PO as needed for up to 5 days. • Advise sleeping on different pillow, avoid prolonged screen time (TV, cellphones and computers) and correct posture. Yes Yes No No Pain over cheeks, thick nasal (or postnasal) discharge, recent common cold, headache worse on bending forward? If unsure or poor response to treatment refer to hospital. 1 Do a peripheral blood film examination or a malaria rapid diagnostic test. 2 Avoid if asthma, heart failure or kidney disease. 3 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give instead erythromycin 12.5mg/kg (up to 500mg) QID PO for 5 days.
  • 136. Child 136 Lumps/swellings in neck, axilla or groin Give urgent attention to the child with lumps/swellings in groin: • Severe abdominal pain, vomiting or not passing stool, incarcerated/strangulated inguinal hernia likely Refer urgently. Approach to the child with lumps/swellings in neck, axilla or groin not needing urgent attention: • First exclude thyroid mass and hernia: - - Lump in neck that moves on swallowing, thyroid mass likely: refer to hospital. - - Lump in groin that bulges on crying/coughing/passing stool, inguinal hernia likely: refer to hospital. • If none of the above, a lump/swelling 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)? Localised lymphadenopathy: is lymph node hot, red and painful? Generalised lymphadenopathy • Look for likely cause: check face, skin, gums/teeth and throat. If sore throat 139. • If lymph node in groin and if sexually active, treat child and partner for lymphogranuloma venereum 36. If child abuse suspected, refer to hospital. Bacterial lymphadenitis likely • If painful neck lymphadenopathy with sore throat, tonsillitis likely 139. • Give amoxicillin 30mg/kg (up to 500mg) TID PO for 5 days. If penicillin allergy (previous anaphylaxis, urticaria or angioedema), give instead erythromycin 12.5mg/kg (up to 500mg) QID PO for 5 days. • If poor response to treatment after 2 days, change amoxicillin to cephalexin 12-25mg/kg (up to 500mg) QID for 7 days. • Review in 2 weeks: if no better, refer to hospital. Generalised lymphadenopathy If local cause found: • Treat the cause. • Advise to return in 4 weeks if no better on treatment and refer to hospital. • If lymph node > 1cm persists for > 2 weeks, refer to hospital. • Advise to return if new symptoms or lymph nodes grow. Refer to hospital. If no cause found: • If close TB contact or TB symptoms (cough or fever ≥ 2 weeks, not growing well/losing weight, tired/less playful), exclude TB. • If status unknown, test for HIV. If HIV positive, manage according to national HIV programme guidelines. • If none of the above: Localised lymphadenopathy Any of: weight loss, fever, night sweats, lymph node growing quickly, weakness, pallor1 ? Yes Yes No No 1 If child’s palm significantly less pink than your own.
  • 137. Child 137 Pallor Give urgent attention to the child with a low Hb and/or pallor and any of: • Hb < 7g/dL • Jaundice • Swollen legs • Widespread/easy bruising • Increased respiratory rate • Increased pulse rate • Palpitations or chest pain • Bone or joint pain • Lethargy or decreased level of consciousness • Purple/red rash that does not disappear with pressure Manage and refer urgently: • If increased respiratory rate, give oxygen 2L/minute via nasal prongs. • Check for malaria2 : if malaria test positive, give artesunate 3mg/kg IM or artemether 3.2mg/kg IM. This refers to the child with pale palms1 and/or conjunctiva. If possible, check Hb: if Hb < 11g/dL, child has anaemia. Approach to the child with pallor not needing urgent attention Are laboratory services available to take blood for complete blood count (CBC)? 1 If child’s palm significantly less pink than your own. 2 Test for malaria with parasite slide microscopy or if unavailable, rapid diagnostic test. 3 MCV: Mean Corpuscular Volume. The MCV helps to decide the underlying cause of anaemia and can be found on FBC result sheet. Check if MCV high, low or normal compared to the reference range for age of child. No Yes Take blood for complete blood count (CBC) and manage further according to MCV3 result: Iron deficiency anaemia likely • Deworm: give single dose albendazole 400mg PO every 6 months. • Give ferrous gluconate or ferrous lactate or ferrous sulphate according to weight TID PO with food. Check Hb monthly. Continue treatment until Hb ≥ 11g/dL: Weight (kg) Ferrous gluconate elixir (30mg iron per 5mL) Ferrous lactate drops (25mg iron per 1mL) Ferrous sulphate tablets (60mg iron per tablet) 10-25kg 5mL TID PO 0.9mL TID PO - ≥ 25kg - - 1 tablet TID PO • If girl who has started menstruation, ask about heavy bleeding and/clots. If problem 42. • If no response to treatment after 2 months, refer to hospital. MCV3 low MCV3 normal Systemic disease or long-term health condition likely • Exclude TB and HIV. • If no cause found, refer to hospital. MCV3 high Folate and/or vitamin B12 deficiency likely Start treatment and refer to hospital: give folic acid 5mg daily PO and vitamin B12 500mcg IM monthly.
  • 138. Child 138 Ear symptoms/difficulty hearing Itchy ear Is ear itchy, painful, discharging or is there difficulty hearing? Discharge from ear3 Discharge ≥ 2 weeks or hole in eardrum © University of Cape Town Chronic suppurative otitis media likely • Clean ear1 . • Apply hydrogen peroxide solution 3% 5-10 drops BID topically to affected ear for 5 days. • Give amoxicillin2 50mg/kg (up to 1g) TID PO for 7-10 days. • If poor response to treatment, test for HIV and TB. • Refer to hospital if: - - No better after 4 weeks - - Large hole in drum - - Difficulty hearing • Refer to hospital same day if: - - Neck stiffness - - New pain in or behind ear - - Yellow/white deposit on eardrum, cholesteatoma likely Foreign body Wax Discharge for ≤ 2 weeks • Ear canal not red/swollen. • Able to view eardrum? Painful ear No Pain > 2 days or pain waking at night? Yes Yes Yes No • Give paracetamol 15mg/kg QID PO for 5 days as needed. • Review in 2 days if no better. No Has temperature been ≥ 38°C in last > 2 days? • Syringe ear4 with warm water. • Avoid syringing and refer to hospital if: - - Hole in eardrum - - Grommets - - Battery/ food in ear. - - Recent trauma to head or ear - - Neck stiffness Syringe ears4 with warm water unless child has grommets/ uncooperative/ has chronic suppurative otitis media. Fluid behind eardrum Otitis media with effusion likely • Keep ear dry. • Advise that this usually resolves on its own. • If communication problem, refer to hospital for hearing test. • If concerns about hearing remain after 3 months or if child clumsy/poor balance, refer to hospital. Red bulging eardrum © University of Cape Town Acute otitis media likely • Give paracetamol 15mg/kg (up to 1g) QID PO for 5 days as needed. • Give amoxicillin2 50mg/kg (up to 1g) TID PO for 7-10 days. • Clean ear1 if discharge and avoid getting ear wet. • If > 1 episode, test for HIV. • Refer to hospital same day if: - - No response to treatment or > 5 episodes per year. • Refer same day if: - - Painful swelling behind ear, mastoiditis likely - - Neck stiffness • If treated above but communication problem present, refer to hospital for hearing test. Ear canal red/swollen (pus may be present) © University of Cape Town Otitis externa likely • Clean ear1 . • Apply hydrogen peroxide solution 1.5% 5-10 drops BID topically to affected ear for 5 days. • Give paracetamol 15mg/kg (up to 1g) QID PO for 5 days as needed. • If severe pain, firm red swelling behind ear or temperature ≥ 38°C, give amoxicillin2 50mg/kg (up to 1g) TID PO for 7-10 days. • If blisters on ear, herpes zoster likely, refer to hospital. Difficulty hearing • If on drug resistant TB medication, discuss with TB health worker. • If itchy or painful ear or discharge from the ear, see left algorithm/s. • Look in ear for foreign body, wax or fluid behind eardrum. If normal looking ear, refer to hospital for hearing test. 1 Cleaning the ear (dry mopping): roll a piece of clean soft tissue into a wick. Insert wick into ear with twisting action. Remove 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. 2 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give instead erythromycin 12.5mg/kg QID PO for 7-10 days. 3 If child has grommets (small tubes in eardrum) and purulent discharge persists > 2 weeks, refer to hospital. 4 How to syringe an ear: fill a 50-200mL syringe with warm water. Ask child/caretaker to hold container under ear to catch water. Pull ear upwards and backwards to straighten ear canal. Place tip of syringe at opening (no further than 8mm into canal) and spray water upwards into canal. Check after syringing to see if wax cleared. • Stop and refer to hospital if unsuccessful after 3 attempts/ causes pain or if foreign body remains in ear. • If no better, refer to hospital for hearing test.
  • 139. Child 139 Mouth and throat symptoms Give urgent attention to the child with mouth and throat symptoms with any of: • Unable to open mouth or swallow at all • Red swelling blocking airway Refer urgently. Assess the child with mouth and throat symptoms not needing urgent attention Examine mouth and throat for a red throat, white patches, blisters or ulcers. Red throat Pus or white patches on tonsils? White patches on cheeks, gums, tongue, palate, or cracks in corners of mouth. Oral thrush/candida likely • Give nystatin suspension 1mL QID PO after meals for 7 days. Keep inside mouth for as long as possible. • Give paracetamol 15mg/kg (up to 1g) QID PO as needed for up to 5 days. • If status unknown, test for HIV. If HIV positive, manage according to national HIV programme guidelines. If difficulty/painful swallowing or refusing to eat, oesophageal candida likely. Refer to hospital. Any of runny nose, cough, hoarseness, conjunctivitis or diarrhoea? Herpes simplex likely • Apply vaseline® to blisters on outside of mouth to prevent spread. • Give paracetamol 15mg/kg (up to 1g) QID PO as needed for up to 5 days. • If HIV or extensive herpes (and < 72 hours from onset), give aciclovir 20mg/kg (up to 800mg) QID PO for 7 days. • If extensive/recurrent or no better after 2 weeks, refer to hospital. • If status unknown, test for HIV. If HIV positive, manage according to national HIV programme guidelines. Groups of painful blisters on lips/mouth Painful ulcer/s with central white patch Aphthous ulcer/s likely • Give paracetamol 15mg/ kg (up to 1g) QID PO as needed for up to 5 days. • Rinse with salt water1 for 1 minute BID. • If recurrent, consider HIV. • If large (> 1cm) or not healed within 3 weeks, refer to hospital. Bacterial tonsillopharyngitis likely • Give paracetamol 15mg/kg (up to 1g) QID PO as needed for up to 5 days. • Give single dose benzathine benzylpenicillin2,3 < 30kg, give 600 000 units IM or ≥ 30kg, give 1.2 million units IM or phenoxymethylpenicillin2 250mg BID PO for 10 days. • If mild, fine red rash after antibiotic, glandular fever likely. - - Stop antibiotic. Reassure will resolve spontaneously. - - Child may return to school when better but can only resume sporting activities > 3 weeks from onset of illness. • If ≥ 5 episodes per year or persistent snoring, refer to hospital. Give bland, soft foods and advise to keep mouth and teeth clean by brushing and rinsing regularly. Viral tonsillo- pharyngitis likely • Give paracetamol 15mg/kg (up to 1g) QID PO as needed up to 5 days. • Salt water gargle1 may help. • Explain that antibiotics are not necessary. Yes Yes 1 Mix ½ teaspoon of salt in ½ cup of lukewarm water. 2 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give instead erythromycin 12.5mg/kg (up to 500mg) QID PO for 5 days. 3 For benzathine benzylpenicillin 1.2 million units injection: dissolve benzathine benzylpenicillin 1.2 million units in 3.2mL lidocaine 1% without adrenaline. No No Advise to return to immediately if any of the following develop: painful or swollen joint/s, strange movements of limbs or face, lumps over joints/tendons or rash (round lesions with pale centre) to exclude rheumatic fever 134.
  • 140. Child 140 Cough and/or breathing problems The child with breathing problems may have noisy breathing, wheeze, grunting, snoring or stridor (noisy, high-pitched breathing). If child not breathing 127. Give urgent attention to the child with cough and/or breathing problems and any of: • Lower chest indrawing • Nasal flaring • Grunting • Blue lips/tongue • Oxygen saturation ≤ 92% • Stridor (noisy, high-pitched breathing) • Decreased level of consciousness/ lethargy • Recent episode of choking • Restless or irritable • Known heart problem Manage and refer urgently: • If wheeze 141. • Give oxygen 2L/minute via nasal prongs or 5L/minute via face mask. • Check finger prick glucose: - - If < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose1 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose1 bolus. - - If ≥ 200mg/dL, diabetic ketoacidosis likely. Assess fluids needs 129 and refer urgently. • Give ceftriaxone 80mg/kg (up to 1.5g) IV/IM. • If stridor (with no recent episode of choking), encourage caretaker to keep child calm. - - Give dexamethasone 0.6mg/kg IM or prednisolone 2mg/kg (up to 60mg) PO and - - Nebulise 1mL adrenaline (1:1000) in 5mL normal saline with oxygen 8L/minute, every 15 minutes until stridor disappears. Monitor closely for at least 3 hours. • If sudden difficulty breathing and generalised itchy rash or face/tongue swelling, anaphylaxis likely: give adrenaline (1mg/mL, 1:1000) 0.3mL IM into mid-outer thigh. If no better, repeat every 5 minutes. Give normal saline 20mL/kg IV bolus. Also give diphenhydramine 1mg/kg IM/IV (up to 50mg). • Refer urgently. 1 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline). 2 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give instead erythromycin 12.5mg/kg (up to 500mg) QID PO for 5 days. 3 Episodes where breathing stops > 10 seconds. 1 episode of cough (or breathing problems) < 2 weeks Is respiratory rate increased (≥ 25 breaths/minutes if 5-12 years old or ≥ 20 breaths/minute if ≥ 12 years old)? Yes Pneumonia likely • Give amoxicillin2 30mg/kg (up to 1g) TID PO for 7 days. • Give paracetamol 15mg/kg (up to 1g) QID PO as needed for 5 days. • Advise to return if condition worsens. • Review after 2 days: if respiratory rate still increased, refer to hospital. No • Exclude TB. • If recent common cold: - - If wet cough ≥ 4 weeks, chronic bronchitis likely, refer to hospital. - - If dry cough, post-infectious cough likely: should resolve by 8 weeks. • If persistent snoring with poor sleep/apnoea3 , refer to hospital. Runny/blocked nose Common cold likely • Check ears 138, throat 139. • Reassure caretaker antibiotics not needed. • Advise to drink warm liquids to relieve symptoms. Barking cough, may be hoarse Viral croup likely • Give single dose dexamethasone 0.6mg/kg PO or prednisolone 2mg/kg (up to 40mg) PO. • Advise to return immediately if worse or stridor develops. Repeated episodes or cough (or breathing problems) ≥ 2 weeks If none of above and repeated episodes of wheeze 142. If cause uncertain or not growing well, chest deformity, cough > 8 weeks cough worse despite treatment, refer to hospital. Approach to the child with cough and/or breathing problems not needing urgent attention: • Approach to the child with cough and/or breathing problems not needing urgent attention: • Reduce indoor pollution (rural setting) and avoid smoking (urban setting). • If wheeze 141. If breathless on exertion, refer same day. • If coughing attacks with “whoop”on breathing in, pertussis likely: give erythromycin 12.5mg/kg (up to 500mg) QID PO for 10 days, report as reportable disease and isolate for 2 days. • Ask about duration and number of episodes:
  • 141. Child 141 Wheeze Give urgent attention to the child with wheeze and any of: • Oxygen saturation < 90% • Marked accessory muscle use1 • Significantly reduced breath sounds • Unable to talk or only able to talk in single words • Agitation or confusion Manage as severe asthma: • Sit child up and give oxygen via face mask and reservoir bag or nasal prongs and • Give salbutamol via spacer 1200mcg (12 puffs) every 20 minutes and • Give prednisolone 2mg/kg (up to 60mg) PO. If unable to take orally, give hydrocortisone 4-5mg/kg (up to 250mg) slow IV or dexamethasone 0.6mg/kg (up to 20mg) IM. • If child presents with absent air entry or no response after 3 doses of salbutamol, give adrenaline (1:1000) 0.01mL/kg (up to 0.4mL) IM/SC every 15-20 minutes. If pulse rate ≥ 180 beats/minute, avoid repeating adrenaline. • Refer urgently to hospital while continuing to give salbutamol puffs. 1 Accessory muscle use is any of: subcostal recession, intercostal recession, tracheal tug, use of neck muscles. 2 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give erythromycin 12.5mg/kg (up to 500mg) QID PO for 5 days. Approach to the child with wheeze not needing urgent attention Manage according to severity of symptoms: • Oxygen saturation 91-94% • Moderate accessory muscle use1 • Wheeze with reduced breath sounds • Able to talk only in phrases Mild asthma likely • Give salbutamol via spacer 1200mcg (12 puffs) every 20 minutes. • Assess response after 20 minutes, repeat for 3 doses if needed: Good response Wheeze improved, no accessory muscle use1 , oxygen saturation ≥ 94% and able to drink and talk Poor response after 1 hour (3 doses), reclassify. Poor response after 1 hour • Refer to hospital while continuing oxygen and salbutamol via spacer 1200mcg (12 puffs) every 20 minutes. • If child’s condition deteriorates despite treatment, consider adrenaline (1:1000) 0.01mL/kg (up to 0.4mL) IM/SC every 15-20 minutes. If pulse rate ≥ 180 beats/minute, avoid repeating adrenaline. • Discharge on salbutamol 2-6 puffs inhaled every 4-6 hours as needed. • If known asthma, also give prednisolone 1mg/kg (up to total daily dose 40mg) BID PO for 4 days. • If respiratory rate ≥ 25, also give amoxicillin2 30mg/kg TID PO for 5 days. • If not known with asthma and wheeze recurrent 142. Moderate asthma likely • Give oxygen via face mask and reservoir bag or nasal prongs and • Give salbutamol via spacer 1200mcg (12 puffs) every 20 minutes and • Give single dose prednisolone 2mg/kg (up to 60mg) PO. If unable to take orally, give single dose hydrocortisone 4-5mg/kg (up to 250mg) slow IV or dexamethasone 0.6mg/kg (up to 20mg) IM. ≥ 1 of above None of the above
  • 142. Child 142 Recurrent wheeze or cough 1 Acute exacerbations infrequent and not severe (child not hospitalised) and in past 4 weeks: daytime cough, wheeze or difficulty breathing < twice a week; able to run/play without easily tiring due to asthma; salbutamol needed < twice a week; little or no night waking /coughing due to asthma. 2 Wheeze improves 15 minutes after salbutamol via spacer 600mcg (6 puffs). If no better, child is not bronchodilator responsive. Do symptoms persist for > 10 days after a common cold or are there symptoms between colds? Symptoms remain the same. Symptoms improve with trial of treatment and worsen when treatment is stopped. Refer to hospital. Asthma likely • Continue beclomethasone 200mcg BID inhaled and • Give salbutamol via spacer 100-200mcg (1-2 puffs) QID inhaled as needed. • If symptoms controlled1 reduce beclomethasone to 100mcg BID inhaled. Recurrent virus-induced wheeze likely • If wheeze is bronchodilator responsive2 give salbutamol via spacer 100-200mcg (1-2 puffs) QID inhaled when needed for 5 days. • Check ears 138, throat 139. Refer to hospital. Does child have recurrent wheeze? Yes Yes Yes ≥ 1 of above No No No Approach to the child with recurrent wheeze or cough First exclude TB. While excluding TB, ask about the following: • History of eczema/allergic rhinitis • Parents with history of eczema/allergic rhinitis/asthma • > 3 episodes wheeze per year • Wheeze episode needing hospital admission • Symptoms worse at night and in early morning • Symptoms triggered by: smoking, pets, pollen, perfume, paint, hairspray, cleaning agents, change in weather or season, exercise, emotion, laughter or stress None of above: are symptoms triggered by common colds? Give a trial of treatment for 2 months: • Give inhaled corticosteroid: beclomethasone 200mcg BID inhaled and • Give salbutamol via spacer 100-200mcg (1-2 puffs) QID inhaled as needed. • Demonstrate inhaler technique as below and encourage child/caretaker to identify and avoid triggers. • Assess response to treatment after 2 months: How to use an inhaler with a spacer • Prime spacer initially with 10 puffs of medication. When medication is finished, replace only the canister. Clean spacer monthly: remove canister and wash spacer with soapy water. Do not rinse with water. Allow to drip dry (no need to re-prime). • Demonstrate inhaler technique 2-3 times until child and/or caretaker understand. Then ask child and/or caretaker to show you how to use it. 1 • Remove cap from inhaler and spacer. • Shake inhaler for 5 seconds and insert into spacer. 2 Put spacer into mouth and close lips around it and form seal with lips around mouthpiece. If needed, make a spacer from a plastic bottle 81. 3 Press pump down once and allow 6 deep breaths before continuing. 4 Remove inhaler and spacer and wait for 30 seconds before repeat. Repeat for each puff prescribed. 5 Rinse mouth after using inhaled corticosteroids (beclomethasone).
  • 143. Child 143 Abdominal symptoms Give urgent attention to the child with an abdominal symptom: • Guarding, rebound tenderness or rigidity of abdomen1 , peritonitis likely • Tender in right lower abdomen and vomiting, appendicitis likely • Cramping pain and jelly-like stool • No stool/wind for 24 hours and vomiting • Bile-stained vomiting • Tender, elevated testes • Painful groin/umbilical swelling • Rash and joint pain • Vomiting, deep sighing respiration, fatigue, acidosis likely Manage and refer urgently: • Check fingerprick glucose: - - If ≥ 200mg/dL, diabetic ketoacidosis likely. Assess fluids needs 129 and refer urgently. - - If < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose2 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose2 bolus. • Assess and manage child’s fluid needs 129. • Keep nil per os. Give maintenance fluid3 IV according to table. • If peritonitis or appendicitis likely, give ceftriaxone 80mg/kg (up to 1.5g) IV/IM. Approach to the child with abdominal symptom not needing urgent attention • If recent injury/trauma 132. If temperature ≥ 38°C or history of fever 134. Check throat: if white patches on throat 139. Check urine: if burning urine or nitrites/leucocytes/blood on dipstick 145. • If close TB contact or TB symptoms (cough or fever ≥ 2 weeks, not growing well/losing weight, tired/less playful), exclude TB. • Is there abdominal swelling? Is swelling localised or generalised? • Advise a high fibre diet (vegetables, fruit, wholemeal cereals and bran). • If no better despite diet change, refer to hospital. • Ensure 6 monthly deworming in place. If worms, give single dose albendazole 400mg PO. • Check growth (weight, height, MUAC): if growth problem 150. If pallor4 137. • Is child constipated: stools infrequent and any of: pain, impaction, involuntary leakage or voluntary withholding? • If girl and pain around time of period, dysmenorrhoea likely: - - Give ibuprofen5 400mg TID PO for 3 days. - - Reassure that is common and encourage to carry on with everyday activities. • If girl and sexually active: - - If lower abdominal pain and/or vaginal discharge, pelvic infection likely 36. - - If lower abdominal pain with amenorrhoea or vaginal bleeding 6-8 weeks after last period, ectopic pregnancy likely, refer to hospital. - - If child abuse suspected, refer to hospital. Yes Yes No No If cause unclear or not resolved, refer to hospital. Localised • If bulge on crying/ coughing/ passing stool in groin or umbilical area, hernia likely, refer to hospital. • If mass felt in abdomen, refer to hospital. Generalised • Exclude TB. • Do urine dipstick: - - ≥ 3+ protein, nephrotic syndrome likely, refer to hospital. • Assess growth (weight, height, MUAC): - - If growth problem 150. - - If growth normal, refer to hospital. 1 Guarding: abdominal muscles tense on palpation. Rebound tenderness: pain on quick release after pressing down slowly on abdomen. Rigidity: abdominal wall is hard/board-like. 2 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline). 3 To make 1000mL: mix 500mL 5% DW + 500mL DNS + 5 vials of 40% glucose (or mix 500mL 5% DW + 500mL NS + 9 vials of 40% glucose). 4 If child’s palm significantly less pink than your own. 5 Avoid if peptic ulcer, asthma or kidney disease. Decide on maintenance fluid3 rate Weight 24 hour fluid need 10-20kg 1000mL + (50mL for every kg body weight over 10kg) e.g.: if 14kg: 1000mL + (50 x 4) = 1200mL/24 hours ≥ 20kg 1500mL + (20mL for every kg body weight over 20kg) Up to 2000mL in girls and 2500mL in boys e.g.: if 23kg: 1500mL + (20 x 3) = 1560mL/24 hours
  • 144. Child 144 Diarrhoea Approach to the child with diarrhoea not needing urgent attention • Confirm child has diarrhoea: ≥ 3 watery or loose stools/day. Ask about duration of diarrhoea. • Do stool microscopy for ova or parasite and inflammatory cells. • Advise child to take more fluids, eat small frequent meals when able and avoid sweet/caffeinated/fizzy drinks. • Give oral rehydration solution to prevent dehydration. Positive If diarrhoea for > 2 weeks, test for HIV. Diarrhoea for > 2 weeks Knowing child’s HIV status helps in the management. Test for HIV. • Check ears 138, check urine 145. Assess growth (weight, height, MUAC): if growth problem 150. • If close TB contact or TB symptoms (cough or fever ≥ 2 weeks, not growing well/losing weight, tired/ less playful), exclude TB. • Give single dose vitamin A 200 000IU PO. • Give zinc 20mg daily PO for 14 days. Review stool microscopy result. If diarrhoea persists despite treatment or cause is not clear, refer to hospital. Review in 2 weeks if diarrhoea still present. Negative Diarrhoea for ≤ 2 weeks HIV negative/ unknown Amoebic trophozoite and RBC/WBC seen RBC/WBC only seen Ova or parasite only seen Avoid antibiotics. Avoid antibiotics. • Give metronidazole 7.5mg/kg (up to 500mg) TID PO for 5-7 days. • If no response after 2 days, add ciprofloxacin 6-10mg/kg (up to 400mg) BID PO for 5 days. Give ciprofloxacin 6-10mg/kg (up to 400mg) BID PO for 5 days. • If amoebiasis, give metronidazole 7.5mg/kg (up to 500mg) TID PO for 5-7 days. • If giardiasis, give single dose tinidazole 50mg/kg (up to 2g) PO. • If strongyloidiasis, give albendazole 400mg BID PO for 3 days. • If other parasites, albendazole 400mg daily PO for 3 days. HIV positive • Give routine HIV care according to national HIV programme guidelines. • Lopinavir/ritonavir can cause ongoing diarrhoea. • If ART not started or ART failed, treat for possible Isospora belli and microsporidiosis with co-trimoxazole 20mg/kg BID PO for 21 days and albendazole 400mg BID PO for 14 days. First assess and manage child's fluid needs 129. Give urgent attention to the child with diarrhoea and any of: • Guarding, rebound tenderness or rigidity of abdomen1 , peritonitis likely • Unable to drink • Shock or severe dehydration • Distended abdomen • Swelling of legs/ wasting • Large volumes of rice colored watery stool: cholera likely Manage and refer urgently: • Check fingerprick glucose: if < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose2 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose2 bolus. • If temperature ≥ 38°C or likely peritonitis, give ceftriaxone 80mg/kg (up to 1.5g) IV/IM. • If cholera likely: - - Report disease and isolate child and follow standard infection prevention precautions122. Assess and manage child’s fluid needs 129 and give doxycycline 6mg/kg daily PO for 3 days. - - Discuss with the head of the facility and/or Woreda Health Office and review after 6 hours: • If no dehydration and < 3 liquid stools in past 6 hours, consider discharge. Give enough ORS for home treatment for 2 days. Advise to return if vomiting, diarrhoea worsens or drinking/eating poorly. • If still dehydrated or > 3 liquid stools in past 6 hours, continue rehydration. If poor urine output, refer to hospital. 1 Guarding: abdominal muscles tense on palpation. Rebound tenderness: pain on quick release after pressing down slowly on abdomen. Rigidity: abdominal wall is hard/board-like. 2 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline).
  • 145. Child 145 Urinary symptoms The child with urinary symptoms may have pain on passing urine, urinating very often/large volumes, urgency, new incontinence, bed-wetting, bloody/brown urine, unable to pass urine or foul-smelling urine. Approach to the child with urinary symptoms not needing urgent attention • Check urine dipstick: look for blood, leucocytes and nitrites on dipstick. - - If glucose/ketones in urine, check finger prick glucose: if ≥ 200mg/dL, diabetic ketoacidosis likely. Assess fluids needs 129 and refer to hospital. - - Manage further according to results: Blood on dipstick, no leucocytes or nitrites Is there protein on urine dipstick? Leucocytes/nitrites on dipstick Urinary tract infection likely • Send urine for microscopy. • Give amoxicillin1 15mg/kg (up to 500mg) TID PO for 5 days. • Advise to wipe from front to back. • Encourage child to drink frequently. • Avoid irritant soaps and bubble baths. • If no response to treatment after 2 days, refer to hospital. • Recurrent urinary tract infections might indicate an abnormal urinary tract, if ≥ 2 urinary tract infections, refer to hospital for investigations once antibiotic complete. Refer to hospital. Schistosomiasis likely • Send urine for S. haematobium ova. • Give single dose praziquantel 40mg/kg (up to 3g) PO. • Advise to avoid contaminated water to prevent re-infection. • Review results in 3 days, repeat dipstick and refer if: - - Urine schistosomiasis test negative - - Blood not cleared - - Symptoms not resolved. • Advise to return if swelling of face or feet and refer to hospital. Has child been in a bilharzia area? Ask caretaker if aware of abuse of child. Ask child if anyone hurts or upsets him/her. If yes to either, child abuse likely, refer to hospital. No No Yes Yes No blood or leucocytes/nitrites Is bed-wetting a problem? No Yes Reassure and reassess in one week if not better. • If previously dry, ask about recent stressful events. Discuss possible solutions. If daytime incontinence, to finger prick glucose to exclude diabetes and refer. • Give advice: - - Reduce fluid intake during evening: avoid fluids 1 hour before bedtime. - - Teach child to wake with urination urge by initially waking him/her to urinate. - - Suggest a reward system like a star chart for a dry bed. - - Advise to avoid punishing child. - - Refer if above measures unhelpful. Give urgent attention to the child with urinary symptoms and any of: • Passing little amounts or unable to pass urine • Temperature ≥ 38°C/rigors/flank pain, pyelonephritis likely • Swelling of face/feet and either blood in urine or passing little amounts of urine, nephritis likely Management: • If nephritis likely and signs of fluid overload (increased pulse/respiratory rate or puffy eyes), give oxygen 2L/minute via nasal prongs and give furosemide 1mg/kg (up to 40mg) IV over 5 minutes (avoid IV fluids). Then check BP. If increased, give nifedipine 0.25mg/kg (up to 10mg) squirted into mouth. • If pyelonephritis likely, give ceftriaxone 80mg/kg (up to 1.5g) IV/IM. • Refer urgently. 1 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give erythromycin 12.5mg/kg QID PO for 7 days.
  • 146. Child 146 Leg symptoms/limp/walking problems Approach to the child with leg symptom not needing urgent attention • If any of: weight loss, night sweats, weakness, fatigue, generalised rash or early morning joint stiffness lasting > 15 minutes, refer to hospital. • Identify leg problem: Problem walking Is child limping? Leg swelling Ask about duration of limp. • If swelling of 1 leg and no history of injury, refer. • If swelling of both legs, do urine dipstick: Abnormal leg shape Limp < 48hrs Limp ≥ 48hrs Sprain/strain likely • Ensure can bear weight on leg, otherwise refer to hospital. • Rest and elevate leg. • Apply pressure bandage. • If skin marks, bruises of different ages or poor growth, suspect neglect and refer to hospital. • Advise child to move leg after 2-3 days if not too painful. • Give paracetamol 15mg/kg (up to 1g) QID PO as needed up to 5 days. If pain not responding to paracetamol, give ibuprofen3 200mg TID PO with food for up to 5 days. • Review after 1 week (or sooner if symptoms worsen): if no better, refer to hospital. • If bow-legs, look for forehead prominence, bowing of arms, bony lumps along ribcage. If present, rickets likely: refer to hospital. • If shape otherwise not normal, refer to hospital. • If injury 132. • If well and leg pain only at night and active during day, growing pains likely, reassure pain will resolve. • If leg pain occurs in day and night, refer to hospital. < 3+ protein Assess growth (weight, height, MUAC). Is there a growth problem? No No Yes Refer to hospital. Heart failure likely. Refer to hospital. Yes Severe acute malnutrition likely. Manage and refer urgently 150. ≥ 3+ protein Nephrotic syndrome likely. Refer to hospital. Leg pain Give urgent attention to the child with leg symptoms with any of: • Sudden refusal to sit, stand or walk • Sudden onset weakness in leg/s • Leg pain and temperature ≥ 38°C • Limping and weight loss/lethargy • Unable to bear weight after leg injury • Any of: strange movements of limbs or face, lumps over joints/tendons or rash (round pink lesions with pale centre), rheumatic fever likely Management: • If rheumatic fever likely, give benzathine benzylpenicillin1,2 IM according to weight: < 30kg, 600 000 units and if 30kg, 1.2 million units. • Refer urgently. 1 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), refer. 2 For benzathine benzylpenicillin 1.2 million units injection: dissolve benzathine benzylpenicillin 1.2 million units in 3.2mL lidocaine 1% without adrenaline. 3 Avoid if peptic ulcer, asthma or kidney disease.
  • 147. Child 147 Generalised rash Bumps become weeping blisters and crusts on face, scalp, trunk and limbs. © University of Cape Town Hyper-pigmented bumps, surrounding skin often hyper- pigmented (not on face) © University of Cape Town Chicken pox likely • Apply calamine lotion and give paracetamol 15mg/kg (up to 1g) QID PO for up to 5 days. If very itchy, give cetirizine, according to weight, until itch controlled (up to 2 weeks): 12-21kg: give 5mg daily PO, ≥ 21kg: give 10mg daily PO. • If rash extensive or child has HIV, give aciclovir 20mg/kg (up to 800mg) QID PO for 7 days. • If rash and surrounding skin red, painful and swollen with temperature ≥ 38°C, impetigo likely 148. • Refer to hospital if any of: - - Does not resolve by 10 days. - - Difficulty breathing - - Signs of meningitis (≥ 2 of: temperature ≥ 38°C, headache, decreased level of consciousness, neck stiffness) • If recurrent, test for HIV. • Highly contagious (spreads in air). - - Allow return to school once blisters crusted. - - Avoid contact with pregnant women. Papular pruritic eruption (PPE) likely • If HIV unknown, test for HIV. If HIV positive, manage according to national HIV programme guidelines. • Exclude scabies. • Apply hydrocortisone 1% cream in morning and moisturise with liquid paraffin at night until improvement. • Give cetirizine, according to weight, until itch controlled (up to 2 weeks): 12-21kg: give 5mg daily PO, ≥ 21kg: give 10mg daily PO. • Advise child/caretaker: - - Explain that PPE may be long- standing. - - May temporarily worsen on starting ART. - - Reduce exposure to insect bites. Scabies likely • Apply benzyl benzoate lotion 25% to whole body from neck to feet after hot bath and dry well. Wash off next day and repeat next night. Repeat treatment after 1 week. • Give cetirizine, according to weight, until itch controlled (up to 2 weeks): 12-21kg: give 5mg daily PO, ≥ 21kg: give 10mg daily PO. - - 12-21kg: 5mg, ≥ 21kg: 10mg • Treat all house members at same time. • Wash linen and clothes in hot water and expose bedding to direct sunlight. • Keep finger nails short and clean. • If blisters and yellow crusts appear, impetigo likely 148. If no response to treatment, refer to specialist for review. If patches of red, scaly, crusted skin in infant or dry scaly skin in older child, usually on flexor surfaces of elbows, knees and on scalp and neck, eczema likely. Urticaria likely • If recently started new medication, consider drug reaction. • Consider possible triggers1 . • Give cetirizine, according to weight, for itch (until 72 hours after resolution of wheals): 12-21kg: give 5mg daily PO, ≥ 21kg: 10mg daily PO. • If not better after 24 hours, refer to hospital within one month. • If repeated episodes, allergy likely. Refer to hospital. • Advise to return immediately if any symptoms of anaphylaxis occur. If sudden onset (few hours) of generalised itchy rash or face/tongue swelling and 1 or more of: 1) difficulty breathing, 2) fainting/ dizziness/collapse, 3) abdominal pain/vomiting, anaphylaxis likely: • Give adrenaline (1mg/mL, 1:1000) 0.3mL IM into mid- outer thigh. If no better, repeat every 5 minutes. • Give normal saline 20mL/kg IV bolus. • Also give diphenhydramine 1mg/kg IM/IV (up to 50mg). A widespread very itchy rash with burrows in web-spaces of hand and feet, axillae and genitalia. © St. Paul's Hospital Millennium Medical College Red raised wheals that appear suddenly, disappear and then reappear elsewhere. © St. Paul's Hospital Millennium Medical College 1 Possible triggers can be a viral infection, food (commonly peanuts, eggs milk, fish), medication or insect sting.
  • 148. Child 148 Localised rash • If itchy rash on scalp/neck, look for nits/eggs in hair. If found, lice likely. • If dry, itchy, scaly skin, usually on flexor surfaces of elbows, knees and on scalp and neck, eczema likely. • Manage according to presenting symptom/s: Vesicles, pimples (pustules) in centre © University of Cape Town Scaling moist lesions between toes and on soles of feet ProjectManhattan/Wikimedia Commons Ring shaped patches, red, scaly edge If rash extensive, recurrent or responds poorly to treatment, refer. Athlete’s foot likely Encourage open shoes/sandals. • Apply clotrimazole 2% cream BID topically for 2 weeks. • Avoid sharing towels/clothes. • Wash skin well before applying treatment and dry well between toes. Tinea (ring worm) likely • If multiple or large lesions, test for HIV. • If HIV positive, manage according to national programme guidelines. • Apply clotrimazole 2% cream 8 hourly for 2 weeks. • Avoid sharing towels/clothes. • Wash skin well before applying treatment. • If lesions on scalp or hair loss: 1 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give instead erythromycin 12.5mg/kg (up to 500mg) QID PO for 7-10 days. Look for blisters/honey coloured crusts and flaky/greasy crusts, flaky pink raised plaques Pus-filled blisters which dry to form honey coloured crusts © St. Paul's Hospital Millennium Medical College Impetigo likely • Keep nails short. Wash and soak sores in soapy water to soften and remove crusts. Cover draining lesions with saline- soaked gauze dressing. • Apply povidone iodine 5% cream TID topically and give cephalexin1 12-25mg/kg (up to 500mg) QID PO for 7-10 days or cloxacillin1 12.5-25mg/kg (up to 500mg) QID PO for 7 days. • If rash does not resolve completely, repeat treatment. • Look for cause: if scabies 147. Also consider eczema and insect bites. • Advise caretaker that impetigo is contagious: - - Ensure regular hand-washing to prevent spread. - - May return to school 1 day after starting antibiotic. • Refer if: - - Extensive lesions - - Cellulitis or abscess - - Temperature ≥ 38°C - - No better after the above treatment • Advise to return immediately if blood in urine or limb/face/ feet swelling and refer to hospital same day. Flaky or greasy crusts with underlying red base on face, forehead, behind ears, eyebrows, eyelids and nasal creases. May be itchy. © St. Paul's Hospital Millennium Medical College Seborrhoeic dermatitis likely • Reassure caretaker that it will resolve without treatment in few weeks/months. • If extensive and HIV status unknown, test for HIV. If HIV positive, manage according to national HIV programme. • Advise caretaker to: - - Trim nails and avoid scratching. - - Wash body with aqueous cream and avoid perfumed soap. • If in > 1 area, apply hydrocortisone cream 1% BID topically until improved. • If extensive and no response to hydrocortisone cream, refer. © University of Cape Town Tinea capitus likely Look hair and scalp symptoms page 149.
  • 149. Child 149 If brown hair has turned reddish or hair become sparse/brittle, assess growth (weight, height, MUAC): if problem 150. Does child have scale, itch, patches of hair loss or pimples/pustules? Itchy scaly patches or plaques • If flaky or greasy crusts with underlying red base, consider seborrhoeic dermatitis 148. • If patches of hair loss: Itchy scalp Look for lice or nits. If no lice/nits seen, exclude tinea capitus. © University of Cape Town Tinea capitus likely • Give griseofulvin 20-25mg/kg daily PO for 6-8 weeks or fluconazole 4-6mg/kg daily PO for 4 weeks. - - Use ketoconazole 2% shampoo twice a week to reduce sheddin of spores • Advise child/caretaker to avoid: - - Shaving head. - - Sharing combs and hairbrushes. Lice/nits likely • Apply malathion 1% shampoo to scalp after bath at night: Comb into hair repeatedly until whole scalp is covered: - - Dip a fine-toothed comb in vinegar and remove lice by combing entire head twice. - - Then rinse hair with lukewarm water and wash malathion out with normal shampoo. • Advise to: - - Avoid broken skin and contact with eyes. - - Wash bed linen in very hot water. - - Treat all household contacts. - - If lice/nits persist, shave hair. • Consider child abuse if lice on pubic, peri-anal areas or eyelashes /eyebrows, refer to hospital. No Yes Alopecia areata likely • Give betamethasone 0.1% gel to apply topically daily for 3 months. • If no response to treatment, refer to hospital. Patches of hair loss Is there scaling? Pimples/pustules © University of Cape Town Folliculitis likely • Keep area clean and dry. • If extensive or redness/pain/ swelling/temperature ≥ 38°C, give cloxacillin2 12.5-25mg/ kg (up to 500mg)QID PO or cephalexin2 12-25mg/kg (up to 500mg) QID PO for 5 days. • Wash hands regularly to prevent spread. Hair and scalp symptoms 1 If malathion 1% lotion unavailable: give benzyl benzoate lotion 25%. Apply benzyl benzoate to whole body from neck to feet after hot bath and dry well. Wash off next day and repeat next night. Put on cleaned washed clothes after treatment. Repeat treatment after 1 week. 2 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give instead erythromycin 12.5mg/kg QID PO for 5 days.
  • 150. Child 150 The underweight child Measure child's weight and height and calculate body mass index (BMI): weight (kg) ÷ height (m) ÷ height (m), then plot BMI 151 (if girl) or 152 (if boy). Also measure MUAC1 . Does child have swelling of both feet? Approach to the underweight child with one or more of: • Visible wasting • BMI below -2 line • Low MUAC1 (< 14cm in a child 5-9 years old or < 18cm in a child 10-14 years old). No Yes Yes Give routine malnutrition care 153. Refer to hospital for inpatient care. Fails the appetite test Fails the appetite test Passes the appetite test Is outpatient care available, home circumstances reliable and caretaker willing? No: does child a BMI below -3 line or very low MUAC1 (< 13cm in a child 5-9 years old or < 16cm in a child 10–14 years old)? Yes Severe acute malnutrition (SAM) likely No Moderate acute malnutrition (MAM) likely Do appetite test (see below). No: severe acute malnutrition (SAM) without medical complications. Do appetite test (see below). Give urgent attention to the child with severe acute malnutrition (SAM) with medical complications: • If fast breathing: give oxygen 2L/min via nasal prongs. • Manage and assess child's fluid needs 129. • If glucose < 54mg/dL give 10% glucose2 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still < 54mg/dL, repeat 10% glucose2 bolus. • Feed at least 2 hourly until transfer. If refusing, give sugar water3 via NGT. • Treat infection: give ceftriaxone 80mg/kg (up to 1.5g) IV/IM. • Give vitamin A: 200 000IU PO. • Keep warm: cover with blanket. • Refer urgently. Yes: severe acute malnutrition (SAM) likely 1 Mid upper arm circumference. 2 If 10% glucose unavailable: make up with 1 part 40% glucose and 3 parts normal saline or distilled water (e.g. 20kg child will need 100mL 10% glucose: mix 25mL 40% glucose and 75mL normal saline). 3 Dissolve 4 teaspoons of sugar (20g) into 200mL water. Does child have any of: • Vomits everything • Unable to eat/drink • Temperature < 35.5°C or ≥ 38°C • Glucose < 54mg/dL • Hb < 10g/dL • Increased respiratory rate • Diarrhoea (> 3 watery stools/ 24 hours) • Weeping skin lesions • Lethargy or decreased level of consciousness How to do an appetite test • Give Ready-to-use-Therapeutic-Food (RUTF/F75®/10% dextrose) according to weight (see table). • Test may take up to one hour. Do not force child to eat. Offer child plenty of water to drink. • If child finishes minimum amount of feed, s/he passes the appetite test. • If child does not finish minimum amount of feed: s/he fails the appetite test. Minimum amount to be given to child Body weight (kg) RUTF Imunut® Sachet (92g) F75® 10% dextrose2 15 -30 70g 200mL 200mL ≥ 30 92g 250mL 250mL
  • 151. Girl's BMI chart World Health Organization. BMI-for-age Girls 5-19 years (z-scores). 2007 5 to 19 years (z-scores) BMI (kg/m²) Age (completed months and years) -3 -2 -1 0 1 2 3 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 Months Years 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 12 14 16 18 20 22 24 26 28 30 32 34 36 12 14 16 18 20 22 24 26 28 30 32 34 36 Child 151
  • 152. Boy's BMI chart World Health Organization. BMI-for-age Boys 5-19 years (z-scores). 2007 5 to 19 years (z-scores) BMI (kg/m²) Age (completed months and years) -3 -2 -1 0 1 2 3 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 Months Years 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 12 14 16 18 20 22 24 26 28 30 32 34 36 12 14 16 18 20 22 24 26 28 30 32 34 36 Child 152
  • 153. Child 153 Malnutrition • Acute malnutrition likely if visible wasting, low BMI < -2 line or low MUAC1 (< 14cm in a child 5-9 years old or < 18cm in a child 10-14 years old). • Severe acute malnutrition likely if BMI < -3 line or very low MUAC1 (< 13cm in a child 5-9 years old or < 16cm in a child 10–14 years old) or if malnutrition with oedema. Advise the caretaker of child with acute malnutrition • Educate caretaker that good nutrition is vital for the normal function of the body. Refer to social worker and link with local NGOs. • Advise caretaker to give foods rich in protein3 , iron4 , vitamin A5 and C6 , dairy, vegetables and fruits. • Advise to feed child 5 times a day (3 meals with 2 nutritious snacks). Add a teaspoon of butter or vegetable oil to porridge. • Give hygiene advice: wash hands with soap and water regularly, especially when handling food/after using toilet. Wash fruit/vegetables and use boiled water if no access to clean water. • Refer for community health extension worker support and physiotherapy/occupational therapy for rehabilitation and physical and emotional stimulation. Treat the child with acute malnutrition • Check immunisations are up to date and give single dose vitamin A 200 000IU PO and albendazole 400mg PO. • If severe acute malnutrition without danger signs, also give amoxicillin7 30-40mg/kg (up to 1g) BID PO for 5 day at diagnosis. • Refer to Therapeutic Feeding Unit/Center (TFU/TFC): ensure a monthly supply of correct product and amount: enriched porridge plus energy drink plus Ready-to-use Therapeutic/Supplementary Food (RUTF/RUSF). • Review weekly until stable (gaining weight at 3 consecutive visits). Then review every 2 weeks until growing well8 . • Once child growing well8 review monthly and continue on supplements from Therapeutic Feeding Unit/Center (TFU/TFC) until weight remains on upward growth curve > 3 months. Advise caretaker to return immediately if condition worsens (unable to drink/eat, vomiting everything, fever, profuse watery diarrhoea, lethargy). 1 Mid upper arm circumference. 2 If child’s palm significantly less pink than your own. 3 Protein-rich foods: chicken, fish, cooked eggs, beans, lentils (shiro watt/thick soup), soya. 4 Iron-rich foods: liver, kidney, dark green leafy vegetables like spinach, cooked egg, beans, peas, lentils, fortified cereals. 5 Vitamin A-rich foods: vegetable oil, liver, yellow sweet potatoes, dark green leafy vegetables like spinach (imifino), mango, full cream milk. 6 Vitamin C-rich foods: oranges, melons, tomatoes. 7 If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give erythromycin 12.5mg/kg (up to 500mg) QID PO for 5 days instead. 8 Growing well: MUAC ≥ 14 cm in a child 5-9 years old or ≥ 18 cm in a child 10-14 years old. Assess the child with acute malnutrition Assess When to assess Note Symptoms Every visit Manage symptoms as on symptom page. Ask specifically about diarrhoea 144. Check if urgent attention needed 150. Feeding At diagnosis Ask the following about diet: is child eating regular protein, dairy, vegetables, fruit; how often is child eating; what quantity is child eating; what fluids is child drinking and advise on correct habits depending on response. TB risk Every visit If close TB contact or TB symptoms (cough or fever ≥ 2 weeks, not growing well/losing weight, tired/less playful), exclude TB. Caretaker Every visit Check HIV status, contraceptive needs and TB symptoms. Social At diagnosis Ask who looks after child most of the time. If concerns about neglect, refer to hospital. Oedema Every visit If swelling of feet, hands or face, severe acute malnutrition (SAM) likely, refer to hospital. Weight-for-age Every visit • If weight loss > 5% [(weight lost ÷ weight at last visit) x 100] at any visit; if child has lost weight on 2 consecutive visits or if no weight gain for 3 consecutive visits, refer to hospital. • If weight-for-age (WFA) still below -2 line after 2 months of supplements from Therapeutic Feeding Unit/Center (TFU/TFC), refer to hospital. BMI Monthly If BMI still below -2 line after 2 months of supplements from Therapeutic Feeding Unit/Center (TFU/TFC), refer to hospital. MUAC1 Monthly If MUAC1 still low (< 14cm in a child 5-9 years old or < 18cm in a child 10-14 years old) after 2 months of supplements from Therapeutic Feeding Unit/Center (TFU/TFC), refer to hospital. Mouth/teeth At diagnosis If white patches in mouth (inside of cheeks/lips and on tongue), oral thrush/candida likely 139. If dental caries, refer to hospital. Hb At diagnosis Look for pallor2 and if possible check Hb: if pallor or Hb < 11g/dL, anaemia likely 137. If Hb < 7g/dL, refer to hospital. HIV At diagnosis Test for HIV. If HIV positive, manage according to national HIV programme guidelines.
  • 154. Child 154 Epilepsy • If child convulsing now or is not known with epilepsy and has had a recent convulsion 130 • A doctor decides to start long-term treatment in a child with ≥ 2 convulsions and no identifiable cause. Advise the caretaker of a child with epilepsy • Explain what to do if child has a convulsion at home 130. Avoid possible triggers: lack of sleep, alcohol/drug use, dehydration and flashing lights. • Educate about epilepsy and need for adherence to be convulsion free. • Advise to keep a home record/convulsion diary to record frequency of convulsion, length of convulsion, possible triggers and changes in medication. Encourage caretaker to take a video of event. • Help caretaker to get Medic alert bracelet. Refer for support. Caretaker to inform teachers, explain what to do if child has a convulsion and what activities child should avoid. • Reduce chance of injury: supervise swimming/bathing/crossing roads (walking to school/shops), shield fireplaces/cookers, avoid contact sports (rugby), advise not to lock doors (bed/bathroom). Assess the child with epilepsy: record epilepsy diagnosis and care plan in birth record. Assess When to assess Note Long term health conditions Every visit If other long-term health conditions present, ensure they are adequately treated. Adherence and side effects Every visit Ask if child takes medication every day. If not, explore reasons for poor adherence. Ask about side effects of treatment (below). Other medication Every visit If child started TB or HIV treatment or antibiotics, refer to hospital to assess for drug interactions. Convulsion frequency Every visit Review convulsion diary. If still convulsing after 2 months and adherent to treatment (correct dose) with no obvious triggers1 or medication interactions, refer to hospital. School problems Every visit If failing grades, not coping with school work or bullying/violence at school, caretaker to arrange meeting with teacher. Family planning If sexually active girl If on valproate, ensure child on reliable contraception 110. Treat the child with epilepsy • A single medication is best. Start low dose and increase slowly every 2 weeks until convulsion free or side effects intolerable (treatment usually initiated at hospital). Medication Dose Maximum dose Indication Side effects Valproate2 • Start dose: 5mg/kg/dose 8-12 hourly • Increase to: 15-20mg/kg/dose 8-12 hourly • Maintenance dose: 20-30mg/kg/dose 8-12 hourly 40mg/kg/day in divided doses • Choose if generalised tonic/clonic seizures, absence seizures, on ART. • Avoid if liver disease. Urgent: jaundice, vomiting, abdominal pain: stop medications and refer urgently. Self-limiting: nausea, diarrhoea, constipation. Carbamazepine3 • Start dose: 2mg/kg/dose 8-12 hourly • Increase to: 5-10mg/kg/dose 8-12 hourly • Maintenance:10-20mg/kg/day in divided doses 10mg/kg/day in divided doses • Choose if focal seizures/convulsion. • Avoid in absence, myoclonic seizures or if child on ART. Urgent: skin rash, refer. Self-limiting: drowsiness, dry mouth, dizziness, ataxia, nausea, loss of appetite, constipation, abdominal pain. If drowsiness affects school performance, refer to hospital. Phenobarbitone Start and maintain: 3-5mg/kg/dose as a single dose at night. 5mg/kg/day Avoid in absence seizures. Drowsiness, behaviour problems, hyperactivity. • If convulsions worsen or persist despite maximum treatment or if loss of milestones, refer to hospital. • If convulsion free, review 6 monthly. If no convulsions for 2 years: discuss stopping treatment with doctor in hospital. Gradually decrease dose of anticonvulsant over 2 months. If convulsions recur, refer to hospital. 1 Triggers include: lack of sleep, dehydration, flashing lights, recent illness (fever), alcohol/drug use. 2 If unable to swallow tablet, give crushable formulation (100mg tablets) TID. If able to swallow, give controlled release (CR) formulation BID. 3 Give syrup formulation TID and tablet formulation BID.
  • 155. Child 155 Assess level of consciousness (LOC) with the AVPU scale: Is child alert and awake? Child has normal LOC (A on AVPU scale) Yes No Child responds Child is lethargic (V on AVPU scale) If this is main presenting symptom. Child responds Child has a decreased LOC (P on AVPU scale) Child still does not respond Child is unresponsive/unconscious/comatose (U on AVPU scale) Child does not respond Check if child responds to pain by firmly rolling a pen over child’s nailbed: Try to rouse child by talking to him/her or shaking his/her arm: Assess level of consciousness with AVPU A Alert V responds to Voice P responds to Pain U Unresponsive/Unconscious Quick reference chart Estimate weight according to age 5-12 years Weight (kg) = (3 x age in years) + 7 Decide if respiratory rate is normal for age Age Respiratory rate (breaths/minute) Respiratory rate decreased if: Respiratory rate increased if: 5-12 years < 20 ≥ 25 ≥ 12 years < 15 ≥ 20 Decide if pulse rate is normal for age Age Pulse rate (beats/minute) Pulse rate decreased if: Pulse rate increased if: 5-12 years < 80 ≥ 120 ≥ 12 years < 60 ≥ 100 Decide if blood pressure is normal for age Age Blood pressure decreased if: Blood pressure increased if: DBP SBP DBP SBP 6-10 years old < 57 < 97 > 76 > 115 10-12 years old < 61 < 102 > 80 > 120 12-15 years old < 64 < 110 > 83 > 131 Decide on maintenance fluid rate Weight 24 hour fluid need < 10kg 120mL/kg 10-20kg 1000mL + (50mL for every kg body weight over 10kg) e.g.: if 14kg: 1000mL + (50 x 4) = 1200mL/24 hours ≥ 20kg 1500mL + (20mL for every kg body weight over 20kg) Up to 2000mL in girls and 2500mL in boys e.g.: if 23kg: 1500mL + (20 x 3) = 1560mL/24 hours
  • 156. Adult 156 About PACK Global The Ethiopian Primary Health Care Clinical Guidelines were developed by localizing the PACK Global Adult (2017) and PACK Western Cape Child (2017) guides developed by the Knowledge Translation Unit of the University of Cape Town Lung Institute, South Africa. The Practical Approach to Care Kit (PACK) was developed, tested and refined since 1999 by the Knowledge Translation Unit (KTU) of the University of Cape Town Lung Institute Proprietary Limited in collaboration with clinicians, health managers and policy makers in South Africa, and expanded upon through research and localization throughout the world. This guide is a comprehensive tool to the commonest symptoms and conditions seen in primary care in low and middle- income countries. It integrates content on communicable diseases, non-communicable diseases, mental illness and women’s health. Each of the almost 3000 screening, diagnostic and management recommendations is informed by evidence and guidance in the BMJ’s (British Medical Journal) clinical decision support tool, Best Practice, as well as the latest World Health Organization guidelines, including the 2015 WHO Model List of Essential Medicines. The content has been carefully localised for health workers in Ethiopia and is, as of October 2017, believed to comprise best practice and comply with local guidelines and policies. The KTU’s involvement in the localisation work was supported by the United Kingdom’s National Institute of Health Research (NIHR) using Official Development Assistance (ODA) funding (NIHR Global Health Research Unit on Health System Strengthening in Sub-Saharan Africa, King's College London (16/136/54)). The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the English Department of Health. To the fullest extent permitted by law, the University of Cape Town Lung Institute (Pty) Ltd or BMJ Publishing Group Limited of Health shall not be held liable or be responsible for any aspect of healthcare administered in reliance upon, or with the aid of, this information or any other use of this information. PACK is also being implemented in South Africa, Brazil and Nigeria, and the content is revised annually in line with latest evidence and WHO guidelines. For access to the most up-to-date templates, tools, associated training materials and a mentorship programme for countries wishing to localise it for their health systems visit: www.knowledgetranslation.co.za or contact [email protected]