Federal Democratic Republic of Ethiopia

Ministry of Health

Ethiopian primary health care clinical guidelines

Addis Ababa
Care of Children 5-14 years and Adults 15 years or older in Health Centers
2014 (EC) | 2021 (GC)
Foreword
The Ethiopian health care system has three tiers: primary health care, Secondary and Tertiary tiers. The primary health care level includes health posts, health centers and primary 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 transformation agendas of both
HSTP(Health Sector Transformation Plans) by strengthening the primary health care. Standardization of patient care at all health tier levels is important and EPHCG has demonstrated well this effort during
the past three years implementation.

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 (2021), List of Medicine for Health Centers (2012), Guidelines on Clinical and Programmatic Management of Major Non Communicable Diseases (2021 , National guidelines for
comprehensive HIV prevention, care and treatment (2021), Guidelines for clinical and programmatic management of TB/HIV and leprosy in Ethiopia (2020), 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.

This Third Edition of the Ethiopian Primary Health Care Clinical Guidelines will continue to serve as 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 children younger than 5 years old.

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.

Dereje Duguma (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 first edition guideline .
• Disease prevention and Health Promotion Directorate, Maternal and Child Health Directorates, Health Extension and Primary Health care 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: Core Technical Team: KTU Team: Contributors: Elnathan Kebebew Nicola Ayers Noor Ramji
Daniel G/Michael Desalegn Tegabu (Project lead) Lauren Anderson (Training lead) Ambachew Teferra Khalid Abdella Samuel Girma Solomon Worku
Desalegn Tegabu Ermias Diro (Localization coordinator) Ajibola Awotiwon (Adult content editor) Anteneh Kassa Mariye Asfaw Tigist Bacha Yared Mamushet
Yibeltal Mekonnen H/mariam Segni (Content expert) Ruth Cornick (Editorial lead) Aschalew Worku Melaku Belay Wondossen Mengistie(MD)
Hassan Mohammed (Project lead) Tracy Eastman (Project coordinator) Ashna Bowry Meron Yakob Zelalem Tadesse(MD)
Solomon Emyu (Localization Coordinator) Lara Fairall (KTU head) Ayalew Marye Meseret Zerihun Meseret Wale
Solomon Shiferaw (M&E expert) Sandy Picken (Child content editor) Charlotte Hanlon Mohammed Shafi Kiflemariam Tsegaye
Telahun Teka (Content expert) Christy-Joy Ras (Training mentor) Damenu Zeleke Molla Gedefaw Aklog Getnet
Wubaye Walelgne (Content expert) Pearl Spiller (Design) Dereje Assefa Megersa Abdella
Yibeltal Mekonnen (Project lead) Izak Volgraaf (Illustrations) Meseret Feleke
Yoseph Mamo (Content expert) Camilla Wattrus (Adult content editor)

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.

Israel Ataro,MPH
Health Extension and Primary Health Directorate 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 [email protected] or inbox us at our Telegram channel @EPHCG-2019.
Glossary
A G P
ALP alkaline phosphatase GCS glasgow coma scale PJP pneumocystis jiroveci pneumonia
ALT alanine aminotransferase GGT gamma-glutamyl transferase PCR polymerase chain reaction
ART antiretroviral therapy PEP post-exposure prophylaxis
AST aspartate aminotransferase H PO orally
H 20 2 hydrogen peroxide PPE papular pruritic eruption
B Hb haemoglobin PR per rectum
BID twice a day HbA1c glycated haemoglobin PTB pulmonary tuberculosis
BMI body mass index HBsAg hepatitis B surface antigen Pulse rate measured in beats per minute
BP blood pressure measured in millimeters of mercury [mmHg] HIV human immunodeficiency virus PVD peripheral vascular disease
HPV human papillomavirus
C Q
CD4 count of the lymphocytes with a CD4 surface marker I QID four times a day
COPD chronic obstructive pulmonary disease IM intramuscular
CPR cardiopulmonary resuscitation IMCI integrated management of childhood illness R
CRP c-reactive protein INR international normalized ratio RF rheumatoid factor
Cu-IUD copper intrauterine device IPT isoniazid preventive therapy RPR rapid plasmin reagin
CVD cardiovascular disease IU international units Respiratory rate measured in breaths per minute
IUD intrauterine device
D IV intravenous S
DBP diastolic blood pressure SC subcutaneous
DKA diabetic ketoacidosis M SBP systolic blood pressure
DMPA depot medroxyprogesterone acetate MTB Mycobacterium tuberculosis STI sexually transmitted infection
DNS dextrose in normal saline MTB/RIF Mycobacterium tuberculosis DNA and
DR-TB drug-resistant tuberculosis resistance to rifampicin T
DS-TB drug-sensitive tuberculosis MU million units TAT tetanus antitoxin
DST drug susceptibility testing MUAC mid-upper arm circumference TB tuberculosis
DVT deep vein thrombosis TBSA total body surface area
DW dextrose water N TIA transient ischaemic attack
NS normal saline TID three times a day
E NSAIDs non-steroidal anti-inflammatory drugs TSH thyroid stimulating hormone
ECG electrocardiogram
EDD estimated date of delivery V
eGFR estimated glomerular filtration rate VIA visual inspection with acetic acid
ELISA enzyme-linked immunosorbent assay
eMTCT elimination of mother-to-child-transmission
EPTB extra pulmonary tuberculosis
ESR erythrocyte sedimentation rate
Adult contents: Address the patient's general health 10
Adult contents: symptoms
A D J S
Abused patient 66 Diarrhoea 34 Jaundice 60 Scrotal symptoms 36
Abdominal pain 32 Disruptive patient 63 Joint symptoms 46 Seizures 15
Abnormal vaginal bleeding 42 Distressed patient 65 Suicidal thoughts/self harm 62
Abnormal thoughts/behaviour 64 Dizziness 21 L Sexual assault 66
Aggressive patient 64 Dyspepsia 32 Leg symptoms 49 Sexual problems 43
Anal symptoms 35 Discharge, genital 36 Lump, neck/axilla/groin 18 Sexually transmitted infection (STI) 36
Arm symptoms 48 Lump, skin 53 Skin symptoms 53
E Lymphadenopathy 18 Sleeping difficulty 67
B Ear/hearing symptoms 25 Smoking 102
Back pain 47 Emergency patient 12
M Stings 52
Bites 52 Mouth symptoms 27 Stressed patient 65
Eye symptoms 23
Blackout 20 Syphilis 41
Body pain 45
Exposure to infectious fluids 68
N
Breast symptoms 31 F Nail symptoms 61 T
Breathing difficulty 29 Nausea 33 Throat symptoms 27
Face symptoms 24
Burn/s 51 Neck pain 48 Tiredness 19
Faint 20
Needlestick injury 122 Traumatised patient 66
Falls 20
C Fatigue 19
Nose symptoms 26
Cardiac arrest 12 U
Cervical screening 40
Fever
Foot symptoms
17
50
O Ulcer, genital 36
Chest pain 28 Overweight patient 84 Ulcer, skin 53
Foot care 50
Collapse 20 Unconscious patient 13
Coma 13
Fracture 14
P Unsafe sex 68
Pain, back 47
Condom broken 68 G Pain, body/general 45
Urinary symptoms 44
Confused patient 64 Genital symptoms 36
Constipation 35
Pain, chest 28 V
Pain, neck 48
Convulsions 15 H Pain, skin 53
Vaginal bleeding 42
Cough 29 Headache 22 Violent patient 64
Pap smear 40 Vision symptoms 23
Hearing problems 25
Poisoned patient 14b Vomiting 33
Heartburn 32
R 66 W
I Rape 53
Injured patient 14 Weakness 19
Rash
Itch 53 Weight loss 16
Respiratory arrest 12
Wheeze 30
Wound 14
Adult contents: chronic conditions
Tuberculosis (TB) Chronic diseases of lifestyle Musculoskeletal disorders
Tuberculosis (TB): diagnosis 71 Cardiovascular disease (CVD) risk: diagnosis 84 Chronic arthritis 107
Drug-sensitive (DS) TB: routine care 72 Cardiovascular disease (CVD) risk: routine care 85 Gout 108
Diabetes: diagnosis 86 Fibromyalgia 109
Diabetes: routine care 87
HIV Hypertension: diagnosis 89

HIV: diagnosis 75
Hypertension: routine care 90 Women’s health
Heart failure 91
HIV: routine care 76 Rheumatic heart disease/previous rheumatic fever 92 Contraception 110
Stroke 93 The pregnant woman 112
Ischaemic heart disease (IHD): initial assessment 94 Routine antenatal 114
Malnutrition 70 Ischaemic heart disease (IHD): routine care 95 care Routine postnatal 116
Peripheral vascular disease (PVD) 96 care Menopause 119

Chronic respiratory disease

Epilepsy 97 Palliative care 120
Asthma and COPD: diagnosis 81
Using inhalers and spacers 81
Asthma: routine care 82
COPD: routine care 83 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

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
Symptoms Long-term health conditions
A F R
Abdominal symptoms 143 Fever 134 Rash, generalised 147 Malnutrition 153
Rash, localised 148
B H Respiratory arrest 128
Resuscitation, child 128
Breathing difficulty, child 140 Headache 135
Epilepsy 154
Burns 133 Head injury 127
Hearing problems 138
S
C Seizures 130
Cardiac arrest 128 I Shock 129
Cardiopulmonary resuscitation (CPR) 128 Injured child 132
Coma 131 T
Confusion 131 L Throat symptoms 139
Convulsions 130 Leg symptoms 146 Quick reference chart 155
Cough 140 Limp 146
U
Cough, recurrent 142 Lymphadenopathy 136
Unconscious child 131
Underweight 150
D M Urinary symptoms 145
Dehydrated child 129 Mouth symptoms 139
Diarrhoea 144 W
P Walking problems 146
E Pallor 137 Wheeze 141
Ear symptoms 138 Wheeze, recurrent 142
Emergency child 127
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.

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.

Amoxicillin 500mg PO TID

for 7 days, 21 capsules

Adult 9
Address the patient's general health
Assess the patient’s general health at every visit
Assess When to assess Note
Symptoms Every visit Manage symptoms as on symptom pages.
TB Every visit If 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/ 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.
abuse
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 • Check glucose 86 at first visit, then depending on result.
• If BMI ≥ 25 and ≥ 1 other • Other risk factors: hypertension, cardiovascular disease, physical inactivity, family history of diabetes, high risk ancestry, previous gestational diabetes or big
risk factor baby, previous impaired glucose tolerance or impaired fasting glucose.
HIV • If status unknown Test for HIV 75.
• If sexually active: yearly
• If pregnant: at first visit and
36 weeks
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.
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 10
 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.

Smoking Be sun safe Avoid substance abuse Have safe sex Diet
If patient smokes • Avoid sun exposure, especially Limit alcohol intake < 2 • Have only 1 partner at a • Eat a variety
tobacco 102. between 10h00 and 15h00. drinks1/day and avoid alcohol time. of foods in
• Use sunscreen and protective on at least 2 days of the week. • If HIV negative, test for HIV moderation.
clothing (e.g. hat) when outdoors. • In the past year, has patient: between partners. Reduce
1) drunk ≥ 4 drinks1/session, • Advise partner to test portion
Stress 2) used khat or illegal drugs for HIV. sizes.
Assess and or 3) misused prescription • Use condoms. • Increase fruit and
manage Physical activity or over-the- vegetables.
stress • Aim for at least 30 minutes of moderate counter • Reduce fatty foods: eat
65. exercise (e.g. brisk walking) on most medications? Road safety low fat food, cut off
days of the week. If yes to any • Use pedestrian animal fat.
• Increase activities of daily living like 103. crossings to cross • Reduce salty processed
gardening, housework, walking instead the road. foods and avoid adding
of taking transport, using stairs instead • Use a seat belt. salt to food.
of lifts. • Avoid using • Avoid/use less sugar.
• Exercise with arms if unable to use legs. alcohol/drugs if driving.

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 11
The emergency patient
Give urgent attention to the emergency patient:
Does patient respond to your voice?
No Yes
Call EMT, request and prepare Ambulance, Feel for carotid pulse for maximum of 10 seconds.

No pulse felt or unsure Pulse felt

Start CPR: Is patient breathing?

• 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. No Yes
• Check pulse: • Give 1 breath every 6 seconds.
--If definite pulse returns, stop CPR and check breathing (as adjacent). • Recheck pulse every 2 minutes.
--If no pulse, continue CPR for at least 30 minutes1. • If no pulse, start CPR (as adjacent).

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

Airway Breathing Circulation Establish Level of consciousness

• If airway obstructed • If difficulty breathing or oxygen • IV access. • Assess Glasgow Coma Score (GCS) or Using AVPU:
(snoring, gurgling, noisy saturation < 90%, give face mask • If systolic BP < 90, pulse ≥ tool):
breathing), open with head- oxygen, aim to maintain >90% 100 or heavy bleeding, give Glasgow Coma Score (GCS)
tilt and chin-lift. If injured, use • saturation. normal saline 1L I V rapidly,
Best motor response Best verbal response Eye opening
jaw-thrust instead, keeping If respiratory rate < 9 or blue lips/ repeat if no response. Sop
tongue, connect bag valve mask to signs of fluid overload. If 6 Obeys commands 5 Orientated 4 Spontaneous
neck stable.
• Remove foreign bodies from oxygen and slowly deliver each breath still no response check for 5 Localises to pain 4 Confused 3 To voice
mouth and suction fluids. with the patient. external bleeding. 4 Withdraws from pain 3 Inappropriate words 2 To pain
• Refer if using bag valve mask and still • Stop bleeding: apply 3 Abnormal flexion to pain 2 Incomprehensible 1 None
• If unconscious, insert
difficulty breathing, oxygen saturation < pressure and elevate limb. 2 Extends to pain sounds
oropharyngeal airway then
90% or blue lips/tongue. If bleeding still severe, 1 None 1 None
refer.
• If sudden breathlessness, more resonant/ apply alternate tourniquet
If patient resists, gags or
decreased breath sounds/pain on 1 side, above injury until surgical
vomits, use lubricated
nasopharyngeal airway deviated trachea: tension pneumothorax intervention or referral. • Add scores to give single score out of 15
likely: refer urgently for chest tube. • Apply pelvic binder for
instead.
hip instability or splint for A:Alert, V:Responds to Voice,P:Responds to Pain, U::Unresponsive
Manage further according to disability and symptoms: signs of fracture
• 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 wheezing give salbutamol
• If patient is chocking(unable to cough, not making sounds) use age-appropriate chest thrusts/abdominal thrusts/back blows.
• If GCS ≤ 8 and none of above, place in left lateral position, place oropharyngeal/nasopharyngeal airway then refer.
• 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.
Exposure: remove all patients clothing and check the back and visually in accessible areas, , decontamination in poisoning 14b
Continue CPR for longer if temperature < 35˚ C patient drowned, poisoned or took medication. NB:Remember to use the medical or trauma check list on patient documentation
1 Adult 12
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:

Blood glucose Temperature Pupils

< 70mg/dL > 200mg/dL ≤ 35°C ≥ 38°C Pinpoint Both Unequal or

or unable to equally respond poorly
measure • Check urine • Remove cold/ Severe pneumonia or sepsis or Illegal drug use Excessive secretions or dilated to light
for ketones: wet clothing meningitis likely and/or respiratory muscle twitching
• Give Glucose 40% if >2+, DKA and cover • Give ceftriaxone2 2g IV/IM or rate < 12 Stimulant • Intracranial
50mL IV over 2-3 likely 87. with warm crystalline penicillin2 3-4M IU IV Organophosphate or other bleeding/
minutes. Repeat if • Otherwise, blankets. with chloramphenicol 500mg IV. Opioid overdose poisoning likely drug mass or
glucose still < 70mg/ give normal • Warm IV • Check for malaria3: if positive, likely • Give atropine 2mg overdose stroke likely
dL after 15 minutes. saline 1L IV fluids to 40°C give artesunate 2.4mg/kg IM or Give 100% face IV. Repeat every 5 likely • Raise head by
Maintain with Glucose over 1 hour, (avoid cold artemether 3.2mg/kg IM. mask oxygen. minutes, doubling 30 degrees.
10% solution1. then 500mL fluids). • If temperature > 40°C: dose of atropine • If injured, keep
• If IV glucose is not hourly for • If no --Remove clothing. each time, until body straight
possible or available, 4 hours, response or --Use fan and water spray to secretions controlled. and tilt to raise
give buccal (inside of then 250mL temperature cool patient. • Remove head (avoid
the cheek) glucose. hourly for ≤ 32°C, refer --Apply ice-packs to axillae, contaminated clothes bending spine).
• If known alcohol user, 4 hours. to hospital. groin and neck. and wash skin. • The pressure
give thiamine 100mg --Stop once temperature < 39°C. must be
IV or vitamin B1+B6 reduced as
+B12 1 tablet PO quickly as
If no response or overdose/poisoning with other or
before glucose. possible.
unknown substance, refer to hospital.
Arrange for
rapid
• Refer urgently. handover/
• While awaiting transport: transfer to a
- -if 3rd trimester pregnant keep mother on left lateral position to avoid aortocaval syndrome surgical centre.
- Check BP, pulse, respiratory rate, oxygen saturation and GCS every 15 minutes, then 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. 2If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), give chloramphenicol only and refer. 3Test for malaria with

parasite slide microscopy or if unavailable, rapid diagnostic test.

Adult 13
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 Wound and one or more of: Fracture and one or more of: Head injury and one or more of:
blood • Poor perfusion (cold, pale, • Poor perfusion (cold, pale, numb, • Weakness/numbness • Any loss of consciousness • Blood or clear fluid leaking
in urine numb, no pulse) below injury no pulse) below fracture below fracture • Convulsion from nose or ear
• Excessive or pulsatile bleeding • Increasing pain, muscle tightness, • Open fracture • Severe headache • Pupils unequal or respond
• Give normal • Penetrating wound to head/ numbness in limb • > 3 rib fractures • Amnesia poorly to light
saline 1L IV neck/chest1/abdomen • Suspected femur, pelvis or spine • Severe deformity • Suspected skull fracture • Weak/numb limb/s
hourly for fracture • Bruising around eyes or behind • Vomiting ≥ 2 times
2 hours. • Give normal saline 1L IV ears • ≥ 1 other injury
• Once urine rapidly, repeat until systolic • Give diclofenac 75mg IM/IV and/or tramadol 100mg IV/IM. • Blood behind eardrum • Drug or alcohol intoxication
output BP > 90. Continue 1L 6 hourly. • If poor perfusion or weakness/numbness below fracture,
> 200mL/ Stop if breathing worsens. gently re-align into normal position. • If GCS < 15, neck/spine tenderness, weak/numb limb or
hour, give • If excessive/pulsatile • If open fracture: remove foreign material, irrigate with abnormal pupils, apply rigid neck collar and sandbags/blocks
500mL bleeding, apply direct normal saline then cover with sterile saline-soaked gauze. on either side of head.
hourly. pressure and elevate limb. If Give ceftriaxone2 1g IV/IM and if dirty wound add • If pupils unequal or respond poorly to light, keep body straight
• Stop if bleeding severe and persists, metronidazole 500mg PO. and tilt to raise head (avoid bending spine).
breathing apply tourniquet above injury. • Splint limb to immobilise joint above and below fracture. • If convulsion, give lorazepam/diazepam
worsens. • If pelvic fracture, tie sheet tightly around hips to immobilise.

• Start TAT prophylaxis.

• 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.

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, compartment syndrome. 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.

Wound Fracture Head injury

• Apply direct pressure to stop bleeding. Remove foreign material, loose/dead skin. Irrigate with normal saline or if wound • Splint limb to • Observe for 2 hours before discharging
dirty use instead povidone iodine solution . immobilise with carer.
• If sutures needed: suture, clean the overlying skin and apply non-adherent dressing for 24 hours. joint above and • If mild headache, dizziness or mental fogginess,
• Avoid suturing if > 12 hours (body), > 24 hours (head/neck), remaining foreign material, infected, gunshot or deep puncture: below fracture. concussion likely:
- Pack wound with saline-soaked gauze and give amoxicillin/clavulanate 500/125mg PO TID for 7 days. If penicillin allergic, • Give --Advise complete rest for 2 days. If no symptoms
give instead erythromycin 500mg PO QID for 7 days. paracetamol after 3 days, gradually increase exertion.
- Review in 2 days. Suture if needed and no infection unless gunshot/deep puncture (irrigate and dress every 2 days instead). 1g PO QID and --Advise that recovery can take > 1 month.
• Give paracetamol 1g PO QID as needed for up to 5 days. ibuprofen5 --Give paracetamol 1g PO QID as needed for up
• Advise to return if infection (red, warm, painful, swollen, smelly, pus): start metronidazole4 500mg PO TID for 7 days and refer. 400mg PO QID. to 5 days.
• Remove sutures after 5 days (face), 4 days (neck), 10 days (leg) or 7 days (rest of body). • Refer to hospital. • Advise to return immediately if any of above
• Refer if unable to close wound easily, weakness/numbness below injury or cosmetic concerns. symptoms of severity develop.
1Avoidsuturing the wound, apply 3-side flap dressing. 2If sever penicillin allergy(previous angioedema, anaphylaxis or urticaria), give single dose erythromycine 500mg PO. 3Inject 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. 4Advise no alcohol until 24 hours after last dose of metronidazole. 5Avoid of peptic ulcer, asthma, hypertension, heart failure or kidney disease.

Adult 14
Poisoned Patient
Give urgent attention to the poisoned patient
 if not witnessed check
• whether any family member has chronic diseases including hypertension, diabetes, epilepsy etc and associated events like missing medications(tablets, injections) or any
emptied medication bottles
• ask presence of any other potential materials around the patient when found at poisoning site
• Note for any odors on the patient’s clothes
if witnessed -immediately identify agent, dose, time, route of exposure
 ascertain whether poisoning was intentional 62 or accidental
 assess ABC and give support accordingly 12
 assess GCS 12, pupillary size, pupillary reactivity to light, RBS
 If patient is seizing give diazepam 10mg IV, if no response add Phenobarbital 100mg PO(if patient unconscious use NG tube)
 Measure core temperature
 undress patient and do thorough examination to assess exposure extent- don’t forget covering patient after examination to avoid hypothermia
 check clothing for retained objects in pockets, hidden places including waistband, groin or skin folds with care to avoid needle or sharp object injuries

Altered Hypothermia Hyperthermia Decontamination

consciousness or
patients with low
or borderline RBS

• Gross Fully • Ocular

• Give Dextrose • Cover with • Do active If exposed to chemical
undress
IV/PO warm blanket cooling with ice apply
patient
• Put patient near water local anesthetic
• Wash with
radiant warmer • immersion with 0.5% tetracaine
copious water
• Give glucose IV If ineffective Copious irrigation with
twice
to prevent immediately crystalloid solution
• Place all
hypoglycemia refer for • If chemical identified is
removed
advanced care Alkalis prolong
clothing in a
plastic bag irrigation for 1 to 2
and seal the hours
bag

Refer urgently, while awaiting transport, monitor vital signs, pupillary size, pupillary light reactivity, RBS and consciousness

Adult | 14b
Seizures/convulsions
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:
--Give phenytoin or phenobarbitone 20mg/kg PO (crushed and diluted in water through NG Tube). Give diazepam 10mg IV at the same time and repeat up to a total dose of 40-60mg if convulsion continues.
--Add phenytoin or phenobarbitone 10mg/kg PO if convulsion persists after 60-90 minutes.
--Refer urgently to hospital.

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 No

Refer patient same day if one or more of: New sudden Collapse with Episodes
• Neck stiffness/meningism, temperature ≥ 38°C, meningitis likely: give ceftriaxone2 2g IM/IV or crystalline penicillin2 4M IU IV with asymmetric twitching of acute
chloramphenicol 500mg IV weakness or lasting anxiety, fully
• Malaria test3 positive: give artesunate 2.4mg/kg IM or artemether 3.2mg/kg IM. numbness of < 15 seconds conscious,
• HIV patient: consider CNS toxoplasmosis, CNS TB, cryptococcal meningitis or HIV associated dementia face arm or following responds
• Reduced level of consciousness for more than 1 hour after convulsions stopped: suspect complications leg; difficulty hot feeling, irregularly,
• New sudden asymmetric weakness or numbness, difficulty speaking or visual disturbance: consider stroke speaking nausea, with
• New/different headache or headache getting worse/more frequent: consider sub-arachnoid hemorrhage or visual prolonged abnormal
• BP ≥ 180/110 one hour after convulsion has stopped: consider hypertensive emergency disturbance standing or body
• Substance abuse: consider overdose or withdrawal intense pain movement
• Head injury within past 6 weeks: consider subdural hematoma Stroke or with rapid and usually
• Pregnant or up to 1 week postpartum: consider eclampsia 112. TIA likely recovery after stressful
93. experience
Approach to the patient who had convulsion but does not need same day referral Faint or
Is the patient known with epilepsy? syncope Conversion
likely 20. Disorder
(Hysteria)
Yes No likely 99.
Give routine Patient has previous history of head trauma, meningitis, family history, stroke or brain tumor?
epilepsy care
97. If diagnosis uncertain, refer.
Yes No
Give routine epilepsy care 97. Refer to hospital.
1
Add 10 vials of glucose 40% in 1L dextrose in normal saline solution at 30 drops per minute. 2If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), give chloramphenicol only and refer. 3Test for malaria with parasite slide
microscopy or if unavailable, rapid diagnostic test.

Adult 15
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.

Step 1. First check for TB, HIV and diabetes

Exclude TB Test for HIV Check for diabetes

• Start workup for TB 71. Test for HIV 75. If HIV positive, Check glucose 86.
• At the same time test for HIV 75 and diabetes 86 and consider other causes below. give routine care 76.

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

Step 3. Ask about symptoms of common cancers

Abnormal vaginal Breast lump/s or Amenorrhea with lower abdominal Change in bowel habit Cough ≥ 2 weeks, bloody sputum,
discharge/bleeding nipple discharge swelling long smoking history
Consider bowel cancer.
Consider cervical cancer. Consider breast cancer. Consider ovarian tumor. If mass on abdominal or rectal Consider lung cancer.
Do a speculum examination Examine breasts and axillae Refer. examination or stool occult blood Arrange chest x-ray and refer.
and VIA 40. 31. positive, refer.

If above excluded, ask about food intake:

Step 4. Food intake inadequate: look for cause/s Food intake is

adequate
Nausea and/or Loss of appetite Assess and Sore mouth or Food insecure
vomiting manage difficulty swallowing (drought, crop failure or unemployed)
• Eat small frequent meals. stress 65.
33. • Advise patient to eat nutrient dense foods (soya, meat, fish, nuts Oral/oesophageal Refer to food safety net program.
and seeds, beans, lentils, potatoes, rice, barley, wheat, maize). candida likely 27.

• 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.
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 16
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 • Respiratory rate > 30 or • Severe abdominal or flank pain • Unable to sit up or walk unaided
• Drowsiness, confusion or agitation difficulty breathing • Jaundice • Purple rash
• Neck stiffness/meningism • BP < 90/60 • Easy bleeding or bruising
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.

Do a peripheral blood film examination or a malaria rapid diagnostic test

Positive for malaria Positive for Borrelia (relapsing fever) Negative for malaria and Borrelia

Plasmodium falciparum or Plasmodium vivax seen Both Plasmodium • Delouse the patient, shave hair and • Avoid Widal and Weil-Felix tests as they are not specific and do
falciparum and change clothing. not show new infection.
Plasmodium falciparum Plasmodium vivax Plasmodium vivax seen • Give procaine penicillin 400,000IU IM. • Ask about pattern of fever, personal hygiene, headache,
seen seen Ensure patient does not become shocked: diarrhoea/constipation and look for lice on body:
• Give artemether/ • Give chloroquine: • Give artemether/ --Establish IV access with normal saline.
lumefantrine PO 4 tabs on days lumefantrine 20/120mg: --Check BP every 15 minutes for first If intermittent fever If persistent fever If fever
20/120mg: 4 tabs PO BID 1 and 2, 2 tabs on 4 tabs PO BID for three 2 hours, every 30 minutes for next with any of: headache, with any of: ≥ 2 weeks,
for three days and single day 3 and days and primaquine 4 hours, then 6 hourly. If BP < 90/60, lives in overcrowded diarrhoea followed exclude TB
primaquine4 0.25mg/kg PO daily for give normal saline 250mL IV rapidly, setting, poor personal by constipation or
doseprimaquine PO3 71 and
0.25mg/kg. 0.25mg/kg PO 14 days. repeat until systolic BP > 90. If breathing hygiene or body lice, poor food hygiene, test for HIV
• If pregnant5 in 1st daily for 14 days. • If pregnant in 1st worsens, stop and refer. typhus fever likely: typhoid fever 75.
trimester, give quinine • If pregnant or trimester, give quinine • If penicillin allergic, give instead • Give doxycycline3 likely:
sulphate 10mg/kg PO lactating, omit sulphate 10mg/kg PO tetracycline3 250mg PO TID for 3 days. 100mg PO BID • Give
TID with food for 7 days. primaquine. TID with food for 7 days. • Repeat peripheral blood film after 12 hours: for 7-10 days or ciprofloxacin3
--If negative: give tetracycline 250mg PO tetracycline3 250mg 500mg PO BID
TID for 3 days. PO QID for 7 days or for 10-14 days or
Advise patient to return if no better. --If positive: repeat procaine penicillin chloramphenicol azithromycine
400,000IU IM and check BP as above. 500mg PO QID for 1g PO daily for 5
If fever persists beyond seven days • Discharge after 12 hours and give 7 days. days.
• Check adherence to treatment and repeat peripheral blood film examination. Check tetracycline3 250mg PO TID for 3 days. If
for associated symptoms as above and manage as on symptoms pages. signs of severity as above, refer.
• Consider other causes of fever: If fever ≥ 2 weeks, exclude TB 71; Test for HIV 75. • Educate patient and family on personal • If none of the above, advise cold compresses and review
• If cause uncertain, refer. hygiene. after 2 days.
• If cause uncertain, or no better after treatment, refer.
1If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), give chloramphenicol only and refer. 2Test for malaria with parasite slide microscopy or if unavailable, rapid diagnostic test. 3Avoid if pregnant

4 Adult 17
Patients on 14- days radical cure treatment with primaquine should be assessed for hemolysis at days 3, 7 and 13, if any change of urine color or signs of anemia occurs, stop the treatment with Primaquine.
5
AL is indicated and can be given in first trimester pregnancy only if this is the only treatment available for P. falciparum malaria.
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 Localised lymphadenopathy

lymphadenopathy Ask about other symptoms and look for cause (infection, skin lesion, rash, bite):

Neck Axilla Groin

Check scalp, • Check arms, Is there risk of STI ( Age < 25 years, > 1 partner, new partner or unprotected sex in last 3 months, or partner/s with STI)?
face, eyes, breasts,
ears, nose, chest, upper No Yes
mouth and abdomen and Is the groin lump hot and tender? Is an ulcer present?
throat. back.
• If lump in
breast 31. Yes No Yes No
Treat patient and partner for lymphogranuloma venereum (Bubo)
Look for cause: Refer to Ulcer • First assess and advise the patient and partner 36.
Check lower hospital. 39 • Give ciprofloxacin 500mg PO BID for 3 days and doxycycline 100mg PO BID for
abdomen, 14 days.
legs, buttocks, • If pregnant/breastfeeding, give instead erythromycin 500mg PO QID for 14 days.
genitals, anal • If fluctuant lymph node, aspirate pus through healthy skin in sterile manner
region. 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
No Yes • Clean skin over largest node with ethanol or povidone iodine. Hold node in fixed position with one hand so that
it will not move.
• Test for HIV 75. If HIV positive, give routine care 76. • Manage as • Insert 22 gauge needle into node, draw back plunger 2-3mL to create vacuum.
• If cough ≥ 2 weeks, weight loss, night sweats or fever on symptom • Partially withdraw and reinsert needle at different angles several times through node (avoid withdrawing needle
≥ 2 weeks, check for TB 71. page. completely, maintain continuous vacuum).
• If no TB found and symptoms persist, refer same week. • If lymph • Release vacuum pressure before withdrawing needle completely.
• Check complete blood count and ESR. If abnormal, refer to node persists • Remove syringe from needle, pull 2-3mL air into syringe, re-attach needle and gently spray contents of needle
hospital. > 4 weeks, on to a glass slide.
• Review medication: atenolol, allopurinol, co-trimoxazole, refer. • Lay another slide on top and pull the slides apart to spread the material.
antibiotics and phenytoin can cause lymphadenopathy. • Allow one slide to air dry and fix other slide with cytology spray.
Consider changing medication. • If enough aspirate, also send for TB and bacterial culture and sensitivity.
• If no cause found, refer. • If aspirate unsuccessful or does not confirm a diagnosis, refer.

Adult 18
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. 2One 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 19
Collapse/faint
Give urgent attention to the patient who has collapsed/fainted and one or more of:
• If new sudden asymmetric weakness or numbness of • Difficulty breathing 29 • Known heart problem
face, arm or leg; difficulty speaking or visual disturbance: • Recent injury • Collapse with exercise
consider stroke or TIA 93. • Systolic BP < 90 • Vomited blood or blood in stool
• Unconscious 13 • Pulse < 50 or irregular • Pregnant or missed/overdue period with abdominal pain and vaginal bleeding
• Convulsion 15 • Palpitations • Severe back or abdominal pain
• Chest pain 28 • Family history of collapse or sudden death • 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.

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 Systolic BP does not drop by ≥ 20 (or ≥ 30 if known hypertension) and diastolic does not drop by ≥ 10
hypertension) or diastolic BP drops by ≥ 10 Before the collapse did patient experience flushing, dizziness, nausea, sweating?

• This is common in the elderly. Yes No

• If thirsty and pulse on standing ≥ 100,
dehydration likely. Give oral rehydration Common faint (Syncope) likely Was collapse associated with a specific action (e.g. coughing, swallowing, head turning or passing urine)?
solution and look for and manage cause. • May have had twitching of limbs
• Check Hb: if < 11g/dL, refer to hospital. that last < 15 seconds (not a
• Review medication: amitriptyline, amlodipine, No Yes
convulsion). Is there known diabetes? Refer to hospital.
enalapril, furosemide, glyceryl trinitrate, • Advise to avoid overheating,
hydrochlorothiazide and metoprolol. prolonged standing, crowded
Consider changing medication. environment and situations where Yes No
• Advise patient to sit first before standing up fainting has occurred previously.
from lying down. • Assess and manage stress 65. Give routine diabetes care 87.

If cause for collapse is uncertain, refer.

1
Add 10 vials of glucose 40% in 1L dextrose in normal saline solution at 30 drops per minute. 2One 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
Dizziness/vertigo
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 • BP < 90/60 • Difficulty breathing, especially on lying flat with leg swelling 91 • New sudden severe dizziness/
numbness of face, arm or leg; difficulty speaking or • Pulse < 50 or irregular • Recent head injury vertigo with nausea/vomiting,
visual disturbance: consider stroke or TIA 93. • Chest pain 28 • Unable to stand without support 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.

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:

Systolic BP drops by Systolic BP does not drop by ≥ 20 (or ≥ 30 if known hypertension) and diastolic BP does not drop by ≥ 10
≥ 20 (or ≥ 30 if known
hypertension) or Ask patient to breathe rapidly for 2 minutes. Are symptoms reproduced?
diastolic BP drops
by ≥ 10
Yes No
Orthostatic
hypotension likely Hyperventilation Ask about associated symptoms and length of dizziness/vertigo. Is there hearing loss, headaches, visual symptoms or tinnitus (ringing/buzzing in ear/s)?
• This is common in likely
the elderly. • Reassure and No Yes
• If thirsty and pulse encourage
on standing ≥ 100, patient to
dehydration likely. breathe at a Sudden dizziness/vertigo lasts seconds, Sudden dizziness/vertigo lasts hours/days with nausea/vomiting. Refer to
Give oral rehydration normal rate. precipitated by head movements May have preceding flu-like illness. hospital.
solution and look for • Assess and
and manage cause. manage stress Positional vertigo likely Vestibular neuritis likely
• Advise patient to sit 65. Reassure patient that dizziness is • If nausea/vomiting, give metoclopramide 10mg PO TID as needed for up to 5 days.
first before standing self-limiting and usually resolves • Encourage to be mobile as soon as possible
up from lying down. within 6 months. • If no better after 2 weeks, or if hearing loss or tinnitus occurs, refer.

• If none of the above, refer to hospital.

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

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 21
Headache
Give urgent attention to the patient with headache and one or more of:
• Sudden severe headache • Pregnant or 1 week post-partum, and BP ≥ 140/90 112 • Recent head trauma
• New/different headache, or headache that is getting worse and more frequent • Decreased level of consciousness • Sudden weakness or numbness
• Headache that wakes patient or is worse in the morning • Confusion of face, arm or leg 93
• Temperature ≥ 38°C, neck stiffness/meningism or vomiting • Sudden dizziness • Speech disturbance
• Worsening/persistent headache in HIV patient recently started on ART • Vision problems (e.g. double vision) or eye pain 23 • Pupils different in size
• BP ≥ 180/110 and not pregnant 89 • Following a first convulsion
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.

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 No
Pain when pushing on forehead or cheek/s, recent common cold, runny/blocked nose?
Migraine likely
• Give immediately, and then as needed: Yes No
ibuprofen3 400mg PO QID with food
or paracetamol 1g PO QID for up to Sinusitis likely • If using analgesia > 2 days/week for ≥ 3 months it can cause headaches:
5 days. • Give paracetamol 1g PO QID as needed for up to 5 days. --Advise against regular use and to cut down on amount used.
• If nausea, also give metoclopramide • If tooth infection, swelling over sinus or around eye, refer. --Headache should improve within 2 months of decreased use.
10mg PO TID as needed up to 5 days. • If patient has recurrent sinusitis, test for HIV 75. • Consider muscular neck pain or giant cell arteritis:
• Give oral hydration. • If nasal discharge for > 10 days or symptoms worsen after
• Advise patient to recognise and treat initial improvement, give antibiotic:
migraine early, rest in dark, quiet room. Constant aching pain, tender > 50 years, pain over temples
--Is there risk of severe infection (> 65 years, alcohol abuse or neck muscles
• Advise regular meals, keep hydrated, impaired immunity4)?
regular exercise, good sleep hygiene. Giant cell arteritis likely
• Keep a headache diary to identify and Muscular neck pain Check ESR. If > 30mm/h, give single dose
avoid migraine triggers like lack of Yes No likely 48. prednisolone 60mg PO and refer same day.
sleep, hunger, stress, some food • Give amoxicillin/clavulanate • Give amoxicillin
or drink. 500/125mg PO TID for 500mg PO TID for
• Avoid oestrogen-containing 7-10 days. 7 days. • In the past month, has patient: felt depressed, sad, hopeless or irritable or worrying a lot, had
contraceptives 110. • If penicillin allergic, give • If penicillin allergic, multiple physical complaints, felt little interest or pleasure in doing things? If yes to any 99.
• If ≥ 2 attacks/month, refer for instead azithromycin give instead • If excessive worry causes impaired function/distress for at least 6 months with ≥ 3 of:
medication to prevent migraines. 500mg PO daily for 3 days, if doxycycline5 100mg muscle tension, restlessness, irritability, difficulty sleeping, poor concentration, tiredness:
available or refer. PO BID for 7 days. generalised anxiety disorder likely 100..

• Warn patient to avoid overusing analgesics.

• If uncertain of diagnosis or poor response to treatment, refer.
1
If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), give chloramphenicol only and refer. 2Test for malaria with parasite slide microscopy or if unavailable, rapid diagnostic test. 3Avoid if peptic ulcer, asthma, hypertension,

heart failure or kidney disease. Known with HIV, diabetes or cancer, pregnant or receiving chemotherapy or corticosteroids. Avoid if pregnant.
4 5

Adult 22
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 • Sudden loss or change in vision (including blurred or • Foreign body that is metal, or from hammering, mechanical
of face, arm or leg; difficulty speaking or visual reduced vision) saw, welding, grinding or explosion
disturbance: consider stroke or TIA 93. • New onset hazy cornea • Chemical burn to eye/s: immediately wash eye/s for at least
• BP ≥ 180/110 and not pregnant 89 • Painful red skin with blisters involving eye, eyelid or nose: 15 minutes continuously with normal saline or clean water.
• Pregnant or up to 1 week post-partum, and BP ≥ 140/90: herpes zoster (shingles) likely • If painful eye with redness, blurred vision, haloes around
treat as severe pre-eclampsia 112. • Whole eyelid swollen, red and painful: orbital cellulitis likely light, dilated unreactive pupil, headache or nausea/
• Yellow eyes: jaundice likely 60. • Penetrating eye trauma vomiting, acute glaucoma likely
• Single painful red eye
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

Eye/s discharging or watery Gradual Red or swollen Superficial foreign

Is there prominent itch? change eyelid margins body
in vision with crusting
Yes: Is there eczema, allergic rhinitis or No: Is the discharge pus or clear? • Wash eye with
asthma and both eyes involved? • Exclude Blepharitis clean water or
Pus Clear diabetes likely normal saline and
No Yes 86 and • Apply warm/ clean corners of
hypertension cool compress eye with damp
Bacterial conjunctivitis likely Viral 89. for 5-10 cotton- tipped
Localised Allergic conjunctivitis conjunctivitis • Test for HIV minutes BID. bud. Advise
cause likely likely likely
• Wash eye • Advise cool compresses Check under upper eyelid for yellows bumps: 75. • Advise regular hydration
if present, trachoma likely. Refer same day. • Advise cool • Refer for to gently • Attempt removal
with clean and normal saline eye compresses. visual wash eyes of foreign body
water. drops as needed. • Advise patient assessment. with baby • Refer to hospital if:
• Identify • Help to identify and to wash hands shampoo. --Unable to
and advise to avoid allergens regularly and to remove remove foreign
remove the that worsen/ trigger not share towels crusts. If no body as above
cause. symptoms. or bedding. better, give --Damage to eye
• If no better • Avoid steroid eye drops Patient can
© BMJ Best Practice erythromycin --Abnormal
after • Give oxymetazoline eye return to work eye drops vision or eye
24 hours, drops 1 drop 3-4 times a after 1 week. 1 drop daily movement
refer. day for 5 days. If no yellow bumps: • Give normal for 2 weeks. --No better
• Give loratadine • Give chloramphenicol 1% ointment QID or gentamycin 0.3% eye saline or clean • If no better 2 days after
10mg PO daily or drops 1 drop 4-6 hourly for 10-15 days. water eye after 2 weeks, removal of
chloropheniramine • Advise patient to wash hands regularly, not share towels/bedding. washes up to refer. foreign body
4mg PO at night as • Patient can return to work after 2 days. 4 times per day
needed.
• If no better after 4 weeks,
refer. If no better after 2 days, refer.

1
If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid ceftriaxone and refer.
Adult 23
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 Sudden progressive weakness of Swelling of face

1 side of face and unable to
wrinkle forehead or close eye. May
If rash on face 53. have impaired taste or dry eye.
Painless swelling in Painful swelling of
patient on enalapril one/both sides of face
Pain of cheek or jaw and on Pain when pushing on forehead or cheek/s, headache, recent with low-grade fever,
Bell’s palsy likely headache, body pain.
tapping or biting on involved common cold, runny/blocked nose • Give prednisolone as soon as Angioedema likely
tooth. May be swollen. possible: give 60mg PO daily for • Stop enalapril and
Sinusitis likely 5 days. Then reduce dose by never start it again. Parotitis (mumps) likely
Gum/tooth infection likely • Give paracetamol 1g PO QID as needed for up to 5 days. 10mg daily. If no better after • Give loratadine • Give paracetamol 1g
• Give paracetamol 1g • If neck stiffness/meningism, tooth infection or swelling over 3 weeks, refer. 10mg PO daily until PO QID as needed for
PO QID as needed for up to sinus/around eye, refer. • If severe/complete weakness, swelling resolved. up to 5 days.
5 days. • If patient has recurrent sinusitis, test for HIV 75. also give aciclovir 400mg PO • Referto hospital • Advise patient s/he can
• If temperature ≥ 38°C or • If nasal discharge for > 10 days or symptoms worsen after initial 5 times a day for 10 days. for review of return to work after
difficulty opening mouth, improvement, give antibiotic: • Protect eye: medication. 5 days and that
give amoxicillin 500mg --Is there risk of severe infection (> 65 years, alcohol abuse or --Advise patient not to rub eye. • Advise patient to symptoms usually
PO TID for 5 days and impaired immunity3)? --Keep eye moist with drops. return urgently resolve within 1 to
metronidazole1 500mg PO --Cover eye with transparent eye should difficulty 2 weeks.
TID for 5 days. If penicillin shield during the day. breathing occur or • Refer if:
Yes No symptoms worsen --Neck stiffness/
allergic, replace amoxicillin --Tape eyelid closed at night.
with doxycycline2 100mg PO • Refer same day if: and that meningism
BID for 5 days. • Give amoxicillin/clavulanate • Give amoxicillin 500mg --Otitis media s/he should never --Painful scrotal swelling
• Advise good oral hygiene 500/125mg PO TID for 7-10 days. PO TID for 7 days. --Any change in hearing take enalapril again. --Loss of hearing
and a soft diet for a few days. • If penicillin allergic, give instead • If penicillin allergic, give --Recent head trauma
• Refer to dentist same week. azithromycin 500mg PO daily for instead doxycycline2 --Damage to cornea
3 days, if available or refer. 100mg BID for 7 days. --Unsure of diagnosis

1
Advise no alcohol until 24 hours after last dose of metronidazole. 2Avoid if pregnant. 3Known with HIV, diabetes or cancer, pregnant or receiving chemotherapy or corticosteroids.
Adult 24
Ear/hearing symptoms
Is ear itchy, painful, discharge from ear, difficulty hearing or tinnitus (ringing/buzzing in ear/s)? Then look in ear.

Itchy ear Painful ear Discharge from ear Difficulty hearing or tinnitus

Redness and/or Normal drum and canal Symptoms < 2 weeks; Symptoms ≥ 2 weeks; • If tinnitus, refer to hospital.
pus in ear canal red or bulging eardrum. perforated eardrum. Painless, • If itchy/painful ear or discharge from ear, see adjacent column/s.
May have fever and/or may have difficulty hearing • Check for wax and foreign body:
difficulty hearing.
Wax Foreign body Normal looking ear

• Syringe ear • If insect, • Look for and if possible

with warm instil oil and remove cause:
water and/ if possible --Ask about prolonged
© University of Cape Town
or dilute remove using exposure to loud noise.
© University of Cape Town hydrogen forceps. --Review medication:
Referred pain likely © University of Cape Town © University of Cape Town peroxide. If • Otherwise, aspirin, NSAIDs and
Otitis externa likely • Look for cause: unsuccessful syringe ear furosemide.
• Clean ear1. --If dental problem, refer after 3 with warm • Refer if:
Acute otitis media likely Chronic suppurative otitis attempts or water. --Sudden onset
• Give paracetamol 500mg to dentist. media likely
--If throat problem • Give paracetamol causes pain, • If unsuccessful --One-sided
PO QID as needed for up 500mg PO QID as • Clean ear1 3 times a day.
to 5 days. 27. stop and refer. after 3 --Dizziness/vertigo
needed for up to 5 days. The ear can heal only if dry. • If hearing does attempts or --Patient taking kanamycin
• If severe pain, temperature --If pain in temporo- • Give hydrogen peroxide
mandibular joint, • Clean ear1 if discharge. not improve causes pain, --No cause found or no
≥ 38°C, impaired • Give amoxicillin 500mg solution 3% 5-10 drops
immunity2 give cloxacillin check for joint problem after wax stop and refer. better 2 weeks after
PO TID for 5 days. If into affected ear BID. removal, refer. removing cause.
500mg PO QID for 5 days. 46. • Refer if:
--If painful swelling of penicillin allergic, give
If penicillin allergy, give instead erythromycin --No better after 2 weeks
instead erythromycin one/ both sides of --Foul-smelling discharge or
face, consider mumps 500mg PO QID for How to syringe an ear
500mg PO QID for 5 days. 5 days. yellow/white deposit on
• If no response after 2 days, likely 24. eardrum, cholesteotoma
• Refer if:
refer. --No response to likely.
antibiotics after 5 days --Large perforation
--Recurrent otitis media --Hearing loss
• Refer urgently if: --Pain in ear
--Painful swelling behind • Refer urgently if:
ear --Painful swelling behind
--Neck stiffness/ ear Fill a large syringe (50-200mL) with warm water. Ask patient to hold
meningism --Neck stiffness/meningism container under ear against neck to catch water. Gently pull ear upwards
• If poor response to and backwards to straighten ear canal. Place tip of syringe at ear canal
treatment, check for opening (no further than 8mm into canal) and direct water spray
TB 71 and HIV 75. upwards in ear canal.
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. Known with HIV, diabetes or cancer or receiving chemotherapy or corticosteroids.
2

Adult 25
Nose symptoms
Runny or blocked nose Bleeding nose
Ask about duration and associated symptoms.
• Firmly pinch nostrils together for 10 minutes.
Sore throat or fever Pain when pushing on forehead or cheek/s, Recurrent episodes of sneezing • Check BP:
headache, recent common cold and itchy nose on most days --If < 90/60, give normal saline 250mL IV
for > 2 weeks. May have itchy eyes, rapidly, repeat until systolic
Body aches/muscle pains or chills
ears or throat. BP > 90. Continue 1L 6 hourly. Stop if
Sinusitis likely
breathing worsens.
• Give paracetamol 1g PO QID as needed for up to 5 days.
No Yes --If ≥ 140/90 89.
• If neck stiffness/meningism, tooth infection, swelling over Allergic rhinitis likely
• If still bleeding:
sinus or around eye, refer. • Advise patient to identify and
--Insert cotton strips or swabs saturated
Common cold Influenza (flu) • If patient has recurrent sinusitis, test for HIV 75. avoid allergens that worsen/
with mixture of lidocaine 4% and
likely likely • If nasal discharge for > 10 days or symptoms worsen after trigger symptoms.
xylometazoline 0.05% into bleeding
initial improvement, give antibiotic: • Give loratadine 10mg daily for up
nostril/s for 15 minutes.
--Is there risk of severe infection (> 65 years, alcohol abuse to 5 days or cetirizine 10mg daily
• Advise patient to avoid contact with --If bleeding persists, refer.
or impaired immunity2)? only when symptoms worsen.
others to prevent spread, use tissues • If patient has recurrent episodes:
• If symptoms occur on ≥ 4 days
when sneezing/coughing and dispose --Advise patient to apply petroleum jelly or
per week for > 1 month, give
of these carefully, and to wash hands Yes No saline spray inside nostrils and avoid
beclometasone nasal spray long
regularly. nose-picking or rubbing, contact sports
term 100mcg (2 sprays) in each
• Give paracetamol 500mg PO QID or and trauma to nose.
• Give amoxicillin/ • Give amoxicillin 500mg nostril daily. Once symptoms
ibuprofen1 400mg PO TID needed for up --Advise patient to avoid aspirin and
clavulanate 500/125mg PO TID for 7 days. controlled, use lowest effective
to 5 days. NSAIDs (e.g. ibuprofen) as they may
PO TID for 7-10 days. • If penicillin allergic, give dose to maintain control.
• Explain that antibiotics are not necessary. prolong bleeding.
• If penicillin allergic, give instead doxycycline3 • If no better with above treatment
• Advise patient to return if symptoms --Educate patient to firmly pinch nostrils
instead azithromycin 100mg PO BID for and symptoms debilitating, refer.
persist > 4 days. together if bleeding occurs.
500mg PO daily for 3 days 7 days.
if available or refer.

1
Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease. 2Known with HIV, diabetes or cancer, pregnant or receiving chemotherapy or corticosteroids. 3Avoid if pregnant.
Adult 26
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.

Red throat White patches on cheeks, Painful blisters on Painful ulcer/s in Dry mouth Red, cracked corners
gums, tongue, palate; may have lips/mouth mouth/throat of mouth
cracks in corners of mouth
Are there 2 or more of: • If thirst, urinary frequency
• Fever • Pus/patches on tonsils Herpes simplex likely Aphthous ulcer/s or weight loss, check for Angular cheilitis likely
• No cough • Tender neck lymph nodes Oral thrush/candida likely • Apply tetracaine likely diabetes 86. • Apply petroleum jelly
• Test for HIV 75 and 0.5% on blisters or • Apply triamcinolone • If runny or blocked nose (Vaseline®) TID.
diabetes 86. gentian violet 0.5% acetonide 0.1% 26. • If crusts and blisters
No Yes
• Give miconazole oral gel solution painted (Oropaste®) TID • Look for and treat oral around mouth,
60mg or nystatin 500 000IU in mouth TID and on the lesions for candida as in adjacent impetigo likely 59.
Viral Bacterial pharyngitis/ tablet PO QID for 7 days. Keep paracetamol 1g PO 7 days or crushed column. • If very itchy, contact
pharyngitis tonsillitis likely in mouth as long as possible. QID up to 5 days. prednisolone 5mg • Review medication: dermatitis likely.
likely • Give paracetamol 1g • If patient uses inhaled • Give aciclovir tablet BID until furosemide, amitriptyline, Identify and remove
• Give PO QID as needed for corticosteroids, ensure s/he 400mg PO TID for healed chlorpheniramine irritant.
paracetamol up to 5 days. uses spacer and rinses mouth 7 days if: • Apply tetracaine antipsychotics and • If using inhaled
1g PO QID as • Rinse with salt water or with water after use 81. --HIV patient 0.5% on ulcers morphine can cause corticosteroids,
needed for H2O2 3% mouthwash • If patient is terminally sick --Blisters for • Give paracetamol 1g dry mouth. Consider advise to rinse mouth
up to 5 days. after meals and survival is predicted to ≤ 12 hours or new PO QID as needed. changing medication. after use.
• Rinse with • Give single dose be short, give palliative care blisters forming • Rinse with • Advise patient to sip
salt water benzathine penicillin 120. --Ulcers are chlorhexidine 0.12% fluids frequently. Sucking
If no better or
or H2O2 3% 1.2MU IM or amoxicillin extensive, recurrent solution 10ml BID on oranges, pineapple,
uncertain of cause:
mouthwash 500mg PO QID for or present for • Test for HIV 75 lemon or passion fruit
If difficulty or pain on • Check hemoglobin.
after meals 10 days; If penicillin > 1 month • Refer if: may help.
swallowing, oesophageal • Test for HIV 75
• Reassure allergic give instead --Severe pain --Not healed within • If patient is terminally sick
candida likely and diabetes 86.
that erythromycin 500mg • Give fluconazole 200mg PO
• Avoid touching the 2 weeks and survival is predicted
• If still uncertain, refer.
antibiotics PO QID for 10 days. lesions and kissing. --Ulcer diameter to be short, give palliative
daily for 14 days.
are not • Advise frequent > 1cm care 120.
• If no response, refer.
necessary. hand washing.
If > 4 episodes in 1 year,
refer for ENT assessment.

• 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.

Adult 27
Chest pain
Give urgent attention to the patient with chest pain and one or more of:
• Respiratory rate > 30 or difficulty breathing • New pain or discomfort in centre or left side of chest • Known with ischaemic heart disease
• BP ≥ 180/110 or < 90/60 • Pain radiates to neck, jaw, shoulder/s or arm/s • At risk of heart attack (diabetes, smoker, hypertension,
• Pulse irregular, ≥ 100 or < 50 • Nausea or vomiting high cholesterol, known CVD risk > 20%, family history)
• Severe pain • Pallor or sweating
Is chest pain worse on palpating the chest or when patient lies down or breathes deeply?

No Yes

Assess for ischaemic heart disease Manage and refer urgently:

94 • 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.

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, Burning pain on
no fever or cough one side of body
with or
Dyspepsia (heartburn) likely
without rash
• 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. Musculoskeletal problem likely
• Ask about smoking. If patient smokes tobacco 102. Support patient to change 125. • Give ibuprofen 400mg PO TID with
• If drinks alcohol ≥ 4 drinks2/session 103. food up to 10 days (avoid if peptic Herpes zoster
• If waist circumference > 80cm (woman) or 94cm (man), encourage weight loss and assess CVD risk 84. ulcer, asthma, hypertension, heart (shingles) likely
• Give omeprazole 20mg PO daily for 4 weeks. failure or kidney disease). 54.
• Refer same week if any of: no better after 14 days of omeprazole, new onset pain and > 50 years, pain on swallowing, persistent vomiting, • If pain persists > 4 weeks, refer.
weight loss, loss of appetite, early fullness, blood in stool or occult blood positive or abdominal mass.

If uncertain of diagnosis, refer same week.

1
If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid ceftriaxone and refer. 2One 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 28
Cough or difficulty breathing
If wheeze/tight chest and no rash or face/tongue swelling 30.

Give urgent attention to the patient with cough and/or difficulty breathing and one or more of:
• Breathless at rest or while talking • Sudden diffuse rash or face/tongue • Respiratory rate > 30 • Confused or agitated
• Difficulty breathing worse on lying flat and leg swelling: heart failure likely 91. swelling: anaphylaxis likely • Coughs ≥ 1 tablespoon • BP < 90/60, shock
• Rapid deep breathing with glucose > 200mg/dl: consider DKA 86. • Temperature ≥ 39°C fresh blood • 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, Sudden diffuse rash or face/tongue swelling, anaphylaxis likely Sudden breathlessness, more resonant/
pneumonia likely • Raise legs and give immediately adrenaline 0.5mL (1:1000 solution) IM into mid outer thigh. Repeat decreased breath sounds/pain on one side,
Give ceftriaxone1 1g IV/IM every 5-15 minutes if needed. If no response, give hydrocortisone 100mg IV and promethazine 50mg IM. deviated trachea, tension pneumothorax likely
or amoxicillin1 1g PO. • Give normal saline 1-2L IV rapidly, regardless of BP. 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.

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:

Cough or difficulty breathing < 2 weeks Cough or difficulty breathing ≥ 2 weeks

Sputum, chest pain, pulse ≥ 100 or temperature ≥ 38°C? • Exclude TB 71.

• Consider asthma and COPD 81 and other cause for cough or difficulty breathing:
No Yes
HIV with CD4 < 200cells/mm3 Smoker Recent common
Acute Pneumonia likely with dry cough, worsening • If patient smokes tobacco 102. cold, no difficulty
bronchitis or breathlessness on exertion • Has patient lost weight? breathing
common cold Is there risk of severe infection
likely (> 65 years, alcohol abuse or impaired immunity2)? Pneumocystis pneumonia Yes No Post-infectious
likely cough likely
• Reassure Consider lung Coughing sputum most days of 3 months Advise that cough
No Yes should resolve
patient Give doxycycline3 Give amoxicillin1 1g PO TID Refer to hospital for x ray and cancer. for ≥ 2 years, chronic bronchitis likely.
antibiotics are inpatient treatment. Refer to hospital. Refer to hospital for COPD workup within 8 weeks.
100mg PO BID for 7 days. and doxycycline3 100mg
not necessary. PO BID for 5-7 days.
• Advise to
return if Relieve cough or difficulty breathing in the patient needing palliative care 120:
symptoms • If symptoms worsen after 2 days of antibiotics, refer. • If thick sputum, give steam inhalations. If more than 30mL/day, try deep fast breathing with postural drainage.
worsen or fever • If not better after 7 days of antibiotics, consider TB 71 • If excess thin sputum, give hyoscine 10mg TID. If annoying dry cough, give dextromethorphan syrup 10mg/5ml
develops. • If no cause found, refer to hospital. or diphenhydramine syrup 10mg/5mL three times a day.
1
If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid and refer. 2Known with HIV, diabetes or cancer, pregnant or receiving chemotherapy or corticosteroids. 3If pregnant, give instead erythromycin 500mg
PO QID for 5 days.
Adult 29
Wheeze/tight chest
• 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.

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

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

No Yes

Mild or moderate Severe

• Give inhaled salbutamol via 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 Worsening

despite treatment
Check respiratory rate. Can patient talk normally?

Able to talk normally and respiratory rate < 20 Unable to talk normally or
respiratory rate > 20
Wheeze/tight chest resolved Wheeze/tight chest still present
Refer• urgently.
• Repeat salbutamol hourly or as needed. While• awaiting transport:
• Is wheeze/tight chest still present at 3 hours? - Increase dosing of salbutamol to 8 puffs every 20 minutes via a metered dose inhaler and spacer1.
- Give face mask oxygen between doses (if known COPD, give 24-28% face mask oxygen).
No Yes - Give hydrocortisone 100mg IV if not already given.

• If first episode of wheeze/tight chest, assess for asthma and Continue

COPD 81. salbutamol
• If known asthma/COPD, give routine care: if asthma 82, and refer.
if COPD 83.

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 30
Breast symptoms
Approach to the patient with a breast symptom who is not breastfeeding

Breast lump/s Breast pain Nipple discharge Breast enlargement/feels different Rash on breast

Both breasts, One breast • Reassure patient that Any one of: blood-stained or one-sided One Both breasts • Check for
with/without pain breast cancer rarely discharge, patient ≥ 50 or a man, skin/ breast breast lump.
Any one of: man, patient > 30 years, causes pain. nipple changes, breast/axillary lump? • Confirm that this • Check axilla
This is likely to be family history of breast cancer, • Advise a well-fitting bra. Refer is not obesity. If for lymph
cyclical. irregular fixed lump, skin/nipple • If pregnant, reassure Yes No same BMI > 25 assess node 18.
• Reassure. changes, nipple discharge or axillary and give antenatal care week. CVD risk 84. • Check for
• If on hormonal lymph node? 114. • Review medication: nipple
• Give paracetamol 1g Refer • If pregnant, reassure and discharge
contraceptive, same give antenatal care 114. efavirenz and
consider PO QID as needed for up amlodipine can • If none of the
No Yes to 5 days. week. • Review medication: above
non-hormonal haloperidol, antidepressants, cause breast
method 110. • May be a side effect of enlargement. 53
Re-examine breast Refer hormonal contraceptive. oral contraceptive and
• If symptoms metoclopramide can cause Consider changing
change/worsen, on day 7 of menstrual same If no better after medication.
cycle. If lump persists, week. 3 months, change nipple discharge. Consider
refer. changing medication.
refer same week. method 110.
• If discharge persists, refer.

Approach to the patient with a breast symptom who is breastfeeding

Painful/cracked nipple/s Painful breast/s

Usually in first few days of Is there a breast lump?
breastfeeding due to poor latching
No Yes
• Avoid soap on nipples. Temperature ≥ 38°C or body pain? Temperature ≥ 38°C or body pain?
• Advise patient to continue
breastfeeding and help patient to Yes No No Yes
latch properly.
• Advise patient to apply breastmilk
to nipples after feeding and Mastitis likely Engorgement likely Blocked duct likely Breast abscess likely
expose to the air. • Give cloxacillin 500mg PO QID for 10 days. If penicillin allergic, give • Give single dose ceftriaxone2
• Advise HIV patient to stop instead erythromycin 500mg PO QID for 14 days. • Advise frequent breastfeeding, warm compresses 1g IM and refer same day.
feeding from the breast, express • Give paracetamol 1g PO QID as needed for up to 5 days. and to gently massage breast. • Advise HIV patient to stop
and heat-treat1 the milk, and • Advise warm compresses and, if HIV negative, frequent breastfeeds. • Advise to return to clinic if worse/no better. feeding from the breast,
cup-feed baby until cracks have • Advise HIV patient to stop feeding from the breast, express and express and heat-treat1 the
healed. heat-treat1 the milk, and cup-feed baby until mastitis resolves. milk, and cup-feed baby until
• If no better after 2 days, refer. abscess resolves.

Ensure the breastfeeding HIV patient and her baby receive routine HIV care 76 and 116.
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.

Adult 31
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 • Jaundice (yellow eyes): consider bile duct infection, hepatitis
• Chest pain: consider heart attack 28 • Temperature ≥ 38°C: consider severe infection of any abdominal organ/structure
• Pregnant or up to 1 week post-partum and BP ≥ 140/90: consider pre-eclampsia 112 • No stool or flatus for last 24 hours with/without vomiting: consider intestinal
• Recent abortion/delivery: consider puerperal sepsis 116 obstruction
• Pregnant and vaginal bleeding, consider ectopic pregnancy or abortion 112 • Sudden severe upper abdominal pain spreading to back with nausea/vomiting:
• If drowsiness, confusion, nausea/vomiting, rapid deep breathing: consider DKA, check glucose 86. consider perforated duodenal ulcer or pancreatitis
• If on ART, check for urgent side effects such as lactic acidosis 80. • Pulsatile abdominal mass: consider abdominal aortic aneurysm
• Peritonitis (guarding, rigidity or rebound tenderness): consider acute abdomen • 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 strongyloidiasis, give albendazole 400mg PO BID for 3 days.
• If amoebiasis, give metronidazole 500mg PO TID for 5-7 days. • If other parasites, give albendazole 400mg PO once daily for 3 days.
--If stool microscopy negative, manage below:

Does patient have epigastric pain which is worse with eating, hunger or lying down/bending forward?

Yes No
Dyspepsia (heartburn) likely Has patient lost weight?
• 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. Yes No
• Ask about smoking. If patient smokes tobacco 102. Support patient to change 125. Does patient have any of: Does the patient report worms?
If drinks alcohol ≥ 4 drinks2/session 103. cough, night sweats,
• fever or HIV?
If waist circumference > 80cm (woman) or 94cm (man), encourage weight loss and Yes No
•
assess CVD risk 84. • Tapeworm or worm segments: give single If pain is recurrent and
• Avoid serologic H pylori tests as they are not specific and not useful for management Yes No dose praziquantel 600mg PO or albendazole relieved when passing stool,
decisions. Exclude Consider 400mg PO once daily for 3 days. with constipation and/
• Give PPIs for 4-8 weeks (omeprazole 20mg BID or Pantoprazole 40mg BID or TB cancer. • Other worm or unsure: give single dose or diarrhoea and bloating,
Esomeprazole-40mg daily) . Alternatives: H2 blockers for 4-8 weeks (Cimetidine 71. Refer same albendazole 400mg. irritable bowel syndrome
400mg BID Rantidine 150mg BID or Famotidine 20-40mg daily. week. • Educate on personal hygiene. likely. Refer to hospital.

Refer if any of: no better after 14 days of omeprazole, new onset pain and > 50 years, • Give paracetamol 1g PO QID as needed for up to 5 days.
pain on swallowing, persistent vomiting, weight loss, loss of appetite, early fullness, • Review regularly until pain resolves or a cause is found.
blood in stool or occult blood positive, abdominal mass or uncertain of diagnosis.
Adult 32
1
If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid ceftriaxone and refer. 2One 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.
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 • Vomiting blood: consider gastric/duodenal ulcer or oesophageal bleeding
• Chest pain: consider heart attack 28 • Jaundice (yellowish eyes): consider hepatitis, bile duct obstruction or gall bladder infection
• Sudden severe upper abdominal pain spreading to back: consider perforated • Abdominal pain/distention and no stools or flatus: consider intestinal obstruction.
duodenal ulcer or pancreatitis • If drowsiness, confusion, abdominal pain, rapid deep breathing: consider DKA, check glucose 86.
• Signs of severe dehydration: decreased urine output, drowsiness/confusion, • If pregnant, signs of severe dehydration and ketone in urine, hyperemesis gravidarum likely.
BP < 90/60, pulse ≥ 100 • If on ART, check for urgent side effects such as lactic acidosis 80.
• Peritonitis (guarding, rigidity or rebound tenderness): consider acute abdomen
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?

Yes No

Dyspepsia (heartburn) likely Viral infection or food poisoning likely

• Advise to avoid caffeine and if heartburn at night, prop up head of bed and avoid eating late at night. • If new onset vomiting, usually with diarrhoea, cramping abdominal pain, loss of appetite, body
• Stop NSAIDS (e.g. ibuprofen), aspirin. pains and weakness, reassure patient that vomiting/diarrhoea should resolve within 1-3 days.
• Ask about smoking. If patient smokes tobacco 102. Support patient to change 125. • Give metoclopramide 10mg TID as needed for up to 5 days.
• If waist circumference > 80cm (woman) or 94cm (man), encourage weight loss and assess CVD risk 84. • If vomiting/diarrhoea, give oral rehydration solution.
• Give treatment for dyspepsia 32. • Advise patient to drink lots of fluids, eat small frequent meals as able and avoid fatty food.

Refer if any of: no better after 14 days of omeprazole, new onset pain and > 50 years, • Refer if any of:
pain on swallowing, persistent vomiting, weight loss, loss of appetite, --Vomiting persists > 3 days
early fullness, blood in stool or occult blood positive, abdominal mass or uncertain of diagnosis. --Not tolerating oral fluids or needing urgent attention as above
--Nausea persists > 2 weeks
--Uncertain of cause

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 33
Diarrhoea
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.

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.

Review stool microscopy result.

Positive Negative

RBC/WBC only seen Amoebic trophozoite Ova or parasite only seen Diarrhoea Diarrhoea for > 2 weeks
and RBC/WBC seen for Knowing the patient’s HIV status helps in the management. Test for HIV 75.
• Give ciprofloxacin • If amoebiasis, give metronidazole2 ≤ 2 weeks
500mg PO BID for • Give metronidazole 2
500mg PO TID for 5-7 days. HIV positive HIV negative/unknown
5 days. 500mg PO TID for • If giardiasis, give single dose Avoid
• If pregnant, 5-7 days. tinidazole2 2g PO. antibiotics. • Give routine HIV care 76. • Avoid antibiotics.
give instead • If no response within 2 • If strongyloidiasis, give albendazole • Lopinavir/ritonavir can cause ongoing diarrhoea. • Review medication: omeprazole,
azithromycin 1g days, add 400mg PO BID for 3 days. • ART not started or ART failed, treat for possible NSAIDs (e.g. ibuprofen) and metformin
PO daily for ciprofloxacin1 500mg • If other parasites, albendazole Isospora belli and microsporidiosis with can cause diarrhoea. Consider change
5 days. BID for 5 days 400mg PO daily for 3 days. co-trimoxazole 2 tablets of 960mg PO BID for 21 of medication if diarrhoea persists.
days and albendazole 400mg PO BID for 14 days. • Give loperamide 4mg PO initially,
If diarrhoea for > 2 weeks, test for HIV 75. • Give loperamide 4mg PO initially, then 2mg after then 2mg after each loose stool,
each loose stool, maximum 16mg/day. maximum 16mg/day.
Review in 2 weeks if diarrhoea still present.
If diarrhoea persists despite treatment or cause is not clear, refer to hospital.

If patient is terminally sick and survival is predicted to be short, give palliative care 120.
1
Avoid if pregnant. Advise no alcohol until 24 hours after last dose of metronidazole/tinidazole.
2

Adult 34
Constipation
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.

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.

Anal symptoms
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.

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 Perianal Red/raw skin Suspected worms

warts
• Advise as for constipation above and to • Advise as for constipation Treat as for • Advise good hygiene. • Give single dose
take sits baths. above and to avoid genital ulcer Treat as for • Look for contact cause. If diarrhoea 34. mebendazole 100mg and
• If constipated, give bisacodyl as above. straining. 39. genital warts • Apply petroleum jelly to raw areas. If severe repeat dose 14 days later.
• Give bismuth compound one • Apply hydrocortisone 1% 40. itching, also apply hydrocortisone 1% If pregnant, give instead
suppository BID for 5 days. cream BID for 5 days. cream BID for 5 days. pyrantel pamoate 11mg/kg
and repeat dose 14 days later.
• Treat family members at the
If no better with treatment, refer.
same time.

Adult 35
Genital symptoms
Assess the patient with genital symptoms and his/her partner/s
Assess Note
Symptoms Ask about genital discharge, rash, itch, lumps, ulcers and 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. If 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

Discharge
Scrotal swelling/pain Itch Ulcer/s Lump/s

Man 37 Woman 38 37 Discharge in woman 38 Glans penis 37 Pubic area 40 39 Groin 18 Skin 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 ceftriaxone 250mg/spectinomycine 2g IM stat & azithromycin 1g PO stat/doxycycline 100mg PO BID for 7days &metronidazole 500mg PO BID for 7days.
Pelvic inflammatory disease (Lower abdominal pain) Give partner ceftriaxone1 250mg IM and azithromycin 1g PO stat and Metronidazole 500mg PO BID for 14 days.
Male urethritis (Urethral discharge) ceftriaxone 250mg IM stat/spectinomycine 2g IM stat and azithromycin 1gm PO stat
Epididymitis/epididymo-orchitis (Scrotal swelling) Give partner ceftriaxone1 250mg IM stat and azithromycin 1g PO stat.
Genital ulcer disease Give partner single dose benzathine benzylpenicillin 2.4MU IM and either ciprofloxacin2 500mg PO BID for 3 days or erythromycin 500mg PO QID for 7 days PLUS
acyclovir 400mg PO TID(200mg PO five times) daily for 10 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 ciprofloxacin 500mg PO BID for 3 days and doxycycline 100mg PO BID for 14 days. If pregnant, give instead erythromycin 500mg PO QID for 14 days.
1
If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), omit ceftriaxone and increase azithromycin dose to 2g orally. 2Avoid if pregnant.
Adult 36
Genital symptoms in a man
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.

Approach to the man with genital symptoms not needing urgent attention
First assess and advise the patient and his partner/s 36.

Urethral discharge Scrotal symptoms Painful, itchy or smelly glans

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

Male urethritis likely Pain with/without swelling Painless swelling Balanitis/balanoposthitis likely
• Advise patient to wash daily with water,
• Give single dose: ceftriaxone 250mg /spectinomycin 2g IM stat PLUS
Epididymitis/epididymo-orchitis likely • If firm lump, avoid soap. Retract foreskin while washing
Azithromycine 1gm PO stat/ Doxycycline 100mg PO BID for 7 days/ then dry fully.
Tetracycline 500mg PO QID for 7 days/Erythromycine 500mg PO QID for 7 • Give single dse ceftriaxone 250mg IM testicular cancer
or spectinomycin 2g IM or ciprofloxacin likely: refer to • Give clotrimazole cream BID for 7 days.
days in case of contraindication for Tetracycline(Child and Pregnancy) • Offer referral for medical male
500mg PO and hospital.
• Give doxycycline 100mg PO BID for 14 days. • If soft lump, circumcision, especially if persistent/
Advise patient to return in 7 days if symptoms persist: • Treat patient’s partner/s 36. hydrocele recurrent or difficulty retracting foreskin.
• If not adherent or was re-exposed, repeat treatment. • For pain, give paracetamol 1g PO QID as likely: if large or • Treat patient’s partner/s 36.
• If fully adherent and no re-exposure: needed for up to 5 days. If no response, uncomfortable, refer • Advise patient to return in 7 days if
--Give single dose ceftriaxone 250mg IM and also give ibuprofen 400mg PO TID with to hospital; otherwise symptoms persist:
--Single dose azithromycin 2g PO and food for up to 5 days (avoid if peptic ulcer, advise patient to --If adherence poor, repeat treatment.
--Single dose metronidazole1 2g PO (if not already given) or tinidazole1 1g PO asthma, hypertension, heart failure or kidney return if it becomes --Test for diabetes 86 and HIV 75.
once daily for 3 days. disease). larger, painful or • If still no better, refer.
-- If severe penicillin allergy2, omit ceftriaxone and refer. • If no better after 7 days, refer. uncomfortable.
1
Advise no alcohol until 24 hours after metronidazole or last dose of tinidazole. 2Penicillin allergy with angioedema, anaphylaxis or urticaria.
Adult 37
Vaginal symptoms
If abnormal vaginal bleeding 42. If vaginal discharge or mass, manage below.

Vaginal discharge Vaginal mass

• It is normal for a woman to have a vaginal discharge. Abnormal discharges are itchy or different in colour or Vaginal/uterine prolapse likely
smell. Not all women with a discharge have an STI. • If cough 29; constipation 35; menopause 119.
• First assess and advise the patient and her partner/s 36. • Examine to confirm prolapse. If unsure, refer.
• If no ulcer on prolapse, refer for surgery.
If the vulva is red, scratched and inflamed or cheese/curd-like discharge, vaginal candida likely: • If ulcer present on prolapse:
• Give clotrimazole vaginal tablet 200mg inserted at night for 3 days or single dose fluconazole 150mg PO. --Apply oestrogen cream or crushed oral contraceptives in petroleum jelly daily for
• If severe, give instead single dose fluconazole 150mg PO and repeat after 3 days. 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.
If patient known with cervical cancer, and survival is predicted to be short, give palliative care 120.

Is there lower abdominal pain or cervical motion tenderness?

No Yes
Treat for vaginitis (trichomoniasis/bacterial vaginosis):
• Give metronidazole1 500mg PO BID for 7 days.
• If recurrent vaginitis, also give partner single dose Give urgent attention to the patient with vaginal discharge and lower abdominal pain/cervical motion tenderness and any of:
metronidazole1 2g PO. • Recent miscarriage/delivery/abortion • Abnormal vaginal bleeding
• Pregnant or missed/overdue period • Temperature ≥ 38°C
• Peritonitis (guarding, rigidity or rebound tenderness) • Abdominal mass
Does patient have any of: Management:
< 25 years, > 1 partner, new partner and unprotected sex in last • If BP < 90/60, give normal saline 1L IV rapidly, repeat until systolic BP > 90. Continue 1L 6 hourly. Stop if breathing worsens.
3 months, ever traded for sex or partner/s with STI? • 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.
No Yes
Approach to the patient with lower abdominal pain or cervical motion tenderness not needing urgent attention:
Also treat for cervicitis (gonorrhoea & chlamydia):
Give Ceftriaxone 250mg/Spectinomycine 2g IM stat
Cervical motion Lower abdominal pain only, no cervical motion tenderness
and Azithromycine 1gm PO stat/Doxycycline 100mg
tenderness with
PO BID for 7 days and Metronidazole 500mg PO BID
or without lower Check urine dipstick. If WBC/nitrites positive, urinary tract infection likely 44. If WBC/nitrites negative, treat below.
for 7 days. abdominal pain
• Treat the patient’s partner/s 36.
Pelvic inflammatory disease likely
• Give single dose ceftriaxone 250mg IM or if severe penicillin allergy3, give instead single dose ciprofloxacin 500mg PO and
Review in 7 days:
• Give doxycycline 100mg PO BID for 14 days and metronidazole1 500mg PO BID for 14 days.
• If ongoing discharge: examine cervix for cancer and do cervical
• 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
screen 40.
5 days (avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure or kidney disease).
• If ongoing vaginal candida also test for diabetes 86 and HIV 75.
• Treat the patient’s partner/s 36.
• Refer same week.
• Review within 3 days. If no better, refer same day.
1
Advise no alcohol until 24 hours after last dose of metronidazole. 2Avoid if pregnant and give single dose azithromycin 1g PO instead. 3Penicillin allergy with angioedema, anaphylaxis or urticaria.
Adult 38
Genital ulcer*
• First assess and advise the patient and his/her partner/s 36.
• The patient may have blister/s, sore or ulcer.

Treatment for Non- Vesicular Genital Ulcer

• Benzathine penicillin 2.4 million units IM stat /Doxycycline(in penicillin allergy) 100mg bid for 14 days PLUS Ciprofloxacin 500mg bid orally for 3 days /
Erythromycin 500mg tab qid for 7 days PLUS Acyclovir 400mg tid orally for 10 days (or 200mg five times per day of 10 day)
Treatment for Vesicular, multiple or recurrent ulcer
Acyclovir 200mg five times per day for 5days OR Acyclovir 400 mg tid for 7 days
Treatment for recurrent infection
© University of Cape Town
• Acyclovir 400 mg tid for 7 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

Check if patient also has hot tender swollen inguinal nodes (discrete, movable and rubbery).

No Yes

If no better after 7 days, refer.

TREATMENT OF INGUINAL BUBO(Lymphogranuloma Venareum)
Ciprofloxacin 500mg BID orally for 3 days
PLUS
Doxycycline 100 mg BID orally for 14 days
If pregnant/breastfeeding, give instead Erythromycin 500mg PO QID for 14 days..
If patient have genital ulcer,ADD Acyclovir 400mg TID orally for 10 days( or 200mg five times per day for 10
days)
© University of Cape Town

Adult 39
1
Known with HIV or lymphoma, pregnant or receiving chemotherapy or corticosteroids. 2If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), omit ceftriaxone and refer.
*This addresses illnesses including Treponema Pallidum(Syphilis, Herpes Virus 1 &2 and Heamophylus ducreyia(Lymphogranuloma Venarum)
Other genital symptoms
First assess and advise patient and partner/s 36.

Lumps Itchy rash in pubic area

Genital warts Molluscum Pubic lice Scabies

• Test for syphilis. If positive 41. contagiosum • Treat patient and partner/s • Treat patient,
• Choose treatment based on availability and/or patient choice. • Papules with • Apply thin film of partner/s and
• Patient administered: central dent permethrin 1% or 5% household contacts
--Apply imiquimod 5% cream directly to warts. Wash off after 6-10 hours. • Usually self- cream to affected areas • Apply permethrin
Apply 3 times weekly for 16 weeks. limiting and and adjacent hairy areas. 5% from the neck
--Alternatively, apply podophyllotoxin 0.5% cream BID for 3 days followed no treatment Wash off after 10 minutes. down. Wash off after
by 4 days of no treatment. Repeat cycle up to 4 times. required. Avoid mucous membranes, 8-14 hours. Avoid
• Provider administered: • If HIV positive, urethral opening and raw mucous membranes,
--Apply Vaseline® to surrounding normal skin and then apply trichloroacetic should resolve areas. Repeat after 7 days if urethral opening and
acid 30-90% solution directly to warts weekly until wart resolves. with ART. needed. raw areas.
--Alternatively, apply podophyllin resin 10-25% directly to warts. Wash after • If no response • Wash all clothes, sheets and • Repeat after 1 week
1-4 hours. Repeat weekly until wart resolves. to treatment, blankets in very hot water. if needed. © BMJ Best Practice
• Do cervical screen. © University of Cape Town refer. • Iron all clothing • Wash clothes in hot water or iron clothes
• If warts > 1cm, multiple, in vagina or on cervix, pregnant or medications not available, refer. • Shave pubic area after normal wash.
• Reassure patient that most warts resolve spontaneously within 2 years.

Cervical screening
• 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.

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.

Inform patient of symptoms of cervical cancer (abnormal vaginal bleeding, vaginal discharge, postcoital/contact bleeding) and advise her to return should they occur.

Adult 40
Positive syphilis result
Approach to the patient with a positive RPR result
First assess and advise the patient and his/her partner/s 36.

Is previous RPR result available?

No Yes

Does patient have a genital ulcer or signs of secondary syphilis1? Is there a negative RPR from the last 2 years?

No Yes Yes No

• Treat for late syphilis: • Treat for early syphilis: • Treat for late syphilis:
--Give benzathine benzylpenicillin 2.4MU IM weekly for 3 weeks. --Give single dose benzathine benzylpenicillin 2.4MU IM. --Give benzathine benzylpenicillin 2.4MU IM weekly for 3 weeks.
--If penicillin allergic and not pregnant/breastfeeding, give --If penicillin allergic and not pregnant/breastfeeding, give --If penicillin allergic and not pregnant/breastfeeding, give
instead doxycycline 100mg PO BID for 28 days. instead doxycycline 100mg PO BID for 14 days. instead doxycycline 100mg PO BID for 28 days.
--If penicillin allergic and pregnant/breastfeeding, give instead --If penicillin allergic and pregnant/breastfeeding, give --If penicillin allergic and pregnant/breastfeeding, give instead
erythromycin 500mg PO QID for 30 days. instead ceftriaxone 1g IM daily for 8-10 days. erythromycin 500mg PO QID for 30 days.
• Repeat RPR in 6, 12 and 24 months. If positive RPR at 24 months, • Repeat RPR in 6 and 12 months. If RPR positive at 12 months, • Repeat RPR in 6, 12 and 24 months. If RPR positive at 24 months,
refer. refer. refer.
• Treat partner/s 36. • Treat partner/s 36. • 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.

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. 2Signs 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.
Adult 41
Abnormal vaginal bleeding (AVB)
Give urgent attention to the patient with vaginal bleeding and one or more of:
• Pregnant 112 • Following miscarriage/abortion 112
• BP < 90/60 • Pallor with pulse ≥ 100, respiratory rate > 30,
• Postpartum 116. 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 Periods have Bleeding after sex Spotting between periods
bleeding > 7 days each period irregular pattern
(< 21 days or
• Assess for STI 36. • Assess for STI 36.
> 35 days
Has the patient been bleeding elsewhere • If assault or abuse 66. • If on hormonal contraceptive, manage according to method:
between periods)
(gums, easy bruising, purple rash)?

• If weight Oral contraceptive: Injectable contraceptive or

Yes No change, pulse • Ensure correct use. subdermal implant:
≥ 100, tremor, • If ≥ 2 days diarrhoea/ • Reassure (common in first 3 months).
weakness/ vomiting, advise condom • If bleeding persists, give combined
• Check • If Hb ≤ 12g/dL, give ferrous sulphate 200mg (65mg
tiredness, dry use (continue for 7 days oral contraceptive: ethinylestradiol/
complete elemental iron) 1 tablet PO TID until 3 months after
skin, constipation once diarrhoea/vomiting levonorgestrel 30/150mcg for
blood Hb reaches 12g/dL.
or intolerance to has resolved). 3 cycles.
count. • Give combined oral contraceptive: ethinylestradiol/
cold or heat, refer • If on ART, rifampicin or • If combined oral contraceptive
• Refer to levonorgestrel 30/150mcg for 3 cycles 110.
to hospital. phenytoin, change to contraindicated (heart disease,
hospital • If combined oral contraceptive contraindicated
• Give injection/IUD. thrombo-embolic conditions, liver
same (heart disease, thrombo-embolic conditions, liver
combined oral • If on ethinylestradiol/ disease, migraine headache, genital
week. disease, migraine headache, genital tract cancer),
contraceptive: levonorgestrel tract cancer), give instead ibuprofen
or pregnancy desired, give instead ibuprofen
ethinylestradiol/ 30/150mcg, change 400mg PO TID with food for 5 days
400mg PO TID with food for 5 days (avoid if peptic
levonorgestrel to ethinylestradiol/ (avoid if peptic ulcer, asthma,
ulcer, asthma, hypertension, heart failure or kidney
30/150mcg for norethisterone hypertension, heart failure or kidney
disease).
6 months. 35mcg/1mg for 3 cycles. disease).
• If on injectable contraceptive or subdermal implant:
reassure (common in first 3 months). If bleeding • If pregnancy
persists, give combined oral contraceptive or desired, refer Refer the patient within 2 weeks if:
ibuprofen as above. instead. • Unsure of diagnosis
• Refer the patient: • Bleeding > 1 week after STI treatment, or after diarrhoea/vomiting stop
--Same week if mass in abdomen • Bleeding persists after 3 months on treatment.
--If no better after 3 months on treatment • Abnormal cervix on speculum examination (suspicious of cancer)
--If excessive bleeding after IUD insertion
Adult 42
Sexual problems
Ask about problems getting or maintaining an erection, pain with sex, painful ejaculation or loss of libido:

Problems getting or maintaining an erection Painful erection Pain with sex (vaginal) Loss of libido
orejaculation
Does patient often wake with an erection in the morning? Is the pain superficial or deep? Ask if pain with sex or if problem
• If genital with erections. Assess and manage in
symptoms 36. adjacent columns.
Yes No Superficial pain Deep pain
• If urinary
symptoms 44.
• Review • Assess and manage stress 65.
• Assess and manage • Assess and manage CVD risk • If genital symptoms 36. • If genital
medication: herbal • Review medication: phenytoin, metoprolol,
stress 65. 84. • If urinary symptoms 44. symptoms 36.
medication, hydrochlorothiazide, spironolactone,
• Ask about relationship • Review medication: • Ask about vaginal dryness: • Refer if:
antidepressants chlorpromazine, fluphenazine decanoate,
problems, anxiety/ propranolol, atenolol, --If woman > 40 years, --Heavy, painful
and schizophrenia risperidone, fluoxetine, amitriptyline and
fear about sex, hydrochlorothiazide, ask about menopausal or prolonged
treatment can lopinavir/ ritonavir can cause loss of libido.
unwanted pregnancy, spironolactone, fluphenazine symptoms: hot flushes, periods
cause painful Consider changing medication.
infertility and decanoate, fluoxetine and night sweats, mood --Infertility
ejaculation. • In the past month, has patient: felt
performance anxiety. amitriptyline can cause changes and difficulty --Abdominal/pelvic
Consider changing depressed, sad, hopeless or irritable or
• If sexual assault or sexual problems. Consider sleeping 119. mass
medication. worrying a lot, had multiple physical
abuse 66. changing medication. --Review medication: oral or
• If no cause complaints, felt little interest or pleasure in
• In the past month, • Screen for substance use/ injectable contraceptive,
found or painful doing things? If yes to any 99.
has patient: felt abuse: In the past year, has antidepressants and
ejaculation or • Screen for substance use/abuse: In the
depressed, sad, patient: 1) drunk ≥ 4 drinks1/ hypertension treatment
erection continues, past year, has patient: 1) drunk ≥ 4 drinks1/
hopeless or irritable session, 2) used khat or can cause vaginal dryness.
refer. session, 2) used khat or illegal drugs or
or worrying a lot, illegal drugs or 3) misused Consider changing
3) misused prescription or over-the-counter
had multiple physical prescription or over-the- medication.
medications? If yes to any 103.
complaints, felt little counter medications? If yes • Advise patient to use
• Ask about relationship problems, anxiety/
interest or pleasure in to any 103. lubricant during sex. Ensure
fear about sex, unwanted pregnancy,
doing things? If yes to • If patient smokes tobacco it is condom- compatible,
infertility and performance anxiety.
any 99. 102. Support patient to avoid using petroleum jelly
• If woman > 40 years, screen for menopause
• Discuss condom use. change 125. with condoms.
Ensure patient knows • Assess and manage stress 119.
• If sexual assault or abuse 66.
how to use condoms 65. • Assess and manage stress 65. • Assess the patient’s contraception needs
correctly. • If no better once chronic
condition/s stable and • If sexual assault or abuse 66. 110.
treatment optimised, refer.

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 43
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 Burning urine or leucocytes/nitrites on urine dipstick Flow Problem

Has patient been in bilharzia area? Check dipstick and microscopy to
exclude urinary tract infection.
Woman Man
Yes No
Leakage of urine Poor stream
Is patient pregnant, catheterised, No discharge Discharge
or difficulty
Schistosomiasis Does patient have known with diabetes or urinary Are there leucocytes and nitrites on
passing urine
likely burning urine? tract problem? midstream urine? Urinary
• Give single dose incontinence
praziquantel likley Benign
No No Yes Yes No
40mg/kg. • Review use of Prostatic
• To prevent re- furosemide hyperplasia
infection advise Leucocytes/nitrites Simple urinary Check for Urethral discharge • Look for vaginal likely.
patient to avoid on urine dipstick? tract infection tender prostate. syndrome likely 37. atrophy 119. • Review
contact with likely • Ask about use of
contaminated • Give ciprofloxacin constipation amitriptyline.
No Yes No Yes
water. 500mg PO BID 35. • Refer for
for 3 days or • Advise patient assessment.
Kidney norfloxacin Complicated urinary Acute prostatitis likely to cut down
If no response to stone likely tract infection likely • Give ciprofloxacin 500mg
400mg PO BID for alcohol and
treatment, refer. Refer for • Give ciprofloxacin PO BID for 21 days.
3 days. caffeine and to
investigation. 500mg PO BID for 7 days. • Give ibuprofen 400mg PO do pelvic muscle
• If pregnant, give instead TID with food for up to exercises3.
cefalexin 500mg PO BID 5 days (avoid if peptic ulcer, • If patient has
or amoxicillin2 500mg asthma, hypertension, heart vaginal prolapse
PO TID for 7 days . failure or kidney disease). or no response
to above
If symptoms do not resolve or recurrent urinary tract infections, refer to hospital. measures, refer.

1
If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria) and able to take orally, give instead ciprofloxacin 500mg PO (avoid if pregnant). 2If penicillin allergic give instead co-trimoxazole 960mg PO BID for 7 days.
3
Repeated contraction and relaxation of pelvic floor muscles.
Adult 44
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 • If temperature ≥ 38°C or fever in

Screen for a joint problem: ask patient to place hands behind head, then behind back. Bury nails in palm and open hand. the past 3 days 17.
Press palms together with elbows lifted. Walk. Sit and stand up with arms folded. • If weight loss ≥ 5% of body
weight in past 3 months 16.
• If sore throat 27.
Unable to do all actions comfortably Able to do all actions comfortably • If runny/blocked nose 26.

Examine the joints.

Joints are warm, tender, Joints are normal.

swollen, have limited
movement.
• Test for HIV 75.
• Assess and manage stress 65.
Arthritis likely 107 • 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:

< 3 months ≥ 3 months

• Give paracetamol 1g • Give paracetamol 1g PO QID as needed for up to 5 days. Advise to avoid
PO QID as needed for long term regular use.
up to 5 days. • Check ESR ,urine protein, blood glucose and Hb.
• Advise patient to • If weakness/tiredness, weight gain, low mood, dry skin, constipation or cold
return if no better after intolerance: hypothyroidism likely. Refer to hospital.
2 weeks.
Results all normal Any result abnormal

• Assess and manage stress 65. Refer for further assessment.

• Consider fibromyalgia 109.

Adult 45
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

Joint problem unlikely Has there been recent trauma?

• If generalised body pain 45. No Yes

• If back pain 47.
• If neck pain 48.
Ask about duration of joint pain Musculoskeletal
• If arm symptoms 48.
sprain/strain likely
• If leg symptoms 49.
• Rest and elevate joint.
• If foot symptoms 50. < 6 weeks ≥ 6 weeks
• Apply ice.
Recent genital discharge or painless non-itchy skin rash?
• Apply pressure bandage.
Chronic arthritis • Give paracetamol 1g PO QID
Yes No likely 107 as needed for up to 5 days. If
no response, give ibuprofen
400mg PO TID with food as
Gonococcal Sudden onset of 1-3 warm, extremely painful, red, needed for up to 7 days (avoid
arthritis likely swollen joints (often big toe or knee)? ibuprofen if peptic ulcer,
• Usually involves asthma, hypertension, heart
wrists, ankles, failure or kidney disease).
No Yes
hand and feet. • Advise patient to mobilise joint
• Refer patient after 2-3 days, if not too painful.
same day. • Give paracetamol 1g PO QID as needed for up Acute gout likely • Advise to avoid traditional
• Treat patient’s to 5 days. If no response, give ibuprofen 400mg 108 practices like massage.
partner/s as for PO TID with food as needed (avoid ibuprofen if • Review after 1 week: if no
cervicitis/male peptic ulcer, asthma, hypertension, heart failure better, refer and if available
urethritis 36. or kidney disease). arrange x-ray.
• Test for HIV 75.
• Review after 1 month or sooner if joint pain
worsens. If worsens, refer.

Adult 46
Back pain
Give urgent attention to the patient with back pain and one or more of:
• Bladder or bowel disturbance - retention or incontinence • Any palpable abdominal mass
• Numbness of buttocks, perineum or legs • If flank pain or fever, check urine dipstick:
• Leg weakness or difficulty walking --If leucocytes/nitrites, pyelonephritis likely. If also vomiting, BP < 90/60, pulse ≥ 100,
• Recent trauma and x-ray unavailable or abnormal temperature > 39°C, pregnant, ≥ 60 years or chronic illness: complicated pyelonephritis likely
• Sudden severe upper abdominal pain with nausea/vomiting: pancreatitis 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.

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 No

Exclude TB 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?
71 and
Yes No

• If available, do back x-ray. Any of: < 40 years, sleep disturbed by pain, pain better with exercise, does not get better with rest?
• Check ESR.
• Refer to hospital. No Yes Unsure

Mechanical back pain likely Inflammatory

• Measure waist circumference: if > 80cm (woman) or > 94cm (man) assess CVD risk 84. back pain likely
• Assess and manage stress 65.
• Reassure patient that back pain is very common, normally not serious and will get better on its own. • If available, do back x-ray
• Advise patient to be as active as possible, continue normal activity and avoid resting in bed. • Check ESR.
• Advise patient that regular exercise may prevent recurrence of back pain. • Refer to hospital.
• 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.
1
If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid ceftriaxone and refer. 2Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease.
Adult 47
Neck pain
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 No

• Arrange cervical spine x-rays if available. • Give paracetamol 1g QID PO as needed for up to 5 days.
• Check ESR and refer to hospital. • 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.

Arm symptoms
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.

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.

Approach to the patient with arm symptoms not needing urgent attention

Painful shoulder Wrist/hand pain: intermittent, worse Elbow pain with or after elbow flexion/extension. Pain at base of thumb worsened by thumb or wrist
at night, relieved by shaking. May be May have decreased grip strength. movement or catching/locking of finger
Referred pain likely numbness/tingling in 1st, 2nd and
Ask about neck pain (see above), 3rd fingers or weakness of hand. Tennis or Golfer’s elbow (medial/lateral epicondylitis) likely Tenosynovitis of hand/wrist likely
cough/difficulty breathing 29, • Advise patient to apply ice to elbow and rest arm. • Rest and splint joint.
abdominal pain 32, Carpal tunnel syndrome likely • Give ibuprofen2 400mg PO TID with food for 10 days. • Give ibuprofen2 400mg PO TID with food for up
pregnancy 112. Refer. • If no better after 6 weeks or worsens, refer. to 14 days.
• If no better after 6 weeks or worsens, refer.
1
If severe penicillin allergy with previous angioedema, anaphylaxis or urticaria, give chloramphenicol only and refer. 2Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease.
Adult 48
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.

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.

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

Pain in buttock radiating down Muscle pain Both legs swollen One leg swollen
back of lower leg in legs or Is there difficulty breathing
buttocks on worse on lying flat?
exercise that Has there been a recent injury?
Irritation of sciatic nerve likely is relieved
• Give paracetamol 1g PO BID and by rest
Yes No
Yes No
ibuprofen1 400mg PO TID with
food only as needed for up to
Heart • If pregnant
1 month (avoid ibuprofen if peptic Peripheral Musculoskeletal sprain/strain likely Examine skin: are there any painful areas,
failure 112.
ulcer, asthma, hypertension, heart vascular • Ensure patient can bear weight on leg, ulcers, lumps or changes in skin colour?
likely • Check for kidney
failure or kidney disease). disease likely otherwise refer same day.
91. disease on urine
• Advise patient to be as active as 96. • Rest and elevate leg.
dipstick: if blood Yes No
possible, continue normal activity • Apply ice.
or protein, refer
and avoid resting in bed. • Apply pressure bandage.
to hospital.
• Advise patient to return and refer • Advise patient to mobilise leg after 53 Check for groin lump/s.
• If weight loss and
same day if: 2-3 days, if not too painful.
MUAC < 21cm,
--Retention or incontinence of • Give paracetamol 1g PO QID for up to
malnutrition Yes No
urine or stool 5 days or give ibuprofen1 400mg PO TID
likely 70.
--Numbness of buttocks, with food up to 7 days (avoid ibuprofen
• If none of the
perineum or legs if peptic ulcer, asthma, hypertension, 18 Refer same week.
above or unsure,
--Leg weakness heart failure or kidney disease).
refer to hospital.
--Difficulty walking • Review after 1 week: if no better, refer to
• If no better after 1 month, refer. hospital.

1
Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease.
Adult 49
Foot symptoms
Check if problem is in the joint: ask patient to walk. Sit and stand up with arms folded. If unable to do all actions comfortably 46.

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.

Approach to the patient with foot symptoms not needing urgent attention

Generalised foot pain Localised pain

Constant burning pain, pins/needles or Foot pain Ensure that shoes fit properly.
numbness of feet worse at night with muscle
pain in legs
or buttocks Heel pain, worse on starting walking Foot deformity
Peripheral neuropathy likely
• Test for HIV 75. If HIV positive, give routine care 76.
• Exclude diabetes 86. Peripheral Plantar fasciitis likely Bony lump at base of big toe; may have callus, redness or ulcer
• Give amitriptyline 10-75mg at night and paracetamol vascular • Advise patient to avoid bare feet and to apply ice.
1g PO QID. If no response, add ibuprofen 400mg PO disease • If BMI > 25, assess CVD risk 84.
Bunion likely
TID with food up to 5 days (avoid if peptic ulcer, asthma, likely • Give as needed: paracetamol 1g PO QID or
• Advise pain relief as needed: apply ice, give paracetamol 1g
hypertension, heart failure or kidney disease). 96. ibuprofen 400mg PO TID with food for up to
PO QID or ibuprofen 400mg PO TID with food for up to 5 days
• Refer same week if one-sided, other neurological signs or 5 days (avoid ibuprofen if peptic ulcer, asthma,
(avoid ibuprofen if peptic ulcer, asthma, hypertension, heart
loss of function. hypertension, heart failure or kidney disease).
failure or kidney disease).
• Check if patient is on IPT, TB treatment or ART: • Refer to hospital for physiotherapy.
• Advise to wear comfortableshoes when possible.
--If on IPT or TB treatment: give pyridoxine 75mg daily. • If severe pain, ulcer or other foot deformity refer.

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. • Avoid walking barefoot or wearing shoes without socks. Change socks/stockings daily. Inspect inside shoes daily.
• Moisten dry cracked feet daily with Vaseline®. Avoid moisturising between toes. • Clip nails straight, file sharp edges. Avoid cutting corns/calluses yourself or chemicals/plasters to remove them.
• Tell your health worker at once if you have any cuts, blisters or sores on the feet. • Avoid testing water temperature with feet or using hot water bottles or heaters near feet.

Adult 50
Burn/s
Give urgent attention to the patient with burn/s:
Give facemask oxygen if: Calculate % total body surface area (TBSA):
• Burns to face, neck or upper chest • Head 9% • Front 18% • Each arm 9%
• Cough, difficulty/noisy breathing or hoarse voice: inhalation burn likely • Neck 1% • Back 18% • Each leg 18%
• Patient drowsy or confused
• Oxygen saturation < 90%
• Percentage total body surface area (%TBSA burnt) > 15%
9%
Remove any sources of heat:
• Remove burnt or hot clothing. Immerse burnt skin in cool water or apply cool, wet towels for 30 minutes. 1%
• Cover patient with clean, dry sheet to prevent hypothermia.
Front
Calculate size and depth of burn: 18%
• Calculate percentage total body surface area (%TBSA) burnt using adjacent guide.
• If red, blistered, painful, wet: partial thickness burn likely
9% Back 9%
• If white/black leathery, painless, dry: full thickness burn likely
18%
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: 18% 18%
--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:
--Burn covering > 10% TBSA --Burn involves face/neck/hands/feet/genitals/joint --Inhalation/electric/chemical burn
--Full-thickness burn of any size --Circumferential burn of limbs/chest --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 51
Bites and stings
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.

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

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

• Remove loose/dead skin and clean wound with soap and water. Irrigate under pressure with normal saline for 15 minutes. Avoid suturing the wound. • Remove stinger. Clean wound with soap
• 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: and water. Apply ice pack for pain/swelling.
--Clean wound thoroughly with povidone iodine or hydrogen peroxide or chlorhexidine solution. • If itch and rash, give loratadine 10mg PO
--Give rabies vaccine 1 ampoule IM into shoulder/upper arm muscle immediately and repeat on day 3. If patient unimmunised or unsure, repeat vaccine daily and ranitidine 150mg PO daily for
on day 7 and 14 and if impaired immunity1, also give a 5th dose on day 28. If unavailable, refer to hospital. 3 days. If no response, give prednisolone
--If patient unimmunised, also give rabies immunoglobulin 20 units/kg immediately. Inject most into wound, and the rest IM at a distant site. 60mg PO daily for 5 days.
• 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 • If pain, give ibuprofen5 400mg PO TID with
TID and metronidazole4 500mg PO TID for 7 days. food for up to 5 days.
• If human bite has broken the skin, also assess need for HIV and hepatitis B post-exposure prophylaxis 68. • If very painful scorpion sting, inject
• Give paracetamol 1g PO QID as needed for up to 5 days. lidocaine 2% 2mL around site.
• If bite infected and no response to antibiotics, refer.

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.

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. 2Known with HIV, diabetes, cancer,pregnancy or receiving chemotheraphy or corticosterroid. 3If
penicillin allergy give instead clindamycin 300mg QID and cotrimoxazole 160/800mg BID for 7 days. 4Advise no alcohol until 24 hours after last dose of metronidazole. 5Avoid if peptic ulcer, asthma, hypertension, heart failure or kidney disease.
Adult 52
Skin symptoms
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

Pain Itch Generalised, Lump/s Ulcers Crusts Changes in

non-itchy rash skin colour
54 No rash Rash 58 59 59
57 60
Localised Generalised

55 56

If rash is extensive, recurrent or difficult to treat, test for HIV 75.

1
If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), give chloramphenicol only and refer.
Adult 53
Painful skin
Firm, red, warm lump which softens in the Sudden swelling of skin with redness, pain and warmth Painful blisters in
centre to discharge pus Are borders poorly or clearly defined? a band along one side

Poorly-defined borders Clearly-defined borders

© University of Cape Town © University of Cape Town

© University of Cape Town CDC Public Health Image Library

Furuncle/carbuncle/boil/abscess likely Herpes zoster (shingles) likely
• Advise patient to wash with soap and water, Cellulitis likely Erysipelas likely • Test for HIV 75.
keep nails short, and avoid sharing clothing • Give cloxacillin 500mg PO • Advise to keep lesions clean and dry, and avoid
• Give cloxacillin 500mg PO
or towels. QID for 7 days. If penicillin QID for 5 days. If penicillin skin contact with others until crusts have formed.
• If fluctuant, incise and drain. allergic, give instead allergic, give instead • Apply calamine lotion to rash 4 times a day as
• If multiple lesions, extensive surrounding erythromycin 500mg PO QID erythromycin 500mg PO QID needed.
infection or impaired immunity1, give for 7 days. for 5 days. • Give aciclovir 800mg 5 times a day for 7 days if
cloxacillin 500mg PO QID for 7 days. If • Give paracetamol 1g PO QID ≤ 3 days since onset of rash (or if ≤ 1 week since
• If HIV+ Amoxicillin 500 mg TID
penicillin allergic, give instead erythromycin as needed for up to 5 days. onset of rash if impaired immunity1).
500mg PO QID for 7 days. for 14 days or erythromycin 500 • For pain:
• Give paracetamol 1g PO QID as needed for mg QID if allergic penicillin. --Give paracetamol 1g PO QID for up to 5 days.
up to 5 days. • Give paracetamol 1g PO QID as --If needed add tramadol 50mg PO BID for 5 days.
• If recurrent boils or abscesses: needed for up to 5 days. --If poor response or pain persists after rash
--Test for HIV 75 and diabetes 86. has healed, give amitriptyline 25mg at night.
--Wash once with chlorhexidine 5% solution Increase by 25mg every week to 75mg if needed.
from neck down. • Refer if: • If infected, give cloxacillin 500mg PO QID
• Refer if: - Temperature ≥ 38°C for 7 days. If penicillin allergic, give instead
--Difficult area to drain (face, genitals, hands) - BP < 90/60 or pulse > 100 erythromycin 500mg PO QID for 7 days.
--No response to treatment within 2 days - Confused • Refer same day if:
- Face or eye involvement --Eye, ear or nose involvement
- Blisters or grey/black skin --Signs of meningitis (headache, temperature
- Poorly controlled diabetes or stage 4 ≥ 38°C, neck stiffness/meningism)
HIV --Rash involves more than one region
- No response to treatment within 2 days

1
Known with HIV, diabetes or cancer or receiving chemotherapy or corticosteroids.
Adult 54
Itch with localised rash
Slow-growing ring-like patch/es Scaling moist lesions Intense itch on scalp Well demarcated, pink, raised plaques Itchy flat purple Oval shaped plaques
with raised edge between toes or or in pubic area covered with silvery scales, usually on papules/plaques with scales at the edges
on soles of feet elbows, knees, trunk and scalp over trunk,
arms and thighs
Lice likely
Look for lice or eggs
in hair and small red
dots from bites.

• Apply malathion
1% lotion to scalp.
© University of Cape Town Rinse after 2 hours.
CDC Public Health Image Library Repeat after 1 week.
© St. Paul's Hospital Millennium Medical College
Tinea (ringworm) likely • Soak all combs © St. Paul's Hospital Millennium
• If extensive or involves nails, test for HIV 75. Tinea pedis (Athlete's and brushes in © St. Paul's Hospital Medical College
If HIV positive, give routine care 76. foot) likely permethrin for at Psoriasis likely Millennium Medical College
• Advise to keep skin clean and dry and avoid • Apply clotrimazole or least 2 hours.
• Wash clothes and Pityriasis rosae likely
sharing towels/clothes. ketoconazole cream • Apply betamethasone 0.1% Lichen Planus likely • Apply liquid paraffin
• Apply clotrimazole or ketoconazole cream twice a day. Continue linen in very hot
water. ointment twice a day. For face, use • Apply liquid once daily.
twice a day. Use for 1 week after rash has for 1 week after rash hydrocortisone 1% cream only. Reduce paraffin once daily. • Reassure patient that it
cleared. has cleared. • Treat household
contacts if infected to once a day when improvement seen. • Apply should resolve within
• If rash on scalp or no response to terbinafine, • Advise to wash and Stop as soon as better. betamethasone 3 weeks.
give griseofulvin 500mg daily until cured (up dry feet well. or share a bed. If
pubic lice, also treat • Advise to avoid using soap and to ointment over the • If persists after 3 weeks,
to 8 weeks) or fluconazole 200mg PO daily • Encourage open moisturise skin 3 times a day. lesion once daily for apply momethason
for 2-4 weeks. shoes/sandals. sexual partners.
• If extensive or no better after 1 month, 1-2 weeks. ointment once daily for
refer. 1 to 2 weeks.

Itch with no rash

Confirm there is no rash, especially scabies, lice or other insect bites.
Is the skin very dry?

No Yes
Did the patient start any new medications in the weeks before the itch started?
Dry skin (xeroderma) likely
Yes No • Advise to avoid soap (wash with aqueous
Medication side-effect likely • Advise to avoid hot baths and soap (wash with aqueous cream instead). cream instead).
• Continue the medication only if no rash and treatment still necessary. • Moisturise skin twice a day. • Moisturise skin twice a day.
• For itch, give loratadine 10mg or cetirizine 10mg PO daily for 5 days. • Give loratadine 10mg or cetirizine 10mg PO daily for 5 days. • For itch, give loratadine 10mg or
• Advise patient to return immediately if rash develops. • If itch persists, refer cetirizine 10mg PO daily.

Adult 55
Generalised itchy rash
Widespread, very itchy rash with burrows, Itchy bumps on extremities or lower trunk. Itchy, thickened, hyperpigmented rash Very itchy, red, raised wheals that appear
in web-spaces of hands/feet, axillae and Skin often remains hyperpigmented. with associated allergic rhinitis, allergic suddenly and usually disappear within 24 hours
genitals. Especially itchy at night. conjunctivitis and other allergies.

© University of Cape Town © St. Paul's Hospital Millennium Medical College

© University of Cape Town

Papular pruritic eruption (PPE) likely © St. Paul's Hospital Millennium Medical College © Urticaria likely
Scabies likely • Test for HIV 75. If HIV positive, give Commonly due to allergy to
• Apply permethrin 5% cream or benzyl routine care 76. food/medication/insect sting
Eczema likely
benzoate 25% lotion or sulphur 5-10% • May temporarily worsen when starting ART.
• Moisturise skin twice a day and immediately
ointment. Avoid eyes and mouth. • First treat for scabies in adjacent column.
after bathing. If sudden rash with difficulty breathing,
Wash off after 12 hours. Repeat for 3 • Moisturise skin twice a day.
• Avoid frequent bath with soap. BP < 90/60 or collapse,
consecutive nights. • Apply betamethasone 0.1% cream twice
• Apply hydrocortisone 1% cream twice a anaphylaxis likely 53.
• Treat all household contacts and sexual a day. For face, use instead hydrocortisone
day until improved (up to 4 weeks). If poor
partners at the same time, even if 1% cream.
response, apply betamethasone 0.1% cream
asymptomatic. • For itch, give loratadine 10mg or cetirizine
twice a day (avoid face). Approach to the patient not needing
• Wash linen and clothing in very hot water 10mg or diphenhydramine 25-50mg PO
• For itch, give loratadine 10mg or cetirizine urgent attention:
and dry well. daily until itch subsides.
10mg or diphenhydramine 25-50mg PO daily • Identify and remove cause.
• For itch, give loratadine 10mg or
until itch subsides. • Give loratadine 10mg or cetirizine 10mg PO
diphenhydramine 25-50mg PO daily
• If infected, treat with cloxacillin 500mg PO daily until rash resolved.
until itch subsides.
QID for 7 days. If penicillin allergic, give instead • If no response after 24 hours, give
erythromycin 500mg PO QID for 7 days. prednisolone 40mg PO daily for 5 days.
• If patient also has asthma, give routine asthma • Advise patient to return immediately if any
care 82. symptoms of anaphylaxis occur.

• If recently started new medication, check for drug reaction 57.

• If no response to treatment, refer.

Adult 56
Generalised non-itchy red rash
Is patient taking any medication?

Yes No

Drug reaction likely • Check patient does not need urgent attention 53.
• Rash may be mild, patchy spots or widespread (like • If bleeding from gums or purple rash, do complete
burns). blood count and refer immediately.
• Can be caused by any medication. Common causes • Patient may have fever, headache, lymphadenopathy,
are antibiotics, anticonvulsants, antiretrovirals muscle pain.
(especially nevirapine), TB medication, co-trimoxazole • If pain or fever, give paracetamol 1g PO QID as
and NSAIDs (e.g. ibuprofen). © University of Cape Town
needed for up to 5 days.
• Test for syphilis and HIV 75.

Are there any markers of severity? Syphilis test HIV negative HIV
• Temperature ≥ 38°C • Difficulty breathing • Abdominal pain • Involves mouth, eyes or genitals • Severe rash positive positive
• BP < 90/60 • Face or tongue swelling • Vomiting or diarrhoea • Blisters, peeling or raw areas • Jaundice
Rash may be
Secondary syphilis part of HIV Give
Yes No likely seroconversion routine
Is patient taking ART, TB treatment, co-trimoxazole or IPT? Rash often on palms illness. HIV care
and soles. 76.
May have wart-like
Yes No • If risk of HIV
lesions on genitals and
• If on abacavir, check for hypersensitivity reaction 80. If likely, stop ART and refer same day. • If itchy, give infection in
patchy hair loss.
• If itchy, give loratadine 10mg PO daily and apply hydrocortisone 1% cream to rash twice loratadine 10mg past 4 weeks,
a day. or cetirizine repeat HIV
• Check ALT and review result within 24 hours: 10mg PO daily test after
and and apply 4 weeks.
hydrocortisone • Encourage
ALT ALT < 100U/L and patient well patient to
1% cream to rash
≥ 100U/L • Continue medication. follow safe
twice a day.
or patient • If on nevirapine: sex practices.
• Refer if:
unwell --If on once daily dose, avoid increasing until rash resolved.
--Any markers of
--Repeat ALT after 1 week. If ≥ 100U/L, refer same day.
severity develop.
--If rash persists > 4 weeks after starting nevirapine, switch medication 79.
Manage as serious drug --Rash does © University of Cape Town
• If on co-trimoxazole prophylaxis1: stop it until rash resolved. Consider
reaction not improve
re-starting co-trimoxazole or changing instead to dapsone 100mg daily.
Stop all drugs and refer within 2 weeks Treat patient for
• Review patient within 2 days.
same day 53. of stopping/ early syphilis 41.
• Advise patient to return urgently if markers of severity develop.
changing
• If rash no better after 2 weeks, refer to hospital.
medication.
If no better after 1 week, refer.

If generalised non-itchy rash and no obvious cause, refer.

1
If on co-trimoxazole treatment for pneumocystis pneumonia (PJP), toxoplasmosis or Isospora belli diarrhoea, refer to hospital.
Adult 57
Skin lump/s
Refer same week the patient with a mole that:
• Is irregular in shape or colour • Differs from surrounding moles • Bleeds easily
• Changed in size, shape or colour • Is > 6mm wide • Itches

If painful, firm, red, warm lump which softens in the centre to discharge pus, boil/abscess likely 54.

Round, raised papules Small, skin-coloured bumps Painless, Painless lumps on Red lumps on face
with rough surfaces with pearly central dimples purple/brown face and extremities
lumps on skin with overlying scales
or central ulcer Dry skin with Oily skin with white/blackheads
redness and visible
vessels on face

Rosacea likely

© University of Cape Town © University of Cape Town • Advise to avoid

aggravating © University of Cape Town
factors.
Warts likely Molluscum contagiosum • Apply zinc oxide
© St. Paul's Hospital
• Usually on hands, knees likely © BMJ Best Practice Millennium Medical College ointment every Acne likely
or elbows but can occur May be extensive in HIV. morning. May involve chest, back and upper arms
anywhere. • Give doxycycline1
• Plantar warts on the soles Kaposi’s sarcoma Cutaneous leish-
• Test for HIV 75. 100mg PO daily • Advise patient to wash skin with mild soap
of the feet are thick and likely maniasis likely
• Reassure patient that lesions for 1 month or twice a day and to avoid picking, squeezing and
hard with black dot/s. Lesions vary from Do slit skin smear
may resolve spontaneously azithromycin scratching.
isolated lumps to microscopy and
after several years or with ART. 250mg PO • Apply benzoyl peroxide 5% cream twice a day
large ulcerating refer to leishmaniasis
• Reassure patient that • If intolerable, remove 3 times a week for after washing. Continue for 2 weeks after lesions
tumours and may treatment center.
warts often disappear with curettage or apply 6 weeks. have gone. Avoid in pregnancy.
also appear in
spontaneously. podophyllum 15% for • Refer if no • If benzoyl peroxide not available, apply
mouth and
• If treatment desired, apply 4 hours, then wash off. Repeat improvement clindamycin 1% gel and tretinoin 0.025- 0.05%
on genitals.
salicylic acid 5% 1-2 drops podophyllum weekly for up or diagnosis cream once daily.
to wart every night and to 6 weeks. uncertain. • If red, swollen and extensive lesions over chest
cover with a plaster. • If podophyllum not available, • Test for HIV 75. and back, also give doxycycline 100mg PO daily
• Advise patient to soak in protect surrounding skin with If HIV positive, give for at least 3 months. Doxycycline may interfere
warm water for 5 minutes petroleum jelly and apply routine care and with oral contraceptive. Advise patient to use
then scrape wart with nail KOH 5-10% solution with ART 76. condoms as well. Avoid in pregnancy.
file between treatments. cotton tip applicator daily for • Refer for biopsy to • In woman needing contraception, advise
• Continue to apply salicylic 2-3 weeks. confirm diagnosis combined oral contraceptive 110.
acid for a week after wart • If extensive or no resolution and for further • Advise patient that response may take several
has come off. after 4 years and intolerable management. weeks to months.
• If warts are extensive, refer. for patient, refer. • If severe or no response after 6 months of
treatment, refer.
1
Avoid if pregnant.
Adult 58
Ulcers and crusts
Ulcer/s Blisters which dry to form
Is patient usually in bed and is ulcer in common bedsore site (see below)? honey coloured crusts

No Yes

Is ulcer on the leg or foot?

No Yes

• If genital Check leg and foot pulses and if patient has muscle pain in legs or buttocks on exercise. © St. Paul's Hospital Millennium
ulcer 39. Medical College
• If elsewhere Pulses normal and no muscle pain in legs or buttocks on exercise Pulses reduced
on body or muscle pain in Impetigo likely
and no legs/buttocks on Often around mouth or nose.
obvious Is there red/brown darkening of skin around ulcer, spidery veins? May complicate insect bites,
exercise that is
cause like relieved by rest scabies or skin trauma.
trauma, No Yes
refer to
exclude Peripheral • Test for HIV 75.
skin cancer. Does patient have diabetes 86? vascular disease Bedsore likely • Impetigo is contagious:
(PVD) likely • Relieve pressure on ulcer and --Advise patient to avoid
reposition patient every 2 hours. close contact with others
No Yes
• Clean ulcer daily and cover with and to wash with soap and
If sudden severe non- adherent dressing. water twice a day.
• If cough Diabetic ulcer likely leg pain at rest • If infected (skin red, warm or --Advise contacts to avoid
≥ 2 weeks, • Avoid pressure/weight-bearing © BMJ Best Practice with numbness, tender), apply silver sulfadiazine sharing towels and to add
weight on ulcer. weakness, 1% cream to ulcer until infection a spoon of potassium
loss, night • Give foot care advice 50. Venous stasis ulcer likely pallor or no better. permanganate solution
sweats or • Clean ulcer daily and cover with • Encourage exercise. pulse, refer • Give paracetamol 1g PO QID (1:10 000) to bathwater
fever non-adherent dressing. • Advise elevating leg when urgently. as needed for up to 5 days. If 2-3 times a week.
≥ 2 weeks, • If infected (skin red, warm, possible and to avoid needed, add tramadol 50mg PO • Apply fusidic acid cream to
exclude TB painful), give erythromycin prolonged standing. BID for 5 days. lesions and nostrils
71. 500mg PO QID and • Clean ulcer daily • Refer to dietician to ensure 3 times a day for 7 days.
• Apply compression
• Refer for ciprofloxacin1 500mg PO BID and cover with adequate calorie and protein • If extensive or no response
bandage from foot to
further for 10 days. non-adherent intake. to above treatment, add
knee.
assessment. • Give diabetes routine care 86. dressing. • Refer if: cloxacillin 500mg PO QID
• Assess and manage CVD
• Refer if • Avoid --Fat, bone, muscle or tendon for 7 days. If penicillin
risk 84.
--Fever, pus or extensive compression visible allergic, give instead
• Clean ulcer daily and
infection bandage. --Yellow/grey/black tissue erythromycin 500mg PO
cover with non-adherent
--Ulcer > 2cm, or tendon or • Give PVD routine --Extensive or worsening infection QID for 7 days.
dressing.
bone visible care 96, and --Ulcer not healing with treatment • Refer if:
• Refer if:
--Ulcer no better after 2 weeks refer to hospital. • If patient is terminally sick and --Cellulitis or abscess
--Recurrent ulcers
of treatment --No better after 3 months survival is predicted to be short, --Temperature ≥ 38°C
also give palliative care 120. --No response to antibiotic
1
Avoid if pregnant.
Adult 59
Changes in skin colour
Yellow skin Darkening of skin Lightening of skin
Is darkened area only on lower leg/s?
Jaundice likely Is skin smooth or scaly?
Yes No
Refer urgently the patient with Smooth
jaundice and one or more of: Red-brown Is skin smooth or scaly?
• Temperature ≥ 38°C discolouration. May
Is there decreased sensation on the skin lesion?
• Hb < 11g/dL have breaks in skin/
Smooth Scaly
• BP < 90/60 ulcers, spidery veins.
• Severe abdominal pain No Yes
• Drowsy or confused Flat, brown patches on cheeks, Light or dark patches with
• Easy bruising or bleeding forehead and upper lip fine scale. Usually on trunk.
• Pregnant
• Alcohol dependent 103 or
recent alcohol binge (≥ 5 drinks1/
session)
• Using any medication or illegal
drugs

© University of Cape Town © St. Paul's Hospital

Approach to the patient with © BMJ Best Practice © University of Cape Town © University of Cape Town Millennium Medical College
jaundice not needing urgent referral:
• Send blood for ALT, AST, GGT, ALP, Vitiligo likely
Venous stasis likely Melasma likely Tinea versicolor likely • Advise patient to use Leprosy likely
complete blood count. • Do baciliary index,
• Advise patient to return immediately • Encourage exercise. • Hormones and sunlight will • Apply selenium sulfide camouflage cosmetics.
• Advise elevating leg worsen melasma: 2% or ketoconazole 2% • If patient requests treatment morphology index
if any above markers of severity • Check for thickened
develop. when possible and --Advise patient to apply shampoo to neck, trunk, and lesions are limited, apply
to avoid prolonged sunscreen daily and avoid arms and legs. Leave for betamethasone 0.1% cream or enlarged peripheral
• Review patient with results within nerve2 with or without
2 days. standing. sun exposure. 10 minutes, then wash twice a day for at least 3
• Apply compression --Avoid oral contraceptive, off. Repeat daily for months (avoid face). Stop if tenderness and
bandage from foot rather use alternative 1 week. skin thinning, stretch marks or manage accordingly.
Is ALP/GGT predominantly raised? to knee. contraception 110. • Advise that colour may bruising occur.
• Assess and manage --If pregnant, advise patient take months to return • If extensive or no response to
CVD risk 84. lesions may resolve up to to normal. treatment, refer to hospital.
No Yes
• If ulcer: 1 year after pregnancy. • If scale persists or • If distressing to patient, refer
--Clean daily and • Avoid facial products other frequent relapses, give for psychological support.
If ALT/AST raised, send Refer. cover with non- than bland emollients. single dose fluconazole
blood for hepatitis adherent dressing. • Often difficult to treat. If 400mg PO.
serology and refer. --If no better after 3 not responding to above • Recurrence is common
months or recurrent and intolerable for patient, and the patient may
ulcers, refer. refer. need frequent treatment.

If diagnosis is uncertain, refer.

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.
2Check for enlarged nerve at great auricular, median, ulnar, radial cutaneous, peroneal and posterior tibial nerves.
Adult 60
Nail symptoms
If nails long and dirty and patient unkempt, screen for mental health problem and abuse/neglect 66.

Disfigured nail with swollen Pain, redness and swelling of White/yellow Blue/brown/black discolouration of nail
nail bed and loss of cuticle nail folds, there may be pus. disfigured nails

CDC Public Health Image Library

© University of Cape Town © BMJ Best Practice © University of Cape Town

Has there been recent trauma to nail?

Chronic paronychia likely Acute paronychia likely Fungal infection likely
Usually associated with Often with history of trauma, • Test for HIV 75.
excessive exposure to water such as nail biting or pushing • Fungal nail infection is difficult Yes No
and irritants like nail cosmetics, the cuticle. to treat.
soaps and chemicals. • Treat if: Haematoma likely • Review medication: chloroquine,
• Advise patient to stop trauma --Previous cellulitis on affected • Treat if injury < 2 days fluconazole, ibuprofen, lamivudine,
to nail. limb old and painful: phenytoin and zidovudine can cause
• Advise patient to avoid water
• If any pus, incise and drain. --Diabetes --Clean nail with discolouration of nails. Consider
and irritants and to wear
• Advise warm saline soaks for --Painful nail povidone iodine changing medication.
gloves if unavoidable.
20 minutes twice a day. --Cosmetic concerns solution. • Refer same week to exclude melanoma
• Apply betamethasone 0.1%
• Apply fusidic acid 1% cream • Send nail clippings for --Hold finger secure (picture above) if:
cream to swollen nail beds
after soaking. microscopy to confirm and gently twist a --New dark spot on 1 nail which is
twice a day for 3 weeks.
• If severe pain, pus, infection diagnosis before starting large bore needle getting bigger quickly and no recent
• If no response, apply
beyond nail fold or treatment. into nail over centre trauma
miconazole 2% cream twice
temperature ≥ 38°C, give • If fungal infection confirmed, of haematoma. Stop --Discolouration extends into nail folds
a day for 4 weeks.
cloxacillin 500mg PO QID for give fluconazole 400mg PO when blood drains --Band on nail that is:
• If no response, refer.
7 days. If penicillin allergic, once weekly for 6-9 months for through hole. • > 4mm wide

give instead erythromycin finger nails and 12-18 months --Cover with sterile • Getting darker or bigger

500mg PO QID for 7 days. for toe nails. gauze dressing. • Has blurred edges
• Nail is damaged.
• If no response, refer.

Adult 61
Self-harm or suicide
Give urgent attention to the patient who has attempted or considered self-harm or suicide:
Has patient attempted self-harm or suicide?

Yes No: does patient have current thoughts or plans to commit suicide?
• 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 Yes No: has patient had thoughts or plans of self-harm or suicide in past month or
activated charcoal 100g in 500mL water via nasogastric tube. Avoid if paraffin, petrol, performed act of self-harm or suicide in past year?
corrosive poisons, iron, lithium or alcohol.
• If opioid (morphine/codeine) overdose and respiratory rate < 12: give 100% face mask Yes: is patient agitated, violent, distressed or uncommunicative? No
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. Yes No
• 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. High risk of self-harm or suicide Low risk of self-harm
or suicide
• Remove any possible means of self-harm (firearms, knives, pills). Manage patient as below.
• 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.

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.

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.

• 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 62
Aggressive/disruptive patient
Give urgent attention to the aggressive/disruptive patient with one or more of:
• Angry behaviour • Frequently changing body position, pacing
• Loud, aggressive speech • Tense posturing like gripping arm rails tightly, clenching fists
• Challenging, insulting or provocative behaviour • 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?

Yes No

• Give diazepam 5mg PO or haloperidol 2-5mg (2mg if > 65 years) PO. Patient refuses oral medication
• Assess response after 30 minutes:

Patient Patient still aggressive/disruptive after 30 minutes

calm
Decide which medication to sedate patient according to likely cause:

Exact cause unknown Alcohol/drug withdrawal Stimulant drug intoxication Alcohol intoxication Psychosis

Give haloperidol 2-5mg (2mg if elderly) IM or diazepam 10mg IV slowly (avoid IM). Give haloperidol 2-5mg (2mg if elderly) IM.
If confused (without alcohol withdrawal), avoid diazepam if possible.

Assess after 30 minutes:

Patient Partial response No response

calm Repeat same dose of IM • If diazepam used above, give haloperidol 2-5mg (2mg if > 65 years) IM.
medication used above. • If haloperidol used above, give diazepam 10mg IV slowly (avoid IM).

• 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.
Refer the mentally ill aggressive patient same day to hospital: document history, details of involuntary admission, and time and dose of medication given.

Adult 63
Abnormal thoughts or behaviour
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 Abnormally Lack of insight with Dilated pupils, Smells of alcohol, Known alcohol/drug user who Exposure via
over hours/days and/or happy, ≥ 1 of: restlessness, slurred speech, has stopped/reduced intake ingestion/
temperature ≥ 38°C energetic, • Hallucinations paranoia, nausea, incoordination, with tremor, sweating, nausea, inhalation/
talkative, (seeing/ hearing sweating or pulse unsteady gait severe restlessness/ agitation or absorption of
Delirium likely irritable or things which are ≥ 100, BP ≥ 140/90 hallucinations medication/
• Give single dose ceftriaxone2 reckless not there for others Alcohol unknown
2g IV/IM or crystalline around the patient) Stimulant drug intoxication likely Alcohol/drug withdrawal likely substance
penicillin2 4M IU IV with Mania • Delusions (unusual/ intoxication likely • Give thiamine • If no other sedation given, give
chloramphenicol 500mg IV. likely bizarre beliefs) If pulse irregular, 100mg IV/IM. diazepam 10mg PO or IV. Poisoning
• If malaria test3 positive, also • Disorganised chest pain or BP • Give normal • If alcohol withdrawal, also give Refer to
give artesunate 2.4mg/kg IM speech or ≥ 140/90, refer saline 1L thiamine 100mg PO or IV/IM and hospital.
or artemether 3.2mg/kg IM. behaviour urgently to hospital. 6 hourly. oral rehydration solution.
If aggressive 63. • Check for head • If ≥ 8 hours since last alcohol,
Psychosis likely injury. refer to hospital for detoxification.
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.

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.

Add 10 vials of glucose 40% in 1L dextrose in normal saline solution at 30 drops per minute. 2If severe penicillin allergy with previous angioedema, anaphylaxis or urticaria, give chloramphenicol only and refer. 3Test for malaria with parasite slide
1

microscopy or if unavailable, rapid diagnostic test.

Adult 64
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 Encourage patient to take time to relax: Get active Access support
If patient has difficulty Do a relaxing Advise Encourage
sleeping 67. breathing regular patient to
exercise exercise. connect with
each day. friends,
family,
spiritual
leaders
Encourage patient to do activities and community groups like Edir,
Spend time with supportive friends or family. s/he enjoyed previously. Mahber, Senbete.

• 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 65
Traumatised/abused patient
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 HIV and Prevent STIs Prevent pregnancy
hepatitis B 68. • Give single doses of ceftriaxone 250mg IM, • Do pregnancy test. If pregnant 112.
metronidazole1 2g PO and doxycycline 100mg PO BID • If not pregnant, not on reliable contraception and ≤ 5 days since rape, give emergency contraception:
for 7 days. --Give single dose levonorgestrel 1.5mg2 PO. If patient vomits < 2 hours after taking, repeat dose or
• If severe penicillin allergy (previous angioedema, --Insert copper intrauterine device instead 110.
anaphylaxis or urticaria), omit ceftriaxone and give • If > 5 days since rape and emergency contraception not given, repeat pregnancy test 6 – 8 weeks
instead single dose spectinomycin 2g IM. 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 negative: repeat If positive 41.
(if sexual assault) after1 month

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.

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.
1
Advise no alcohol until 24 hours after metronidazole. 2If patient taking ART, rifampicin or phenytoin, offer copper intrauterine device instead or increase single dose levonorgestrel to 3mg. 3One 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
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.

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.

If still no better after 1 month on medication, refer patient for further assessment.

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 67
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

Was there sexual contact, sharps injury, splash to eye, mouth, nose or broken skin?

Yes No

• Give immediate attention: • Reassure that HIV

--If broken skin, clean area immediately with soap and water. and hepatitis B
--If splash to eye, mouth or nose, immediately rinse mouth/nose or irrigate eye thoroughly with water or normal saline. transmission
--If sexual assault 66. is unlikely.
• Assess need for HIV post-exposure prophylaxis: • Avoid giving HIV
or hepatitis B
Patient known Patient HIV negative or unknown: do HIV test 75. post-exposure
HIV positive prophylaxis.
Positive Negative, one positive and one negative or patient refuses HIV test • If unsure, refer to
hospital.
• Send blood for HBsAg, hepatitis C • Give HIV post-exposure prophylaxis (PEP) only if ≤ 72 hours since exposure (ideally within 1 hour):
antibody. If sexual exposure, also check • Give tenofovir/lamivudine 300/300mg and efavirenz 600mg PO daily for 28 days.
syphilis. • If known kidney disease, give zidovudine/lamivudine 300/150mg PO BID instead of tenofovir/lamivudine .
• Avoid giving HIV post-exposure • If source on ART, start PEP as above and refer to hospital to adjust PEP if needed.
prophylaxis, give routine HIV care 76. • 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?

Yes No or not sure

Reassure that hepatitis B transmission is unlikely. Give 1st dose of hepatitis B vaccine 1mL IM.

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.

1
If giving zidovudine, check complete blood count instead of creatinine.
Adult 68
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.
eGFR 1
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
(by referral to hospital) 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.

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. Check source HBsAg result.

Source HBsAg positive or not known Source HBsAg negative

Refer to hospital. 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.

1
Calculate eGFR = [(140 - age) x weight (kg)]/[72x creatinine (mg/dL)]. If patient is a woman, multiply by 0.85.
Adult 69
Malnutrition: routine care
Diagnose malnutrition
The patient has malnutrition if not pregnant MUAC < 18.5 or if pregnant/breastfeeding and MUAC < 23 or if oedema of both feet with no other cause.

Give urgent attention to the patient with malnutrition and one or more of:
• Hb < 7g/dL • Jaundice
• Respiratory rate ≥ 30 29 • Extensive skin lesions
• BP < 90/60 • Very weak, lethargic or unconscious
Management
• If BP < 90/60, give normal saline 250mL IV. Avoid or stop if breathless.
• Refer urgently.

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.

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.
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 70
 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.

Give urgent attention to the presumed TB patient with one or more of:
• Respiratory rate > 30 • Confusion or agitation
• Breathless at rest or while talking • Coughs ≥ 1 tablespoon fresh blood
Management:
• Give ceftriaxone1 1g IV/IM. If unavailable, give amoxicillin1 1g PO.
• Give face mask oxygen.
• Refer same day.

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?

No

Presumed Pulmonary TB (PTB) Yes

Access to same day Xpert service
Presumed
No
Extra-pulmonary
TB (EPTB)
- Documented HIV infection - Seriously sick - Prior TB Rx
- Contact hx with RR/MDR - Congregated setting Yes
- Age <14yrs

No Yes

Submit 3 sputum samples-2 for AFB 1 for Xpert

Send 2 spot sputum samples for AFB and 1 for pert MTB/RIF Send single sputum sample for Xpert MTB/RIF assay

Both sputum AFB negative At least one positive for AFB Review Xpert MTB/RIF assay results3

MTB detected MTB not

• Give doxycycline 100mg PO BID for 7 to 10 days or
clarithromycin 500mg PO BID for 5 to 7 days. detected
If antibiotic use in last 3 months, add amoxicillin 1g PO Diagnose drug-sensitive TB Diagnose rifampicin-resistant TB(RR-TB)
TID for 5 to 7 days. Advise patient to return if no better or
symptoms worsen for re-evaluation. Refer to TIC for RR-TB. Refer to hospital.
Give routine DS-TB care and start DS-TB treatment same day 72:
1
If severe penicillin allergy (previous angioedema, anaphylaxis or urticaria), avoid and refer. 2If patient previously tested negative for AFB and no better after antibiotic therapy. 3If unsuccessful or error result seen, repeat with new sample. 4Avoid if pregnant.

Adult 71
MALNUTRITION TB
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 • Trace and screen symptomatic contacts, HIV positive contacts and contacts < 15 years of age for TB.
symptomatic • Exclude TB and administer TPT(daily INH for 6 mo|HP weekly for 12 wks|RH daily for 3 mo) to asymptomatic contacts < 15 yrs of age and to HIV+ 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 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
poor 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 Test for HIV 75. If HIV positive and not already on ART, start ART once tolerating TB treatment 76:
unknown • 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, End of month 2, month 5 • IIf smear negative at end of month 2, change to continuation phase.
if smear positive at diagnosis and month 6 • If smear positive at end of month 2, manage as on month 2 smear positive algorithm 74.

Treatment outcome End of treatment Manage according to smear status at diagnosis:

• Smear positive at diagnosis:
- If smear or culture negative at at the last month of treatment and on atleast one previous occasion assign “Cure” outcome.
- If AFB positive at either month 5 or month 6, assign “Treatment failure” outcome and refer to hospital.
- A TB patient who completed treatment without evidence of failure BUT with no record to show that sputum or culture results in the last month of
treatment were negative, either because tests were not done or because results are unavailable, 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.

Advise and treat the patient with TB 73.

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 72
 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.

Treat the patient with TB

• Treat the patient with TB 7 days a week for 6 months: Intensive phase: 8 weeks Continuation phase: 4 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 Weight RHZE (150/75/400/275) RH (150/75|300/150)
positive at end of 2 months, manage further 74. 20-29kg 11/2 tablets 11/2 tablets (150/75)
• If TB meningitis, TB spine or TB of hip or knee, extend continuation phase to 10 months. 30-39kg 2 tablets 2 tablets (150/75)
• If TB meningitis or TB pericarditis, also give prednisolone 60mg PO daily for first 4 weeks, then gradually 40-54kg 3 tablets 3 tablets (300/150)
taper off over the next 4 weeks.
≥ 55kg 4 tablets 4 tablets (300/150)
• Give pyridoxine 50mg PO daily until treatment completed.
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 Most TB medications Stop all medications and refer Nausea/poor appetite Rifampicin Take treatment at night. Give metoclopramide 10mg PO TID up to 5 days.
vomiting same day. Joint pain Pyrazinamide Give ibuprofen 400mg PO TID up to 5 days (avoid if peptic ulcer, asthma,
Skin rash/itch Most TB medications Assess and manage 53. hypertension, heart failure or kidney disease).
Loss of colour vision Ethambutol Refer same day. Orange urine Rifampicin Reassure.
Burning feet Isoniazid Increase pyridoxine to 100mg PO daily.

Review the patient with DS-TB at diagnosis, at 2 weeks and then once a month throughout DS-TB treatment.

Adult 73
 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 and FL-LPA, Start continuation phase. 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 Rifampicin or INH or bothresistant

Diagnose RR/MDR-TB or Hr-TB

• Stop First line TB Rx;
• Assign “Moved to DRTB” as outcome,
At the end of month 5 and month 6, send sputum specimen for smear. and and refer to DRTB center

Smear positive Smear negative

Assign treatment failure. Assign cured/completed

• Stop treatment Stop treatment at 6 months.
• Refer to hospital

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:

Treated for <1 month Treated for 1-2 months Treated for >2 months

Interrupted for Interrupted for Interrupted for Interrupted for Interrupted for Interrupted for 2-7 weeks
2-7 weeks >8 weeks 2-7 weeks >8 weeks ≥ 8 weeks

• Restart TB IRestart TB Treatment Smear +Ve Smear +Ve Smear -Ve

Smear -Ve
• treatment. Perform DST(Xpert, FL-LPA
and/or Conventional DST
Continue Treatment at the For Both Smear +ve and -ve Continue Treatment at
point it was stopped Perform DST (Xpert test and FL-LPA/or conventional DST) the point it was stopped
and Re-register the patient ,Start re-treatment,

Adult 74
HIV: diagnosis
Decide who to test for HIV
• Occupational/Sexual assault exposure
• Pregnant woman and her partner/s if HIV status unknown • Patient whose family member is HIV positive • Refugees and inmates
• Patient in labour and her partner/s if HIV status unknown • Patient with symptoms of HIV/AIDs • Discordant couples
• Postpartum woman and her partner/s if HIV status unknown • Patient with TB if HIV status unknown • Vulnerable adolescents/youth clients 15-24 years of age.
• Patient seeking contraception and her partner/s with identified risk • Patient with STI and partner/s if HIV status unknown
• Patient whose partner is HIV positive • MARP1 patient .

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 Stat Pack® (A1).

Positive Negative Indeterminate/Invalid

Do a second rapid HIV test on finger-prick blood using Abon®. (A2) HIV test result negative • Advise patient to
practice safe sex and
Positive Negative return after 2 weeks for
repeat test.
Repeat A1 only • If results are still
indeterminate, send
blood specimen to
Result A1+,A2+ laboratory for ELISA
test.
Do third rapid test on fingure-prick using SD biolin®.(A3)

Positive Negative

Result A1+,A2+,A3-
Patient has HIV 2 Report as HIV test inconclusive and
recommend testing after 14 days.
•
• Give routine HIV care at this visit 76. Result A1+ and A2- Report as HIV • Result A1-,A2-Negative
• Offer to help disclose status to sexual partner/s. inconclusive.
Report as HIV
• Encourage HIV testing for sexual partners and children. Recommend testing after 14 days.

Support
Ensure patient understands test result and knows where and when to access further care.
1MARP include commercial sex workers, long distance drivers, university students and community around and workers of Mega projects. 2Patient must be retested at ART
clinic before starting ART.
Adult 75

HIV
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,OI 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 Every visit • Advise reliable2 contraception (IUD, injectable or sterilisation plus condoms) 110.
planning • 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 If pregnant/breastfeeding and MUAC < 23cm or if not pregnant/breastfeeding and MUAC < 21cm, malnutrition likely 70.
or unable to stand
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 • Recurrent sinusitis, tonsillitis, otitis media, • Pulmonary TB • Extrapulmonary TB • Kaposi’s sarcoma, lymphoma, invasive
• Persistent painless pharyngitis • Oral candida • Weight loss ≥ 10% and diarrhoea or fever cervical cancer
swollen glands • Papular pruritic eruption (PPE) • Oral hairy leukoplakia > 1 month • Cytomegalovirus infection
• Fungal nail infections • Unexplained weight loss ≥ 10% body weight • Pneumocystis pneumonia (PJP) • Toxoplasmosis
• Herpes zoster (shingles) • Unexplained diarrhoea > 1 month • Recurrent severe bacterial pneumonia • HIV-associated dementia, encephalopathy
• Recurrent mouth ulcers • Unexplained fever > 1 month • Herpes simplex of mouth or genital area • Cryptococcal disease (including
• Angular cheilitis • Severe bacterial infections (pneumonia, meningitis) > 1 month meningitis)
• Unexplained weight loss < 10% body weight • Unexplained anaemia < 8g/dL, neutropaenia < 0.5x10/L, or chronic • Oesophageal candida • Cryptosporidium or Isospora belli diarrhoea
thrombocytopaenia < 50x10/L
Cervical screen At diagnosis, then 5 yearly If VIA abnormal 40.
(VIA) if normal
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. 2The 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 76
 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 • Starting AZT: CBC AZT: CBC AZT: CBC AZT: CBC • Viral load • Viral load Viral load • CD4: If viral load test not available, Patient on OI
• If available: • Starting DTG: ALT/HBsAg preventive therapy and need CD4 monitoring
--Cryptococcal antigen • Starting TDF: eGFR or creatinine1 for discontinuation.
--HBsAg and Hepatitis C antibody tests • Changing from TDF: HBsAg
AZT – zidovudine CBC – complete blood count Hb – haemoglobin

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 if patient on • Start ART regardless of CD4 count.
OI prophylaxis and need CD4 • If CD4 ≤ 350cells/mm3, also give co-trimoxazole.
monitoring for discontinuation. • If viral load test available, stop CD4 testing after base line.
• 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. 2Calculate eGFR = [(140 - age) x weight (kg)]/[72x creatinine (mg/dL)]. If patient is a woman, multiply by 0.85. 3If previously on zidovudine, refer to hospital.
Adult 77
 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 • No TB symptoms • Isoniazid 300mg daily • Peripheral neuropathy 50 Stop IPT after 6 months.
preventive • If also starting ART, start IPT once • Pyridoxine 25mg daily • Rash 53
therapy (IPT) tolerating ART. • Hepatitis
• Avoid if TB symptoms, on TB --If jaundice: refer same day.
treatment, peripheral neuropathy, --If nausea, vomiting, abdominal pain: check ALT and review result
liver disease, alcohol abuse. within 24 hours 80.
Co-trimoxazole • CD4 ≤ 350cells/mm3 Co-trimoxazole 960mg PO daily • Nausea/vomiting 33 Stop co-trimoxazole after 1 year
• Stage 3 or 4 • Rash 53 on ART and 2 consecutive CD4
• Fatigue, dizziness (if Hb ≤ 7g/dL, refer to hospital) counts of >350cells/mm3 or viral
• Easy bruising, bleeding from gums: stop medication and refer same day. load < 1000 copies/mL
• Hepatitis
--If jaundice: refer same day.
--If nausea, vomiting, abdominal pain: check ALT and review result
within 24 hours 80.
Fluconazole • Cryptococcal antigen positive or • If pregnant, breastfeeding or known liver disease, • Nausea/vomiting 33 Stop after at least 1 year on ART
• Cryptococcal antigen unavailable avoid fluconazole and refer same day. • Hepatitis and fluconazole if 2 consecutive
with CD4 ≤ 100cells/mm3 • If symptomatic (headache, confusion), refer same day. --If jaundice: refer same day. CD4s ≥ 100cells/mm3 or viral
• If asymptomatic, give fluconazole 800mg PO daily for --If nausea, vomiting, abdominal pain: check ALT and review result load < 1000copies/mL.
2 weeks, then 400mg daily for 2 months, then 200mg within 24 hours 80.
daily to complete at least 1 year.

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 78
 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.
Never had ART Previously had ART and interrupted

Switch to a medication
Choose 1st line ART* • Do viral load test.
from the same
• Is viral load > 1000copies/mL?
section 80.
Are there contraindications to TDF?
No Yes
Yes No
Choose same Refer to
Are there contraindications to DTG? Are there contraindications to DTG?? regimen as hospital for
before. 2nd line ART
No Yes No
Yes

Choose zidovudine, Choose tenofovir, Choose tenofovir,

Choose zidovudine,
lamivudine and lamivudine and lamivudine and
lamivudine and efavirenz.
dolutegravir.** efavirenz. dolutegravir.

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 as soon as possible-including same day.
• 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 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 79
*ABC or boosted PIs (ATV/r, LPV/r) can be used in special circumstances for those clients who could take neither DTG nor EFV due to contraindication and/or side effects.
**In case of TB-HIV co-infection, the dose of DTG should be 50mg BID.
 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 Self-limiting side effects (refer to hospital if Long-term side effects
refer same day) persist after 6 weeks)
1 Tenofovir (TDF) • 300mg PO daily Kidney failure Nausea, diarrhoea -
• Avoid if eGFR < 50mL/min/1.73m3
Zidovudine (AZT) 300mg PO BID • Lactic acidosis1 • Headache Fat loss in face, limbs and buttocks;
• Symptomatic anaemia (pallor with respiratory • Nausea fat accumulation (central obesity,
rate > 30, dizziness/faintness or chest pain) • Muscle pain breast enlargement); switch to
• Fatigue (if Hb ≤ 7g/dL switch medication 79) tenofovir or abacavir 79.
Abacavir (ABC) 300mg PO BID or 600mg PO daily Abacavir Hypersensitivity Reaction likely if ≥ 2 of: • Nausea -
Avoid if previous Abacavir • Fever • Vomiting
Hypersensitivity Reaction • Rash • Diarrhoea
(AHR) • Fatigue/body pain
• Nausea/vomiting/diarrhoea/abdominal pain
• Sore throat/cough/difficulty breathing
2 Lamivudine (3TC) 150mg PO BID or 300mg PO daily Uncommon Uncommon. Occasional nausea and diarrhoea Uncommon
3 Efavirenz (EFV) • 400mg PO daily • Rash 53 • Rash 53 • Central obesity, breast
Avoid if active psychiatric • If pregnant or TB, give 600mg PO daily • Jaundice/hepatitis2 • Headache, dizziness, sleep problems, low mood enlargement, switch to
illness • Avoid taking drug with fatty meal • Psychosis - take dose at night. If on 600mg daily, consider nevirapine 79.
giving 400mg PO daily. • Dyslipidemia
Dolutegravir(DTG) 50mg PO daily • Uncommon • Rash 53 -Birth defects
Avoid if a woman wants to 50mg PO BID if on Rifampin • Jaundice/hepatitis • Nausea, vomiting and diarrhea
be pregnant/unreliable containing anti-TB
family planning.

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). 2If jaundice: refer same day. If nausea, vomiting,
abdominal pain: check ALT and review result within 24 hours 77.
Adult 80
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:

Asthma likely if several of: • Onset after 40 years of age COPD likely if several of:
• Symptoms since childhood or early adulthood • Symptoms are persistent and worsen slowly over time
• History of allergic rhinitis, eczema, allergic conjunctivitis, other allergies • Cough with sputum starts long before difficulty breathing
• Symptom severity changes over time with symptom-free periods in between. • Symptoms that are persistent with little day-to-day variation
• Symptoms worse at night, early morning, with cold, stress or common cold • History of smoking>20 cigarettes per day for more than 15 years
• Patient or family have a history of asthma • History of heavy and prolonged exposure to burning biomass and fossil fuels in an
• Previous diagnosis of asthma enclosed space, or high exposure to dust in an occupational setting
• Symptoms respond to salbutamol • Previous diagnosis of TB
Give routine asthma care 82. • Poor response to inhaled salbutamol Give routine COPD care 83.

If unsure of diagnosis, treat as asthma 82 and refer to hospital within 1 month.

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 2 • Wind a steel wire around 1 Shake inhaler and 2 • Stand up and
cold-drink bottle with the open mouth of inhaler insert into spacer. breathe out.
soapy water. to form a mould. • Then form a seal
• Leave to air-dry. • Keep some wire for a with lips around
• Discard the lid. handle. mouthpiece.
• Heat the mould with a
flame until it is red hot.

3 Apply the hot mould to 4 • Insert mouth of inhaler 3 Press pump once to 4 • Then take 4 breaths
the bottom end of the immediately to create a release one puff into keeping spacer in
bottle for 10 seconds tight fit. spacer. mouth.
then rotate 180° and • Apply quick-setting • Repeat steps 3 and 4
reapply until the plastic glue to seal the inhaler for each puff.
melts. permanently to the spacer. • Rinse mouth after
using inhaled
corticosteroids.

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. 2If no spacer available, explain how to use inhaler without spacer: take off cap and
shake inhaler. Stand up and breathe out. Then form seal with lips around inhaler mouthpiece. Breathe in slowly. While breathing in, press pump once and keep breathing in slowly. Close mouth and hold breath for 10 seconds. Breathe out.
Adult 81
CHRONIC RESPIRATORY
DISEASE
Asthma: routine care
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 > 25, manage acute exacerbation 30.
• Any of the following indicate that the patient’s asthma is not controlled: Asthma is controlled when
- Daytime cough, difficulty breathing, tight chest or wheeze > 2 times a week - Symptoms only during the day (daytime asthma)
- Night-time or early morning waking due to asthma symptoms – Salbutamol use is limited to no more than twice a week
- Limitation of daily activities due to asthma symptoms – Night symptoms occur fewer than twice a month
- Need to use salbutamol inhaler > 2 times a week – No or minimal limitation of daily activities
- frequent exacerbations > 2 in past 12 months – No severe exacerbations within a month
• 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.

Advise the patient with asthma

• Ask about smoking. If patient smokes tobacco 102. The need for regular exercise . 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

Step 1: Give inhaled salbutamol 200mcg (2 puffs) as needed, up to 4 times a day. Plus low-dose inhaled beclometasone 100 ug taken whenever inhaled salbutamol is needed.
Step 2a: Standing dose of daily beclometasone inhaler 100 g(1 puff) BID plus salbutamol puff when needed.
Step 2b: Standing dose of daily beclometasone inhaler 200 g(2 puffs) BID plus salbutamol puff when needed.
If total daily dose of beclometasone inhaler is more than 400 g, refer to hospital.
Stepping down asthma treatment.
•Consider step-down after good control maintained for 3 months.
•Find each patient’s minimum effective dose that controls both symptoms and exacerbations.
If asthma is controlled: continue medication at same dose. If controlled and no acute exacerbations for more than 3 months, step down treatment:
• If on beclomethasone, decrease total daily dose by 200 g. If on 200 g daily, stop beclomethasone.
-If symptoms worsen while stepping down treatment, step up again to same medication and dose as when the patient was controlled.
Additional criteria for referal:
- asthma remains poorly controlled
- the diagnosis of asthma is uncertain

• 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.

Adult 82
Chronic obstructive pulmonary disease (COPD): routine care
Assess the patient with COPD
Assess When to assess Note
COPD symptoms: cough Every visit • If patient has wheeze/tight chest and breathless at rest or while talking or respiratory rate > 30, manage acute exacerbation 30.
and difficulty breathing • 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 • Assess CVD risk 84.
depending on risk • If <10%, reassess after 1 year. If 10% to < 20%, reassess after 6 months.

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.
• indoor air pollution are the major risk factors for COPD :therefore, patients with COPD must stop smoking and avoid dust and tobacco smoke
• keep the area where meals are cooked well ventilated by opening windows and doors
• cook with wood or carbon outside the house, if possible or build an oven in the kitchen with a chimney that vents the smoke outside
• stop working in areas with occupational dust or high air pollution
• 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

• For mild COPD(breathless on more than ordinary activity): Give inhaled salbutamol 200mcg (2 puffs) when needed, up to 4 times a day.
• Re-assess after one month,if no improvement or worsening give theophedrine 125 mg TID.
• 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
• Moderate and severe COPD cases(breathless on ordinary activity, less than ordinary activity and at rest) should be referred to hospital.

If stable and mild COPD review 6 monthly. If moderate/severe COPD or frequent/recent exacerbation review monthly.
Adult 83
Cardiovascular disease (CVD) risk: diagnosis
CVD risk is the chance of having a heart attack or stroke over the next 10 years Green <5%
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. Yellow 5% to <10%
• 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. Orange 10% to <20%
• 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: Red 20% to <30%
• 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. Deep red ≥30%
• 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 on page 156 using body mass index, 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 > 20%.

• Plot the patient's CVD risk using non-lab based chart on page 156 if his age lies between 40 and 74.
• Plot the patient's CVD risk using lab based chart on page 157 if his age lies between 40 and 74 and tests on cholesterol and diabetes is available.
• The patient is said to have high CVD risk if the CVD score is >10% using non-lab based chart.
• If patient has established CVD or kidney disease,treat as if the patient has a CVD risk>20%.

• If CVD risk factors or CVD risk ≥ 10% or established CVD, manage the CVD risk 85.
• If CVD risk < 5% and no CVD risk factors, reassess CVD risk after 12 months.

1HEARTS technical package for cardiovascular disease management in primary health care: risk based CVD management. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO.

Adult 84
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 < 5% reassess after1 year. If 5%–10%, every 3 mo, then 6–9 months thereafter If > 10%, 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 At baseline if no CVD or diabetes within • If no CVD or diabetes no need to repeat cholesterol or adjust simvastatin.
(by referral to hospital) 3 months of diagnosis. • If CVD or diabetes, increase simvastatin based on repeat cholesterol on relevant page.

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.
Physical activity Diet Screen for
• Aim for at least 30 minutes of moderate • Eat a variety of foods in moderation. Reduce portion sizes. substance abuse
exercise (e.g. brisk walking) on most days of • Increase fruit and vegetables. • Limit alcohol intake
the week. • Reduce fatty foods: eat low fat food, cut off animal fat. Use ≤ 2 drinks1/day and
• Increase activities of daily living like liquid oils instead of solid or semisolid oils avoid alcohol on most
gardening, housework, walking instead of • Avoid adding salt to food. days of the week.
taking transport, using stairs instead of lifts. • Avoid/use less sugar and sugary foods/drinks. • In the past year,
• Exercise with arms if unable to use legs. has patient: 1) drunk
Weight Stress ≥ 4 drinks1/session,
Smoking • Aim for BMI < 25, and waist Assess and 2) used khat or illegal drugs or
• Encourage patient circumference < 80cm (woman) manage stress 3) misused prescription or over-the-
not to start and < 94cm (man). 65. counter medications? If yes
• If patient smokes • Any weight reduction is beneficial, to any 103.
tobacco 102. 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.

Treat the patient with CVD risk

• Atorvastatin 20-40mg/day if not available Simvastatin 40mg/day for all with established CVD, or CVD risk ≥ 10% non-lab based or >20% lab based.
• For patients with previous cardiovascular events or for patients with very high cholesterol levels (Total cholesterol >320mg and/or LDL cholesterol >190mg/dl) double the above doses.
• If diabetes, decide if patient needs simvastatin 87.

If CVD risk remains > 10% after 6 months, refer.

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 85
CHRONIC DISEASES
OF LIFESTYLE
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 Random glucose > 200mg/dL
140-199mg/dL
Check if patient has >1 risk factors: Check if patient needs urgent attention:
• BMI ≥ 25 • Unconsciousness 13 • Drowsiness • Nausea or vomiting • Severe dehydration: BP
• Hypertension • Chest pain 28 • Confusion • Abdominal pain < 90/60, pulse ≥ 100
• History of stroke, ischemic heart • Convulsions 15 • Rapid deep breathing • Temperature ≥ 38oC
disease or peripheral arterial disease
• Physical inactivity
• First degree family history of diabetes No Yes
• Triglyceride >250mg/dl or HDL
cholesterol<35 mg/dl Check urine for ketones.
• History of Gestational DM or big
baby No ketones Ketones >+2,
• Age>40 repeat in 1 hour
Check for symptoms of diabetes: thirst, urinary frequency, weight loss and if still >2+
Yes
No Yes
• Regular insulin O.3 iu/kg Sc
Check fasting plasma glucose after an 8-hour fast. immediately
• Give normal saline 1L IV
< 100mg/dL 100-125mg/dL ≥ 126mg/dL over 30 minutes. May repeat
• Patient has impaired fasting glucose. this until stable/referred.
• Repeat fasting plasma glucose within one week. • Refer urgently.
• Assess and
manage CVD
risk 84. < 100mg/dL 100-125mg/dL ≥ 126mg/dL
• Repeat
fasting Confirm with another fasting plasma glucose from same or different sample.
plasma
glucose after
3 years, or < 126mg/dL ≥ 126mg/dL
if CVD or
hypertension, • Assess and manage CVD risk 84. Diagnose diabetes
1 year. • Repeat fasting plasma glucose every 1 year. • 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.

Adult 86
Diabetes: routine care
Give urgent attention to the patient with diabetes and one or more of:
• Chest pain 28 • Confusion or unusual behaviour • Sweating • Nausea or vomiting • Temperature ≥ 38°C
• Convulsing 15 • Weakness or dizziness • Palpitations • Abdominal pain • Severe d ehydration: decrease urine output,
• Decreased consciousness, drowsiness • Shaking • Rapid deep breathing • Thirst or hunger BP < 90/60, pulse ≥ 100
Check random fingerprick glucose:
Glucose < 70mg/dL with/without symptoms Glucose > 200mg/dL with symptoms Glucose > 200mg/dL without symptoms

• Give oral glucose 20g. If unable to take orally, give instead glucose 40% Check urine for ketones.
50mL IV over 2-3 minutes. Repeat if glucose still < 70mg/dL after 15 minutes.
Maintain with glucose 10% solution1. Ketones in urine No ketones in urine
• Give the patient food as soon as s/he can eat safely.
• Identify cause and educate about meals and doses 88. • Give normal saline 1L IV over 30 minutes. May repeat this until Give routine diabetes care below.
• If incomplete recovery, refer same day. stable/referred.
• Discuss referral if on gliclazide or insulin. • Give regular insulin 0.3iu/kg single dose.
• Refer urgently.

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 Every visit 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 • Visual assessment: look for ulcers, calluses, redness, warmth, deformity.
• Comprehensive: at diagnosis then yearly, more often if problems • 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 T2DM at diagnosis,T1DM 5Yrs after diagnosis, then yearly in both. If urine protein > detected repeat after 3 months and if persistent, start enalapril 5mg PO daily and increase to a
maximum of 20mg PO BID. Check RFT and then monthly. 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 • At diagnosis, 6 mo after treatment initiation and then yearly in • If baseline cholesterol > 300mg/dL, start simvastatin.
(by referral to hospital) T2DM patients • IStart simvastatin 20mg/dfor all diabetic patients age >40 years of age and LDL 70-190mg/dl
• • If CVD risk is >20% or total cholestrol>320mg/dl or LDL>190 mg/dl or there is established
CVD start simvastatin 20mg/day
•
1
Add 10 vials of glucose 40% in 1L dextrose in normal saline solution at 30 drops per minute. Adult 87
 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(headache, hunger,irritability,palpitations, sweating , trembling)
- 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

• Treatment goal FBG 90-130mg/dl.
• If CVD risk is >20% or total cholestrol>320mg/dl or LDL>190 mg/dl or there is established CVD start simvastatin 20mg/day. If repeat LDL 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 . 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 insulin at 0.4U/kg in two divided doses (2/3 morning, 1/3 evening). Doses as follows: 0.2 u/kg as Regular Insulin (1/2 AM&1/2 PM) and 0.2 u/kg as NPH(2/3 am and 1/3 pm).
- Increase by 2-4 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 500mg PO daily 1g BID • Review in one month or immediately if symptoms appear. If treatment goal not achieved, increase to 1000mg daily.
(take with or after meals) If still not achieved after 1 month, increase to 1000mg twice daily.
• If on maximum dose, move to step 2.
2 Add glibenclamide 5mg PO daily 20mg daily • Continue metformin.
(take with food) • Review in one month or immediately if symptoms appear. If goal not achieved, Glibenclamide is mostly escalated from
5 mg /d to 5 mg BID.Then, if still goal not achieved, 10mg (am)/5(pm) and finally review in 2 months or immediately if
goal not achieved, escalate to 10 BID.
• Avoid in severe kidney or liver disease. If on maximum dose, move to step 3.
3 Add basal insulin 0.1 units/kg/dose subcutaneously • Take at bedtime.
(NPH insulin) • Stop glibenclamide/glimepiride and add NPH 10 iu bedtime and escalate insulin dose by 2 iu every 3 days by checking
FBG until morning fasting glucose is between 90 and 130mg/dL.
• If a dose of >20 iu is needed at bedtime, split into morning and evening dose ( 2/3rd am and 1/3rd pm).
• 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 88
Hypertension: diagnosis
Check blood pressure (BP)
• The patient should be sitting with back supported, legs uncrossed, empty bladder, relaxed for 5 minutes and not talking.
• Use a larger cuff if mid-upper arm circumference is > 32cm.
• Record systolic BP (SBP) and diastolic BP (DBP): SBP is the first appearance of sound, DBP is the disappearance of sound.
• It is preferable to take at least two readings on each occasion of measurement and to use the second reading.
• If patient is pregnant, interpret reading 112.

Give urgent attention to the patient with BP ≥ 180/110 and one or more of:
• Visual disturbances • Headache
• Dizziness • Chest pain 28
• Weakness or numbness • Difficulty breathing worse on lying flat or with leg swelling 91
• Confusion • BP > 200/120
Management:
• Give nifedipine 20mg PO.
• Refer urgently.

Approach to the patient not needing urgent attention

BP < 140/90 BP ≥ 140/90 BP ≥ 180/110

No evidence of End organ damage Evidence of End organ damage

Repeat BP check on 2 occasions.

Avoid diagnosing hypertension based on one reading alone.

Confirm with 1 month if BP is 140-159/90-99mmHg.
Confirm within a week if BP is 160-179/100-109mmHg

BP < 140/90 on repeat checks

Assess CVD risk 84.

BP < 120/80 BP 120/80 -139/89 BP confirmed on 2 occasions ≥ 140/90

Recheck BP after 5 years. Patient’s BP is a CVD risk factor. Diagnose hypertension

• Manage CVD risk 85. • Give routine hypertension care 90.
• Recheck BP after 1 year. Once hypertension diagnosis is confirmed, perform CVD risk assessment using non-lab based chart. 84
• If < 40 years, refer to exclude secondary hypertension.
Adult 89
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. • If BP < 140/90 (< 150/90 if ≥ 60 years), BP is controlled: continue current treatment and review 3 monthly.
• For correct method 89. • 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 < 5% with CVD risk factors reassess after 1 year. If 5-10% followup every 3 months. If > 10% 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.
eGFR (by referral to hospital) At diagnosis, then every 6 mos and as indicated If eGFR < 60mL/min/1.73m3, refer to hospital.
1

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 At baseline if no CVD or diabetes within • If no CVD or diabetes no need to repeat cholesterol or adjust simvastatin.
(by referral to hospital) 3 months of diagnosis. • If CVD or diabetes, increase simvastatin based on repeat cholesterol on relevant page.
• Hepl patient to manage CVD risk 85. Emphasize salt restriction < 1teaspoon/day weight reduction and smoking cessation. If patient smokes 102.
• Advise patient to avoid NSAIDS(e.g Ibuprofen) and combined oral contraceptives 110. If pregnant or planning pregnancy calcium channel blockers should be used if not controlled with intensification of
refer to hospital.
• Explain importance of adherence and patient needs lifelong hypertension care to prevent stroke, heart disease and kidney disease. If newly diagnosed refer for health extension support.

Treat the patient with hypertension

• If no diabetes, give Atrovastatin 20-40mg PO daily if CVD>10%, if cholesterol > 320mg/dL or CV event. double the dose. 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 Already on hypertension medication

BP 140-159/90-99 SBP ≥ 160-179 Adherent Not adherent

Any of: CVD, diabetes, CVD risk ≥ 10%, retinopathy or kidney disease? Or DBP>100-109 • Increase current medication • Check patient using medication correctly.
Start treatment or if at maximum dose, add • Discuss any side effects.
Yes: Start treatment with No: Start 1 medication only after trying CVD risk with 1 new medication. • Refer for health extension worker support.
1 medication. management 85 alone for 3-6 months. medications. • Review in 1 month. • Review in 1 month.
Review in 1 month.

Medication Decide which medication to use Start dose Maximum dose Side effects
Amlodipine First-line therapy for uncomplicated primary hypertension. 5mg PO daily 10mg daily Oedema,Fatigue,Headache, Palpitations
IHypokalaemia, Hyperuricaemia(gout), Hyperglycaemia,
Add if no response with Amlodipine. Avoid in gout, severe liver/kidney 12.5mg PO daily o
Hydrochlorothiazide 25mg daily Dyslipidaemia.
disease.
Lisinopril 2 Add if no response with maximum dose of HCT. Preferred in chronic 40mg daily Cough (common), dizziness, angioedema (swelling tongue, lips, face,
Kidney disease with close clinical & biomedical monitoring 20mg PO daily difficulty breathing: stop enalapril immediately 24).
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
1Calculate eGFR = [(140 - age) x weight (kg)]/[72x creatinine (mg/dL)]. If patient is a woman, multiply by 0.85.

2Do not give Lisinopril, enalapril, or hydrochlothiazide to pregnant women or women of child bearing age if not on effective contraceptive. Consider enalapril 5 and 10 mg if lisinopril is not available. Adult 90
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.

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.

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.

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.

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.
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. 2Calculate eGFR = [(140 - age) x weight (kg)]/[72x creatinine (mg/dL)]. If patient is a woman, multiply by 0.85.
Adult 91
Rheumatic heart disease/previous rheumatic fever: routine care
• 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.

Assess the patient with rheumatic heart disease/previous rheumatic fever

Assess When to assess Note
Symptoms Every visit • If cough/difficulty breathing fatigue,decreased exercise tolerance 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.

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.

Adult 92
Stroke: diagnosis and routine care
Sudden onset of one or more of the following suggests a stroke(lasting >24hrs) or a transient ischaemic attack (TIA)(lasting <24hrs):
• Weakness or numbness of the face, arm or leg, especially on one side of the body • Difficulty speaking or understanding
• Blurred or decreased vision in one/both eyes or double vision • Difficulty walking, dizziness, loss of balance or co-ordination
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.

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 2-3L IV over 24 hours. 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.

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 3 months after starting simvastatin and then • If cholesterol ≥ 190mg/dL: increase simvastatin to 40mg. If already on 40mg daily, refer to hospital.
(by referral to hospital) after 3 months if ≥ 190mg/dL • If cholesterol < 190mg/dL, no need to repeat.
HIV At diagnosis or if status unknown Test for HIV 75.

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.

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 93
Ischaemic heart disease (IHD): initial assessment
Is patient known with ischaemic heart disease (or angina1)?

No Yes

Is current or previous chest pain/discomfort any of: Is chest pain/discomfort any of:
• Feels like pressure, heaviness or tightness in centre or left side of chest • Occurs at rest or with minimal effort or
• Spreads to jaw, neck, arm/s • Not relieved by rest or
• May be associated with nausea, vomiting, pallor, sweating or shortness of breath • Lasts ≥ 15 minutes or
• Worse/lasts longer than usual or
• Occurs more often than usual
No Yes

Yes No
Chest pain different Is chest pain/discomfort:
to above • Occurs at rest or with minimal effort or
• Not relieved by rest or Patient has stable angina.
• Lasts ≥ 15 minutes Give routine ischaemic
Assess for other causes of
heart disease care 95.
chest pain 28.
No Yes

Stable angina likely Acute coronary syndrome (heart attack or unstable angina) likely
• Refer to hospital to • If oxygen saturation < 90% or oxygen saturation machine not available, or
confirm diagnosis. respiratory rate ≥ 30, give face mask oxygen.
• Give routine ischaemic • Give single dose aspirin 300mg chewed.
heart disease care 95. • Establish IV access.
• If BP < 90/60, give normal saline 250mL IV. Avoid if breathless.
• Control pain with strong analgesia like opioids (Morphin or pethedine) if available
• Give 50 mg atenolol if available
• Refer to hospital urgently.

1
Chest pain caused by ischaemic heart disease.
Adult 94
Ischaemic heart disease (IHD): routine care
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 3 months after starting simvastatin and • If cholesterol ≥ 190mg/dL: increase simvastatin to 40mg. If already on 40mg daily, refer to hospital.
(by referral to hospital) then after 3 months if ≥ 190mg/dL • If cholesterol < 190mg/dL, no need to repeat.

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.

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 50mg PO daily 100mg PO daily Avoid atenolol in asthma/COPD, uncontrolled heart failure, pulse < 50, systolic BP < 100 or side effects (headache, cold
(immediate release) 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.

If atenolol and amlodipine contra-indicated/not tolerated or chest pain/discomfort persists on full treatment, refer to hospital.

Adult 95
Peripheral vascular disease (PVD): diagnosis and routine care
• Peripheral vascular disease is characterised by intermittent 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.

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 3 months after starting simvastatin and • If LDL ≥ 190mg/dL: increase simvastatin to 40mg. If already on 40mg daily, refer to hospital.
(by referral to hospital) then after 3 months if ≥ 190mg/dL • If LDL < 190mg/dL, no need to repeat.

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 45-60 minutes at least 3 times a week for 12 weeks add 6.5 minutes walking time after 6 months. 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.

Adult 96
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.

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 • Refer same week if patient is pregnant or planning to be, for epilepsy and antenatal care.
age women) • Assess family planning needs: avoid oral contraceptives and implants on carbamazepine or phenytoin 110.

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.

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. Avoid in pregnancy. Side effects: facial hair , drowsiness, large gums. Toxicity: balance problem, double vision, slurred speech.
Maximum dose: 600mg daily. 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 Side effects: skin rash, blurred or double vision, ataxia, nausea. Drug interactions: isoniazid, warfarin, fluoxetine, cimetidine,
3 divided doses 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 Avoid if liver problem, pregnant or a woman of childbearing age unless on reliable contraception. Use as first choice in
to maintenance dose of 1-2 g daily in divided doses. Maximum dose: 2.5g daily. 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.
Adult 97

EPILEPSY
Admit the mentally ill patient
Assess the mentally ill patient first on appropriate symptom or chronic condition pages.

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:

Yes No

Does patient agree to admission?

Yes No

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

Yes No

• Refer to hospital. Manage as an outpatient.

• 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.

Adult 98
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

Yes No
Has patient had 4 or more of the following features of depression for at least 2 weeks?
• Depressed mood most of the day, nearly every day • Disturbed sleep, sleeping too much/too little • Reduced concentration, indecisiveness ,forgetfulness
• Loss of interest or pleasure in activities that are usually enjoyable • Change in appetite or weight • Agitated/restless or talking/moving more slowly than usual
• Fatigue or loss of energy • Feeling guilty or worthless • Ideas, plans or acts of self-harm or suicide

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

Yes No
Check for anaemia Check for thyroid disease Screen for substance abuse Check for medication side effects Review
If pallor, check Hb. Check TSH. If abnormal, refer In the past year, has patient: 1) drunk ≥ 4 medication: prednisolone, efavirenz, Continue to assess and manage the
If < 11g/dL, refer to hospital. drinks1/session, 2) used khat or illegal drugs or metoprolol, metoclopramide, theophylline stressed or distressed patient 65.
to hospital. 3) misused prescription or over-the-counter and contraceptives etc can cause depression.
medications? If yes to any 103. If on any of these, refer to hospital.

One or None of above: does the patient have any psychotic symptoms2?
more of
above Yes 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?
Refer to hospital. • Elevated mood and/or irritability • Increased activity, feeling of increased energy, talkative, rapid speech
• Decreased desire to sleep • Impulsive/reckless behaviour like excess spending, thoughtless
• Inappropriate social behaviour decisions, sexual indiscretion
• Easily distracted • Inflated self esteem

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

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

No: has patient had depression in the past? Yes • Refer to a

mental health
professional.
No Yes
• If aggressive/
disruptive 63.
Provide support 65. Depression likely, treat 100.
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. 2Psychotic symptoms include any of: hallucinations (hearing voices/seeing things that are not there); delusions:
(unusual/bizarre beliefs not shared by society; beliefs that thoughts are being inserted or broadcast); disorganised speech (incoherent or irrelevant speech); behaviour that is disorganised or catatonic (inability to talk, move or respond).
Adult 99

MENTAL HEALTH
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.

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 Encourage patient to take time to relax: Get active Access support
If patient has difficulty Do a relaxing Regular Encourage
sleeping 67. breathing exercise patient to
exercise may help. connect with
each day. friends,
family,
spiritual
leaders
Find a creative or and community groups like Edir,
Spend time with supportive friends or family. fun activity to do. Mahber, Senbete.

Give drug treatment to the patient

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 100
 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 9-12 months after symptom resolution or resumption of functionality:
Medication Dose Note Side effects
Fluoxetine • Start 20mg PO alternate days for 1 week then increase to 20mg daily in • Refer to specialist if patient has epilepsy, liver or kidney disease. Changes in appetite and weight,
the morning. • Monitor blood glucose more often in diabetes. headache, restlessness, difficulty sleeping,
• If partial or no response after 4 weeks, increase by 20mg every 2 weeks, nausea, diarrhoea, sexual problems
up to 60mg/day.
Amitriptyline Start 25mg PO at night. Increase by 25-50mg weekly, up to 100-150mg/ • Use if fluoxetine contraindicated. Dry mouth, constipation, difficulty
day (150mg max), in elderly/medically ill start at 25mg at bed time to • If suicidal thoughts, avoid, or if fluoxetine not an option, supply only a few doses urinating, blurred vision, sedation
50-75mg (Max 100mg/day). Do not use in children/adolescents. at a time and ensure close supervision by carer (can be fatal in overdose).
• Avoid if heart disease, urinary retention, glaucoma, epilepsy.

Plan when to stop antidepressant

Has patient has previous episode/s of depression?

No Yes

Does patient have any of: onset in adolescence, severe depression, suicide attempt, sudden onset of symptoms, family history of bipolar disorder?

No Yes

Does patient have generalised anxiety, panic, phobia or post-traumatic stress? Consider long term
treatment for at least
No Yes 3 years. If ≥ 3 episodes,
advise lifelong treatment.
Consider stopping antidepressant when patient has had no/minimal symptoms Consider stopping antidepressant when patient has had no/minimal symptoms
and has been able to carry out routine daily activities for 9-12 months. and has been able to carry out routine daily activities for > 1 year.

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

Review 2 weekly, even if not on antidepressants, until symptoms improve, then monthly. If no better after 8 weeks, refer.

1
Patient has felt nervous, anxious or panicky or been unable to stop worrying or thinking too much over the past month.
Adult 101
Tobacco smoking
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

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.
− Tobacco use is a major cause of heart attack and stroke, of serious lung problems and certain Cancers.
− Tobacco can damage every part of the body.
− Secondhand smoke damages the health of your family and others around you.
• 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.

Adult 102
Alcohol/drug use
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.

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/ • 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.
harmful use • 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.

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 Harmful/hazardous drug use without dependence Alcohol/drug dependence
• If pregnant, harmful drinking, previous dependence or contraindication • Advise to stop using illegal or misusing prescription drugs completely. • Advise that alcohol/drugs need to be
(like liver damage, mental illness), advise to stop alcohol completely. • The patient with harmful/hazardous drug use without dependence stopped slowly. If stopped suddenly,
Avoid drinking places and keeping alcohol at home. can safely cut down on his/her own: encourage the patient to set goals withdrawal effects can be harmful.
• If none of above and patient chooses to continue alcohol, advise low-risk for reducing use and a ‘quit date’. • If patient wishes to stop, refer to a
use: ≤ 2 drinks1/day and avoid alcohol at least 2 days/week. • If patient chooses to continue, advise to reduce harm: avoid injections hospital for detoxification. Ensure
or use sterile injection technique, test regularly for HIV and hepatitis. patient is motivated to adhere.

If harmful/hazardous use, review in 1 month then as needed.

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 103
Psychosis: diagnosis and routine care
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 for Depression , Psychosis, Mania and Dementia
- 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 Check glucose 86.
• Also 4 monthly if gaining weight
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.

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 104
 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 • Increase every 2 weeks if needed. Give as a single dose at night once symptoms controlled.
divided dose • 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.

Look for and manage psychosis treatment side effects

Urinary retention Stop treatment and refer same day. Breast enlargement, Discuss with specialist whether to change medication.
nipple discharge
Blurred vision Refer same day.
Amenorrhoea Discuss with specialist whether to change medication.
Painful muscle spasms Usually within 2 days of starting medication. Give benzhexol 2-5mg PO TID if needed.
(acute dystonic reaction) Refer same day. Dizziness/fainting on Usually when starting/increasing dose. Usually self-limiting
standing over hours to days. Advise patient to stand up slowly.
Extra-pyramidal Abnormal involuntary movements Reduce dose. If no better, stop treatment and refer. Dry mouth/eyes Usually self-limiting.
side effects
Slow movements, tremor or rigidity May occur after weeks or months on treatment, refer. Constipation Usually self-limiting. Advise high fibre diet and adequate fluid
Muscle restlessness Stop treatment and refer same day. intake.

• 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.

Adult 105
Dementia: diagnosis and routine care
• 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.

Assess the patient with dementia with the help of the carer
Assess When to assess Note
• If recent change in mood, energy/interest levels, sleep or appetite, consider depression and refer.
Symptoms Every visit
• Assess for Depression , Psychosis ,Mania and subtance use
• 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.

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) --Use simple short sentences. --Remove clutter and potential hazards at home.
--Stimulate memories and give current information with newspaper, radio, TV, photos. --Maintain a routine. --Maintain physical activity and plan recreational activities.

Treat the patient with dementia

• 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 106
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: Inflammatory arthritis likely if:
• Affects joints only. • May be systemic: weight loss, fatigue, poor appetite, muscle wasting.
• Weight-bearing joints and possibly hands and feet • Hands and feet are mainly involved.
• Joints may be swollen but not warm. • Joints are swollen and warm.
• Stiffness on waking lasts less than 30 minutes. • Stiffness on waking lasts more than 30 minutes.
• Pain is worse with activity and gets better with rest. • Pain and stiffness get better with activity.

If inflammatory arthritis likely or uncertain of diagnosis, refer.

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.

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.

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.
Adult 107
MUSCULOSKELETAL
DISORDERS
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.

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 • Assess CVD risk 84. If < 10% with CVD risk factors or 10-20% reassess after 1 year, if > 20% reassess after 6 months.
on risk • If BMI < 18.5 or patient < 40 years, refer within 1 month to exclude possible cancer cause for gout.
eGFR2 (by referral At diagnosis, then 6 monthly If eGFR < 60mL/minute/1.73m2, refer.
to hospital)
Urate • At diagnosis • Wait at least 2 weeks after an acute gout attack before checking urate level.
• On allopurinol • If on allopurinol, repeat monthly and adjust allopurinol dose until urate level < 6mg/dL, then repeat 6 monthly.

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

© Stellenbosch University
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.

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. 2Calculate eGFR = [(140 - age) x weight (kg)]/[72x creatinine (mg/dL)]. If patient is a woman, multiply by 0.85.
Adult 108
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. Press tender points
• Fibromyalgia diagnosis more likely if any of: woman, family history, fatigue, reduced ability to think and remember clearly, mood or with the pressure
sleep disturbances. that would blanch a
• Check for other causes of general body pain: fingernail. Compare
--If weight loss 16. with a control site
--Screen for a joint problem: patient to place hands behind head; then behind back. Bury nails in palm and open hand. Press on forehead.
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.

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.

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.

Adult 109
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.

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 • Check BP 89.
on pill or injectable • 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 When needed • If HIV negative and asymptomatic: screen 5 yearly from age 30-49.
(VIA) • 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.
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.
Adult 110
 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) • Effective for 10 - 12 years. • Always exclude Pregnancy first. • Heavy or painful periods: reassure usually improve within 3-6 months. To
• Better inserted before day 12 of cycle .
• Copper IUD (Cu-IUD) • Fertility returns immediately on removal. • Can be inserted < 48 hrs or > 4 wks of delivery . assess and manage 42. If excessive bleeding occurs after insertion or if
• Avoid if current STI, unexplained vaginal bleeding, • Can be inserted <12 days of abortion. tired and Hb < 11g/dL, refer.
abnormal cervix/uterus. • Must be inserted/removed by trained staff. • Irritation of partner’s penis during sex: cut IUD strings shorter.
Subdermal implant • Lasts for 3-5 years. • Plastic rod just under skin of upper arm. • Amenorrhoea: reassure that this is common.
• Implanon: Etonogestrel • Fertility returns immediately on removal. • If inserted after day 5 of cycle, use condoms • Abnormal bleeding: common. To assess and manage 42.
(one-rod: 3 years) • Avoid if unexplained vaginal bleeding, previous breast cancer or abstain for 7 days. • Acne: change to combined oral contraceptive or non-hormonal method.
• Jadelle: Levonorgestrel or active liver disease. • Must be inserted/removed by trained staff. • Headaches: if severe, change to non-hormonal method.
(two-rods: 5 years) • Use with caution1 if BMI > 28 or on ART, rifampicin or • Weight gain (less with progesterone-only pill)
phenytoin. • Moodiness: reassure that this should resolve. In the past month, has patient:
Progestogen injection • 3 monthly injection • If started after day 5 of cycle, use condoms felt depressed, sad, hopeless or irritable or worrying a lot, had multiple
• Medroxyprogesterone • Fertility can be delayed for up to 1 year after last injection. or abstain for 7 days. physical complaints, felt little interest or pleasure in doing things? If yes to
acetate (DMPA) IM 150mg • Avoid if diabetic complications. • No need to adjust dosing interval for ART, any, consider changing method and 99.
every 3 months TB or epilepsy treatment.
Progestogen-only pill (POP) • Must be motivated to take pill reliably every day. • Must be taken every day at the same time
• Levonorgestrel 30mcg PO • Fertility returns once pill is stopped. (no more than 3 hours late).
(especially if postpartum or • Avoid both if active liver disease or on rifampicin or • If started after day 5 of cycle, use condoms
breastfeeding) phenytoin. or abstain for 2 days.
Combined oral • Use both with caution2 if on ART. • Must be taken every day at the same time. • Abnormal bleeding: common in first 3 months. To assess and manage 42.
contraceptive (COC) • Also avoid COC if smoker ≥ 35 years, migraines and • If started after day 5 of cycle, use condoms • Breast tenderness, nausea: reassure usually resolve within 3 months.
• Ethinylestradiol/ ≥ 35 years or visual disturbances, postpartum3, BP ≥ 140/90, or abstain for 7 days. • Headaches: if migraines and ≥ 35 years or visual disturbances, change to
levonorgestrel 30/150mcg hypertension, CVD risk > 10%, current or previous deep vein • If ≥ 72 hours diarrhoea/vomiting, advise to non-hormonal method.
PO thrombosis/pulmonary embolus, previous stroke, ischaemic use condoms or abstain (continue for • Moodiness: reassure that this should resolve.In the past month, has patient:
heart disease or diabetic complications. 7 days once resolved). 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 • Permanent contraception • Refer for assessment. Wound pain, infection or bleeding: refer.
• Tubal ligation/vasectomy • Surgical procedure • Written informed consent is needed.

Manage the patient who has missed injections or pills

Late injection Missed progestogen-only pill Missed combined oral contraceptive (> 24 hours late)
• If ≤ 2 weeks late for the DMPA: give the injection. (> 3 hours late) • 1 or 2 active pills missed: take 1 pill immediately and take next pill at usual time.
• If > 2 weeks late for the DMPA: • Take pill as soon as remembered, • ≥ 3 active pills missed: take 1 pill immediately and take next pill at usual time. Use condoms or
--Exclude pregnancy. If pregnant 112. continue pack and use condoms or abstain for 7 days:
--If not pregnant: give injection and use condoms or abstain for 2 days. --If 2 or more pills missed in last 7 active pills of pack: omit inactive pills and start next active pill.
abstain for 7 days. If unprotected sex in past 5 days, • If unprotected sex in past 5 days, also --If 2 or more pills missed in first 7 active pills of pack and patient has had unprotected sex in past
also offer emergency contraception 110. offer emergency contraception 110. 5 days: also offer emergency contraception 110.

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.
1
The subdermal implant may be less effective on ART, rifampicin and phenytoin. Advise patient to use condoms as well. 2The oral contraceptive may be less effective on ART. Advise patient to use condoms as well. 3Avoid COC for 6 weeks after delivery
and for 6 months if breastfeeding.
Adult 111

WOMEN'S HEALTH
The pregnant Woman
Give urgent attention to the pregnant woman with one or more of:
• Convulsing or just had a convulsion • Swollen painful calf
• BP ≥ 140/90 and persistent headache/blurred vision/abdominal pain: treat as severe pre-eclampsia • Vaginal bleeding
• BP ≥ 160/110 and ≥ 1+ proteinuria: treat as severe pre-eclampsia • Decreased/absent fetal movements 114
• BP ≥ 160/110 without proteinuria: treat as severe hypertension • Painful contractions < 37 weeks: preterm labour likely
• Temperature ≥ 38°C and headache, weakness, back pain, abdominal pain • Sudden gush of clear or pale fluid from vagina with no contractions: premature
• Difficulty breathing 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.
Convulsing or just had Severe pre- Severe Vaginal bleeding Preterm labour Premature rupture of
a convulsion eclampsia hypertension membranes (PROM)
Early pregnancy < 28 weeks3 Late • Give dexameth-
• If < 20 weeks 15. pregnancy asone 6mg IM, • Confirm amniotic fluid
• If between 20 weeks and 1 week Cervical os open/dilated or products of ≥ 28 weeks3 record time given with sterile speculum:
postpartum, treat for eclampsia: - conception in cervical os/vagina? in referral letter. - examination.
- Lie down patient in left lateral position. • Avoid digital Give nifedipine7 • Avoid digital vaginal
- Avoid placing anything in mouth. No Yes vaginal 20mg PO stat. examination.
- Give 100% face mask oxygen. examination. - Check VS every • If term PROM and no risk
- Give magnesium sulphate: Threatened Incomplete, Missed or • Give IV 30 minutes on the admit to labor ward and
or complete inevitable miscarriage likely fluids as way to referal. monitor. If no labor after 8
• Give magnesium sulphate 4g as 20% solution IV over 5 hours give Ampicillin 2gm
miscarriage above. If BP < 90/60, give
minutes. Mix 8ml of 50% MgSo4 with 12ml of D5W or • If ≥ 12 Wks, secure IV line and refer • Refer IV/IM and refer.
likely IV fluids as above.
normal saline to make 20% solution. Follow promptly with same day. • If labor started manage as
urgently. • Ampicillin 2gm IV
10 gm of 50% magnesium sulfate solution, 5 gm in each • If < 12 Wks, do MVA or MA if <9 normal labor and if >8hrs
Refer same as initial loading
buttock as deep IM injection with 1 mL of 2% lidocaine in Wks. cover with Ampicillin 2gm
day to dose.
the same syringe.. • If pain, give ibuprofen 400mg PO IV QID till delivery.
• If convulsion recurs after 15 minutes, give 2 gm magnesium exclude • If delivery is
ectopic TID. imminent attend • If chorioamnionitis4: - Give
sulfate (20% solution) IV over 5 minutes and Refer to hospital5 pregnancy. • If bleeding heavy (pad soaked in < delivery with ampicillin1 2g IV/IM OR
Insert urethral catheter and record urine output every 4 5 minutes): essential newborn ampicillin1 2g IV/IMand
hours.Stop magnesium sulphate if urine output - Give IV fluids as above. care and refer gentamicin 80mg IM and
<100mL in 4 hours or respiratory rate < 162 or knee - Give single dose misoprostol Refer urgently to hospital.
reflexes disappear. • Refer urgently.
800mcg intravaginally & Refer • Preterm PROM
• If convulsion recurs or does not respond, refer urgently same day • If chorioamnionitis give
to hospital.
If temperature ≥ 38°C, pulse ≥ 100 or smelly Ampicilline 2g IV and
• Give hydralazine65mg IV over 5 minutes every 20 min till DBP vaginal discharge, give ceftriaxone1 1g IM/IV or Erythromycine 250mg PO
<110mmHg. Repeat hourly as needed or Give 12.5mg IM 2 hourly if ampicillin1 2g IV/IM and gentamicin 80mg IM. Refer urgently.
IV route not possible. The total max dose is 20mg per 24 hours.
• Arrange urgent referral after giving the first doses of medications. 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. 2If respiratory rate < 16, give calcium gluconate 10% 1g IV slowly over 10 minutes. 3If gestation not known, manage as late pregnancy if uterus palpable above
umbilicus. 4Temperature ≥ 38°C, maternal pulse ≥ 100, fetal heart rate ≥ 160, painful abdomen or smelly amniotic fluid.
5If admission possible in health center the Maintenance dose should give MgSO4 50% solution 5gm +1ml Lidocaine 2% IM every 4 hrs into alternative buttock for 24 hrs after delivery or the last convulsionwhichever occurs last.

6
Labetalol 200mg po repeating after an hour as needed (upto maximum of 1200mg over 24hrs)or 10mg IV with additional 20mg after 10 minutes if no response(maximum of 300mg over 24 hrs) can be used. Adult 112
7 Do not give nifedipine in cases of preterm prelabor rupture of membranes (PPROM), chorioamnionitis, antepartum hemorrhage, cardiac disease, fetal death, fetal congenital abnormality not compatible with
life, cervical dilatation >4 cm and effacement >80%.
 Approach to the newly diagnosed pregnant patient not needing urgent attention.

Does the patient want the pregnancy?

No or unsure Yes

• Discuss the options around continuing with pregnancy, choosing adoption or abortion. Refer to psychosocial worker.
• Determine gestational age by dates and on examination. If unable to determine gestational age, arrange ultrasound.

Patient requests abortion Patient decides to continue with pregnancy.

Any one of < 18 years old, pregnant following incest or rape, severe mental illness or congenital malformation and
the continuation of the pregnancy endangers the life of the mother or the child health.

Yes No

• < 12 weeks: do MVA or provide medical abortion. • Abortion is not an option..

• ≥ 12 weeks: refer to hospital for TOP. • Give routine antenatal care.
• Discuss future contraception 110. • Psychosocial support

Identify the pregnant patient who needs referral level antenatal care
• Current medical problems: diabetes, heart/kidney disease, Cancer, DVT, 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.

Adult 113
Routine antenatal care
Assess the pregnant woman at first visit(12wks) and then at 20,26, 30, 34,36, 38,40 weeks.
Assess When to assess Note
Symptoms Every visit Manage symptoms as on symptom pages. Check if patient needs urgent attention 112.
Gestational Age 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.
HBsAg Second Visit

Mid upper arm First visit MUAC < 23cm: exclude TB 71, HIV 75 and give routine malnutrition care 70.
circumference
Abdominal Every visit • If mass other than uterus in abdomen or pelvis, refer for assessment.
examination • 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 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:
(BP is normal if • No proteinuria: start methyldopa 250mg PO TID and refer to hospital.
< 140/90) • 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 12,26 and 34weeks • If dipstick normal with dysuria (burning urine) or if leucocytes or nitrites present, treat for complicated urinary tract infection 44.
clean, midstream • If proteinuria, check BP:
urine, --BP ≥ 160/110, manage as severe pre-eclampsia 112.
microscopy --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 • 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 risk3: also at • If high risk at first visit, check blood glucose 86. If diabetes, refer to hospital.
first visit
Haemoglobin (Hb) First visit ,26 and 34 • 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.
weeks • If Hb 8-10g/dL at the first visit , treat 115 and repeat Hb monthly until Hb > 10g/dL.
Rh status and blood First visit • If Rh-positive, continue routine care.
group • 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 woman 115.
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. BMI = weight (kg) ÷ height (m) ÷ height (m). 3High risk of gestational diabetes if any of: previous gestational diabetes,
2

glucose in urine, family history of diabetes, BMI > 30 or previous large baby > 4.5kg. 4Oral 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.
Adult 114
 Continue to assess the pregnant woman
Syphilis First visit, 32 week If positive 41.
HIV First visit and at 36 • Test for HIV 75. If patient refuses, offer test at each visit, even in early labour.
weeks if negative • If HIV positive give routine care 76 and start ART same week 115.
HIV viral load At first visit if HIV positive; • If viral load > 1000copies/mL for 1st time, give increased adherence support 78 and repeat viral load after 3 months.
On ART: 3 months, then • If viral load > 1000copies/mL for 2nd time, patient has virological failure: refer to hospital.
6 monthly

Advise the pregnant woman

• 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 woman
• Give iron/folic acid 60mg/400mcg PO daily. Avoid tea/coffee 2 hours after taking tablet. If Hb 7-11g/dL, give iron/folic acid 60mg/400mcg PO TID for 3 months and reassess after 4-6 weeks.If anemia
persists or Hb <7g/dl refer to hospital.
• Check if Td vaccines are up to date (3 doses of tetanus in the past):
- If up to date, give 1 dose of Td vaccines at 27-36 weeks gestation.
- If not up to date/unknown, give 2 doses of Td vaccines: at first visit , then after 1 month.
• 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.
• Treat the HIV positive patient1:
- 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.
f not on ART, start ART within 1 week 80.

Treat the HIV positive woman 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 and AZT as soon as possible after birth 118.

Give postnatal care to mother and baby 116.

Adult 115
1All HIV positive pregnant or lactating women should be retested with a second specimen before initiating ART
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 • BP < 90/60
• Convulsing or just had a convulsion up to 1 week postpartum 112. • Pulse ≥ 100
• BP ≥ 140/90 and persistent headache/blurred vision/abdominal pain: treat as • Tear extending to anus or rectum
severe pre-eclampsia 112. • Pallor with respiratory rate > 30, dizziness/faintness or chest pain
• Feeling unwell and temperature > 38°C • 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:
- Massage uterus and empty bladder (with catheter if needed).
- Give oxytocin 10IU IM, then 30IU in 1L normal saline at 40 drops/minute IV.
- if placenta not expelled apply controlled cord traction, if it fails, try manual delivery and give ampicillin1 2g IV/IM.
- If uterus still soft after this, give ergometrine2 0.2mg IM/IV or misoprostol 800mcg 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.
- Look for and repair any perineal tears.
• If feeling unwell and temperature > 38°C: give ceftriaxone1 1g IM/IV or amoxicillin1 1g PO with metronidazole 1g PO.
• Refer urgently6.

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.sk about continous urinary or fecal incotinence after child birth
suspect obestatric fistula, screen refer to hospital.
 44.
• Ask about urinary incontinence (leaking or dribbling urine). If still present at 6 weeks, treat for flow problem

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. 2Avoid if eclampsia, pre-eclampsia or known hypertension. 3Bimanual 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. 4External aortic compression: press down with fist just above umbilicus until femoral pulse not felt. 5One 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. 6If still bleeding heavily, apply bimanual or external aortic compression4 or non-pneumatic anti-shock garments (if available) during referral.
Adult 116
Assess When to assess Note
HIV test in mother • If not done • Test for HIV 75. If HIV positive, give routine care 76. If not on ART, start ART 79.
• At 6 weeks • 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.
• If breastfeeding: 3 monthly
HIV test in • 6 weeks or at the earliest time • Decide which HIV test to do:
HIV-exposed baby there after before 18 months of --If < 9 months, do PCR. If positive, start ART and confirm result with 2nd PCR.
age --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.

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, AZT and co-trimoxazole prophylaxis.
- 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 6 months, introduce complementary food while continuing with breast feeding
- 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 and AZT 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).
• Advise mother on family planning and baby immunization.

• If Hb 7-11g/dL, give iron/folic acid 60mg/400mcg PO BID for 3 months and reassess Hb. Treat the mother
• 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 300mcg IM as siin as possible(within 28
days).
• 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 HIV positive and not on ART, start ART 79. If mother is already on ART, continue.
• If painful perineal or abdominal wound, give paracetamol 1g PO QID as needed for up to 5 days.
− If Infection of perineal and abdominal wounds considered
− if superficial give Ampicillin 500mg PO QID and Metronidazole 500mg TID for 5 days
− If infection deep involving muscles and skin necrosis(necrotizing fascitis) start Ampicilline 2g IV , Gentamycine 5mg/kg and Metronidazole 500mg IV TID and refer urgently

Treat the HIV-exposed baby

Give eMTCT regimen 118.

Adult 117
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:

Give nevirapine and zidovudine PO daily for 6 weeks then

continue with nevirapine for another 6 weeks(see table).

Treat the HIV-exposed baby

• Give eMTCT: NVP+AZT. 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.

Infant age/weight Formulation Dosing Co-trimoxazole syrup (40/200mg/5mL)

Weight Dose
0-6wks <2500gm NVP 10mg/ml 1ml once daily
+ + 3.0-5.9kg 2.5mL daily
AZT 10mg/ml 1ml twice daily 6.0-13.9kg 5mL daily

NVP 10mg/ml 1.5ml once daily

0-6wks >2500gm +
+ 1.5ml twice daily
AZT 10mg/ml

6-12wks NVP10mg/ml 20mg(2ml) once daily

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.
Adult 118
Menopause
• 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 • Assess CVD risk 84.
on risk • 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.

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.

Adult 119
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.

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.

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.

Adult 120
 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.

Mild pain Moderate pain Severe pain

Start pain medication at step 1. Start pain medication at step 2. Start pain medication at step 3.

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?

Nerve pain Muscle spasms Bone pain Organ cramps Anxiety

Use paracetamol in step 1 and add amitriptyline. Add diazepam. Use ibuprofen or diclofenac in step 1. Add hyoscine. Add diazepam.

Step Pain medication Start dose Maximum dose Note

Step 1 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
Use one of: 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 Codeine 30mg PO 4 hourly 240mg daily If no diarrhoea , give bisacodyl 5-15mg PO daily to prevent constipation.
Add one of:
Tramadol 50mg-100mg PO QID 400mg daily • If no diarrhoea, give bisacodyl 5-15mg PO daily to prevent constipation.
• Avoid in epilepsy
Step 3 Morphine oral syrup 2.5mg-5mg PO 4 hourly None. If respiratory rate < 12, • If no diarrhoea, give bisacodyl 5-15mg PO daily to prevent constipation.
Stop step 2 and add: skip 1 dose, then halve dose. • 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 Amitriptyline 25-75mg PO 75mg/daily Use at night. Advise it may cause dizziness and sedation and to avoid driving and using heavy machinery.
medication to any
Diazepam 5mg PO TID 15mg/daily Explain about dizziness which will clear in few days but avoid driving, heavy machinery
step if needed.
Hyoscine 10-40mg PO TID 120mg /daily -

• 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.

Adult 121

PALLIATIVE CARE
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 • Vaginal secretions
• Blood-stained fluid/tissue • Semen
• Pleural/pericardial/peritoneal/amniotic/synovial/cerebrospinal fluid • 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 Protect your facility
Adopt standard precautions with every patient: Clean the facility:
• Wash hands with soap/water or use alcohol-based cleaner before and after contact with patients or body fluids. • Clean frequently touched surfaces (door handles, telephones, keyboards) daily with
• Do not recap or bend needles soap and water.
• Safely pass sharp instruments • Disinfect surfaces contaminated with blood/secretions with 70% alcohol or
• Dispose of sharps correctly in sharps bins. chlorine-based disinfectant.
Wear personal protective equipment: Ensure adequate ventilation:
• Wear gloves when handling blood, body fluids, secretions or non-intact skin. • Leave windows and doors open when possible and use fans to increase air exchange.
• Wear face mask if in contact with respiratory virus suspects Organise waiting areas:
• Wear N95 respirator if caring for MDR TB patient. • Prevent overcrowding in waiting areas.
• Wear face mask with a visor or glasses if at risk of splashes. • Fast track influenza and presumed TB patients.
• Wear personal protective equipment if in contact with viral haemorrhagic fever1 suspects. Manage sharps and other infectious wastes safely:
Get vaccinated: • Ensure sharps bins are easily accessible and regularly replaced.
• Get vaccinated against hepatitis B and yearly against influenza. • Segregate and dispose wastes properly
Know your HIV status: Manage infection control in the facility:
• Test for HIV 75. ART and IPT can decrease the risk of TB. • Appoint an infection control officer for the facility to coordinate and monitor
• If HIV positive, you are entitled to work in an area of the facility where exposure to TB is limited. infection control policies.

Manage possible occupational exposure promptly

Reduce TB risk Reduce risk of respiratory viruses (including influenza)

Identify the presumed TB patient promptly: • Wash hands with soap and water.
• The patient with cough ≥ 2 weeks is a presumed TB patient. • Wear a face mask over mouth and nose during procedures on patient.
• Separate presumed TB patient from others in the facility. • Encourage patient to cover mouth/ nose with a tissue when coughing/sneezing, to dispose of used
• Educate about cough hygiene and give face mask/tissues to cover mouth/nose to protect others. tissues correctly and to wash hands regularly with soap/water.
Diagnose TB rapidly: • Advise patient to avoid close contact with others.
• 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.

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.
Adult 122
Protect yourself from occupational stress
Experiencing pressure and demands at work is normal. However, if these demands exceed knowledge and skills and challenge your ability to cope, occupational stress can occur.

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.

Adopt measures to diminish your risk of occupational stress

Protect yourself Protect your team
Look after your health: Decide on an approved way of behaving at work:
• Get enough sleep. • Communicate effectively with your patients and colleagues 124.
• Exercise, eat sensibly, minimise alcohol and don’t smoke 85. • Treat colleagues and patients with respect.
• Get screened for chronic conditions. • Support each other. Consider setting up a staff support group.
Look after your chronic condition if you have one: • Instead of complaining, rather focus on finding solutions to problems.
• Adhere to your treatment and your appointments. Cope with stressful events:
• Don’t diagnose and treat yourself. • Develop procedures to deal with events like complaints, harassment/bullying, accidents/mistakes,
• If you can, confide in a trusted colleague/manager. violence or death of patient or staff member.
Manage stress: Look at how to make the job less stressful:
• Delegate tasks as appropriate, develop coping strategies. • Examine the team’s workload to see if it can be better streamlined.
• Talk to someone (friend, psychologist, mentor). • Identify what needs to be changed to make the job easier and frustrations fewer: equipment, drug
• Do a relaxing breathing exercise each day. supply, training, space, décor in work environment.
• Find a creative or fun activity to do. • Discuss each team member’s role. Ensure each one has say in how s/he does his/her work.
• Spend time with supportive friends or family. • Support each other to develop skills to better perform your role.
Have healthy work habits: Celebrate:
• Manage your time sensibly. • Acknowledge the achievements of individuals and the team.
• Take scheduled breaks. • Organise or participate in staff social events.
• Remind yourself of your purpose as a clinician.
• Be sure you are clear about your role and responsibilities.

Identify occupational stress in yourself and your colleagues:

Possible alcohol or drug problem Change in mood Recent distressing event Poor attendance Marked decline in
• In the past year, have you or your colleague: drunk ≥ 4 • Indifferent, tense, irritable or angry • Diagnosis of chronic condition at work work performance
drinks1/session, used khat or illegal drugs, or misused • In the past month, have you or colleague: felt depressed, sad, • Bereavement • Frequent • Reduced
prescription or over-the-counter medications? hopeless or irritable or worrying a lot, had multiple physical • Needlestick injury absenteeism concentration
• Smells of alcohol complaints, felt little interest or pleasure in doing things? • Traumatic event • Fatigue

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 123
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 The patient might feel: Don’t The patient might feel:
• Give all your attention • ‘I can trust this person’ • Talk too much • ‘I am not being listened to’
• Recognise non-verbal behaviour • ‘I feel respected and valued’ • Rush the consultation • ‘I feel disempowered’
• Be honest, open and warm • ‘I feel hopeful’ • Give unwanted advice • ‘I am not valued’
• Avoid distractions e.g. phones • ‘I feel heard’ • Interrupt • ‘I cannot trust this person’

Discuss
Discussing a problem and its solution can help the overwhelmed patient to develop a manageable plan.
Do The patient might feel: Don’t The patient might feel:
• Use open ended questions • ‘I choose what I want to deal with’ • Force your ideas onto the patient • ‘I am not respected’
• Offer information • ‘I can help myself’’ • Be a ’fix-it’ specialist • ‘I am unable to make my own decisions’
• Encourage patient to find solutions • ‘I feel supported in my choice’ • Let the patient take on too many • ‘I am expected to change too fast’
• Respect the patient’s right to choose • ‘I can cope with my problems’ problems at once

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

Summarise
Summarising what has been discussed helps to check the patient’s understanding and to agree on a plan for a solution.
Do The patient might feel: Don’t The patient might feel:
• Get the patient to summarise • ‘I can make changes in my life’ • Direct the decisions • My health worker disapproves of
• Agree on a plan • ‘I have something to work on’ • Be abrupt my decisions’
• Offer to write a list of his/her options • ‘I feel supported’ • Force a decision • ‘I feel resentful’
• Offer a follow-up appointment • ‘I can come back when I need to’ • ‘I feel misunderstood’

Adult 124
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: If the patient is not ready to change:
• Assist the patient to set a realistic change goal. • Respect the patient's decision.
• Explore the factors that may help the patient to change or may make it difficult. • Invite patient to identify the pros and cons of change.
• Help the patient plan how s/he will fit the change into the routine of the day. • Acknowledge patient’s concerns about change.
Encourage patient to use strategies s/he used successfully in the past. • Explore ways of overcoming the difficulties preventing change.
• Offer more information or support if the patient would like to consider the issue further.

Arrange support and follow up

• Offer referral to counselor and available support services (social worker, health promoter, 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.

Adult 125
Child contents
Symptoms Long-term health conditions
A F R
Abdominal symptoms 143 Fever 134 Rash, generalised 147 Malnutrition 153
Rash, localised 148
B H Respiratory arrest 128
Resuscitation, child 128
Breathing difficulty, child 140 Headache 135
Epilepsy 154
Burns 133 Head injury 127
Hearing problems 138
S
C Seizures 130
Cardiac arrest 128 I Shock 129
Cardiopulmonary resuscitation (CPR) 128 Injured child 132
Coma 131 T
Confusion 131 L Throat symptoms 139
Convulsions 130 Leg symptoms 146 Quick reference chart 155
Cough 140 Limp 146
U
Cough, recurrent 142 Lymphadenopathy 136
Unconscious child 131
Underweight 150
D M Urinary symptoms 145
Dehydrated child 129 Mouth symptoms 139
Diarrhoea 144 W
P Walking problems 146
E Pallor 137 Wheeze 141
Ear symptoms 138 Wheeze, recurrent 142
Emergency child 127

Child 126
The emergency child
Give urgent attention to the emergency child
Does child respond to voice or physical stimulation?

No Yes
Feel for pulse for maximum of 10 seconds: feel carotid pulse.

No pulse felt or no signs of life. Pulse felt

Pulse rate < 60 Pulse rate ≥ 60

Call for help and start CPR 128. Check breathing:

Child gasping or not breathing Child breathing well

• Check airway clear and give 1 breath with bag valve mask
attached to oxygen every 4 seconds.
• Recheck pulse every 2 minutes.

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

Airway Breathing Circulation Glucose/level of consciousness

• If noisy breathing, position in • If difficulty breathing or • Establish IV access: try 3 times for < 90 seconds • Check fingerprick glucose:
‘sniffing position’. If injured, oxygen saturation ≤ 92%, give each, if unsuccessful and trained to do so, insert --If glucose if < 45mg/dL (or < 54mg/dL if malnourished),
keep neck stable, use instead facemask oxygen 140. external jugular or intra-osseous line3. give 10% glucose4 5mL/kg IV/IO. Recheck glucose after
jaw-thrust1 only. • If respiratory rate decreased, • If ≥ 2 of: 1) cold hands/feet, 2) weak/fast pulse, 30 minutes. If still low, repeat 10% glucose4 bolus.
• Check for foreign body in or blue lips/tongue, assist 3) capillary refill3 > 3 seconds, 4) decreased level of • Determine AVPU:
mouth: if easy-to-reach, each breath with bag valve consciousness 5) decreased urine output: --A: alert
remove. Suction secretions. mask attached to oxygen (at shock likely 129. --V: responds to voice
• If unresponsive, insert an least every 4 seconds). • If actively bleeding or enlarging/ pulsating --P: responds to pain
oropharyngeal airway2. swelling, elevate and apply direct pressure. If --U: unresponsive
unsuccessful, compress the nearest large artery. • If decreased level of consciousness 131.
Manage further according to disability and symptoms and refer urgently:
• If injured: 3
If trained, insert an intraosseous line:
--If head injury, neck/spine tenderness, decreased level of consciousness or weak/numb limb, immobilise head with tape Clean with antiseptic, locate site on medial surface of tibia,
and sandbags/bags of IV fluid on either side of head. Use spine board if needing to move patient. 2 finger breadths below tibial tuberosity, stabilize thigh/knee,
--Identify all injuries: undress child fully and assess front and back using log-roll to turn. Then cover and keep warm. Manage insert 15-18 gauge intraosseous needle 90o angle to bone with
injuries 132. bevel towards foot. Advance with twisting motion, stop when
• If pupils unequal or respond poorly to light, tilt bed to raise head by 30 degrees. If injured, avoid bending spine: keep body sudden decrease in resistance (needle should be fixed in bone).
straight with head/neck in midline. Remove stylet (if present) and confirm position by aspirating
• Manage further according to symptoms: if covulsing 130, if just had convulsion 130, if unconscious 131, if burn 133. 1mL of blood/marrow with 5mL syringe. Flush with 5mL IV
• Keep child warm. fluid. Apply dressing and secure. Monitor for calf swelling.

1
Lift chin forward with fingers under bony tips of jaw. 2Size 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. 3Capillary 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. 4If 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 127

CHILD
Cardio-pulmonary resuscitation (CPR) of the child
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): Use heel of hand/s.

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.

Decide when to stop CPR:

Return of pulse ≥ 60 No return of pulse after 20 minutes

127. • 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.

1
Lift chin forward with fingers under bony tips of jaw. 2If 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
Assess and manage child’s fluid needs
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?

Yes: shock likely No

• Establish IV access: try 3 times for < 90 seconds each, if unsuccessful, insert external jugular or • If lethargic, check finger prick glucose if < 45mg/dL (< 54mg/dL if malnourished), give 10%
intra-osseous (IO) line. If IV access not possible, refer urgently with ORS 20mL/kg/hour NGT or orally if glucose2 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, repeat 10% glucose2 bolus.
NGT not possible. • Is there ≥ 2 of: 1) sunken eyes, 2) drinking poorly, 3) lethargic, 4) very slow skin pinch3 (≥ 2 seconds)
• Is there ≥ 1 of: 1) severe acute malnutrition4 2) difficulty breathing 3) suspected meningitis? 5) decreased urine output?

No Yes Yes No
• Give normal saline 20mL/kg bolus IV/IO rapidly. • Give DNS 10mL/kg IV/IO over 20 minutes. Severe dehydration (10%) Is there ≥ 2 of: 1) sunken eyes, 2) thirsty/drinks eagerly,
• Then assess response: feel hands, check pulse • Then assess response: feel hands, check pulse likely 3) restless/irritable, 4) slow skin pinch3?
and CRT. and CRT. Is there ≥ 1 of: 1) severe
acute malnutrition4, Yes No
Good Poor response: hands still cold or Poor response: hands still cold or Good 2) difficulty breathing, Moderate dehydration (5%) likely Child not
response: pulse weak or not felt, pulse weak or not felt, response: 3) suspected meningitis? Is there ≥ 1 of: 1) severe acute malnutrition4, dehydrated
hands CRT > 3 seconds CRT > 3 seconds hands 2) difficulty breathing, 3) suspected meningitis?
warmer, warmer, No Yes
Return to
CRT Still shocked CRT
Still shocked No Yes relevant
faster, Is pulse rate up by 25 beats/ faster, Give Give
Are eyelids puffy, leg swelling Give ORS 20mL/kg/ Give ORS 10mL/kg/ symptom
pulse minute or respiratory rate up by pulse normal ReSoMal
worse, is pulse rate up by hour orally, using hour orally using page to
slower 5 breaths/minute or eyelids puffy? slower saline 5mL/kg
25 beats/minute or respiratory small frequent sips, small frequent sips, assess and
and and 30mL/kg orally/NGT
rate up by 5 breaths/minute? for 4 hours. for 4 hours. manage
stronger stronger IV over every
No symptom/s.
30 minutes, 30 minutes
Yes No • Record weight.
No longer No longer then give for the first
shocked. Give 2nd bolus: normal 70mL/kg 2 hours. • If child vomits, wait 10 minutes, then continue
shocked.
saline 20mL/kg bolus Stop IV fluids, Give 2nd bolus: DNS for 2½ Then more slowly.
IV/IO and urgently refer give oxygen 15mL/kg IV/IO over hours. 5-10mL/kg/ • If refusing to drink, give via NGT.
to hospital. 2L/minute via 1 hour and urgently hour orally/ • Give more ORS if child wants it.
nasal prongs, refer to hospital. NGT for the • Check fingerprick glucose and manage as
and refer next above, if necessary.
Continue with normal saline 30mL/kg
over 30 minutes, then give 70mL/kg for urgently to Continue ORS 10mL/kg/hour orally 4 hours.
2½ hours. hospital. (or NGT if vomiting). Reassess after 4 hours:
• If still dehydrated or weight not up, refer to
hospital.
Refer urgently. While awaiting transfer: • If no longer dehydrated and child has
• If not already done, check finger prick glucose: if < 45mg/dL (< 54mg/dL if malnourished), give 10% glucose2 5mL/kg IV/IO. diarrhoea 144.
Recheck glucose after 30 minutes. If still low, repeat 10% glucose2 bolus. • Address other symptoms on symptom page.
• 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.
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. 2If 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). 3Pinch skin on abdomen between 2 fingers. Release. Skin usually snaps rapidly back to its normal position. A slow skin pinch
takes longer. 4Severe 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).
Child 129
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 supportive treatment and treat possible causes
• Give rectal1 diazepam 0.1mL/kg PR or if IV line already inserted, give diazepam 0.05mL/kg IV slowly (see table below). • Open airway: clear mouth, stabilise neck if trauma patient and
• Expect a response within 5 minutes. Monitor breathing: suction secretions.
Weight/age Rectal1 diazepam IV diazepam
if decreased respiratory rate, breathing stops or gasping, • If not trauma patient, place in recovery position2. Avoid
(10mg/2mL) (10mg/2mL)
ventilate with bag-valve mask (1 breath every 3-5 seconds) placing anything in mouth.
0.1mL/kg 0.05ml/kg
127. • Give facemask oxygen 5 L/minute.
• If child still convulsing after 5-10 minutes, give a 2nd dose 18-25kg (5-8 years) 1.5mL 0.9mL • Check fingerprick glucose: if < 45mg/dL (or < 54mg/dL if
of diazepam. If child still convulsing 5-10 minutes after this, ≥ 25kg (≥ 8 years) 2mL 1mL malnourished), give 10% glucose3 5mL/kg IV/IO. Recheck
give a 3rd dose of diazepam. glucose after 30 minutes. If still low, repeat 10% glucose3 bolus.
• If child still convulsing or repeated convulsions without regaining consciousness despite diazepam: give phenytoin • If meningitis4 likely, give ceftriaxone 100mg/kg (up to 2g) IV.
20mg/kg PO via nasogastric tube (NGT) or phenobarbitone 20mg/kg (up to 1g) PO via NGT. • If malaria is suspected/confirmed5: give artesunate 3mg/kg IM
• Refer to hospital urgently. or artemether 3.2mg/kg IM.

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.

Refer patient same day if one or more of:

• Temperature ≥ 38°C • > 1 convulsion in 24 hours • Dehydration6 • Family history of epilepsy7
• Convulsion > 15 minutes • Convulsion occurs only on one side • Suscpted/confirmed malaria5 • HIV positive
• Unresponsive to voice > 1 hour • Neck stiffness/ meningism • Ingestion of medication/potentially harmful substance • Head injury within past week
after convulsion • Weakness of arm/leg/face, even if resolved • Previous birth trauma, head injury, meningitis • Close TB contact

Has child had ≥ 2 convulsions in the last year on 2 different days?

Yes No
Refer to hospital. • 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.
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. 2Recovery 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). 3If 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). 4Meningitis likely if: temperature ≥ 38°C, neck stiffness, headache and/or vomiting. 5Test 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. 7Family history of epilepsy refers to a parent or sibling with childhood onset epilepsy.
Child 130
Decreased level of consciousness
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.

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 Temperature Pupils Skin rash

• If glucose < 45mg/dL ≤ 35.5° C ≥ 38°C Both pupils dilated or Unequal Purple/red rash that Sudden rash
(or < 54mg/dL if pinpoint or respond does not disappear
malnourished), give • Clothe Treat for likely poorly to with pressure. There may be swelling of
10% glucose1 including head infection: Poisoning likely light face/tongue or wheezing.
5mL/kg IV/IO. and cover • Give ceftriaxone • If pinpoint pupils, Meningococcal disease
Recheck glucose with warmed 100mg/kg (up excessive drooling/ Tilt bed to likely Anaphylaxis likely
after 30 minutes. If blankets. Place to 2g) IV/IM. sweating, coughing raise head by • Establish IV/IO. • Lie child flat and give 100%
still low, repeat 10% near heater. • If malaria is up or choking on 30 degrees. • If ≥ 2 of: 1) cold hands/ facemask oxygen at 5L/minute.
glucose1 bolus. • Give ceftriaxone suspected/ secretions, slow pulse, If injured, feet, 2) weak/fast pulse, • Give adrenaline (1mg/mL,
• If glucose ≥ 200mg/ 100mg/kg (up confirmed2: organo-phosphate avoid 3) capillary refill time3 1:1000) 0.3mL IM into mid-
dL, DKA likely. to 2g) IV/IM. give artesunate poisoning likely: give bending > 3 seconds, 4) decreased outer thigh. If no better, repeat
Assess fluids needs 3mg/kg IM or atropine 0.05mg/ spine: keep level of consciousness 5) every 5 minutes. Give normal
129. artemether kg IV. If no response, body straight decreased urine output: saline 20mL/kg IV bolus. Also
3.2mg/kg IM. double the dose with head shock likely 129. give diphenhydramine 1mg/kg
every 3 minutes until and neck in • Give ceftriaxone 100mg/ IM/IV (up to 50mg).
improving. midline. kg (up to 2g) IV/IM.
• 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.

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). 2Test for malaria with parasite slide microscopy or if
unavailable, rapid diagnostic test. 3Capillary 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.
Child 131
The injured child
Give urgent attention to the injured child with any of:
• Decreased level of consciousness • Pulsatile or growing swelling • Weak/numb limb
• Difficulty breathing: abnormal respiratory rate, • Burns 133 • Stab or gunshot wound
grunting, nasal flaring or chest indrawing • Weak/numb limb • Severe mechanism: high
• Distended abdomen • Multiple injuries speed collision, car accident,
• Bleeding despite direct pressure • Poor perfusion below injury: cold, pale, numb, no pulse fall from height

Also give urgent attention to the child with a head injury and any of:
• Lethargy or decreased level of consciousness • Vomiting ≥ 2 episodes • Blood or clear fluid leaking from ear/nose
• History of loss of consciousness • Severe headache • Bruising around eyes or behind ears
• Strange behaviour or memory loss since injury • Pupils unequal or respond poorly to light • Blood behind eardrum
• Suspected skull fracture • Blurry/double vision • 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

Wound Head injury Painful limb

• Apply direct pressure to stop bleeding. • Advise caretaker to observe child • Give single dose
• If open wound, give tetanus toxoid 0.5mL IM if none in past 5 years. If unavailable, check for tetanus antitoxin (TAT) hypersensitivity1: carefully for 24 hours and limit paracetamol 15mg/kg
if no hypersensitivity, give single dose TAT 3000U SC. activity for at least 48 hours. (up to 1g) PO.
• Remove foreign material, loose/dead skin. Irrigate with normal saline or if dirty, dilute povidone iodine solution. • Advise to return immediately if • Apply firm, supportive
• If sutures needed: suture and apply non-adherent dressing for 24 hours. Plan to remove sutures after 5 days (face), 4 days (neck), any of: blurred vision, vomiting, bandage, refer to
10 days (leg) or 7 days (rest of body). headache despite paracetamol, hospital.
• Avoid suturing if wound > 12 hours old (or > 24 hours on head/neck), infected, remaining foreign material or deep puncture, instead: difficult to wake, balance problem.
--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.

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.
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. 2If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give
instead erythromycin 12.5mg/kg (up to 500mg) QID PO for 7-10 days.
Child 132
Burns
Calculate percentage total body surface area (%TBSA) burnt using below figure.

Give urgent attention to the child with burn/s and any of:
• Electric/chemical burn • Circumferential burn of chest/limbs • Burn of face, hand, foot, genitals, joint
• Full-thickness burn (white/black, painless, leathery, dry) • Temperature ≥38°C • ≥ 2 of: 1) cold hands/ feet, 2) weak/fast pulse,
• Partial thickness burn (pink/red, blisters, painful, wet) > 10% TBSA • Sudden skin swelling with redness, 3) capillary refill time1> 3 seconds, 4) decreased
• Likely inhalation burn (burns to face/neck, hoarse, stridor or black sputum) pain or warmth level of consciousness: shock likely
Management:
How to calculate %TBSA of burn
• 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. Front Back
• 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 7% 7%

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 18% 18%
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. 4.5% 4.5% 4.5% 4.5%
--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. 8% 8% 8% 8%
• 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. Child's open hand (area of palm) represents is 1% TBSA.
Do not include simple erythema (redness) in calculation.

Approach to the child with burn/s not needing urgent attention: Decide on maintenance fluid2 rate
• 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. Weight 24 hour fluid need
• Give tetanus toxoid 0.5mL IM if none in past 5 years. If unavailable, check for tetanus antitoxin (TAT) hypersensitivity3: if no hypersensitivity, 10-20kg 1000mL + (50mL for every kg body weight over 10kg)
give single dose TAT 3000U SC. e.g.: if 14kg: 1000mL + (50 x 4)
• If cigarette burn, glove and stocking type burn or history given inconsistent with burn, consider child abuse, refer to hospital. = 1200mL/24 hours
• 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 ≥ 20kg 1500mL + (20mL for every kg body weight over 20kg)
before changing dressing. Up to 2000mL in girls and 2500mL in boys
--Refer if infection likely (skin red, warm, painful), rash develops, pain despite medication or burn not healing. e.g.: if 23kg: 1500mL + (20 x 3)
= 1560mL/24 hours
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. 2To 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). 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. If 10%
3 4

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 133
Fever
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 • Purple/red rash that does not disappear with pressure • Little or no urine 145
• Decreased level of consciousness • Increased respiratory rate and/or difficulty breathing 140 • Features of rheumatic fever1
• Headache • Tenderness right lower abdomen, appendicitis likely • Previous rheumatic fever or known
• Neck stiffness • Jaundice 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.

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

Positive for malaria Positive for Borrelia (relapsing fever) Negative for malaria & Borrelia6
Manage according to type of parasite/s seen:
• Report. Delouse, shave hair and change clothes. Ask about pattern of fever, personal hygiene, headache,
Plasmodium Plasmodium Both Plasmodium • First insert IV line, then give procaine penicillin5 diarrhoea/constipation and look for lice on body:
vivax falciparum falciparum and 200 000-400 000IU IM. Monitor for reaction every
Plasmodium 15 minutes for next 2 hours, then every 30 If intermittent fever with any of: headache, If persistent fever If fever
Give chloroquine: vivax minutes for next 4 hours: if drop in BP, increased lives in overcrowded setting, poor personal with any of: diarrhoea ≥ 2 weeks,
16.6mg/kg (up pulse rate, collapse, give 20mL/kg normal saline hygiene or body lice, typhus fever likely: followed by exclude TB
to 1g) PO initially, • Give artemether/lumefantrine bolus. • Give doxycycline (children >8 yrs)for constipation or poor and test
then 8.3mg/kg 20/120mg BID PO for 3 days • Repeat peripheral blood film after 12 hours: 7-10 days according to weight: food hygiene, typhoid for HIV.
(up to 500mg) at according to weight: - If negative: give tetracycline 250mg TID PO for 3 - < 45Kg: 2.2mg/kg (up to 200mg) BID PO fever likely: give
6, 24 and 48 hours --15-24kg: 2 tablets; days for children older than 8 years or - ≥ 45kg: 100mg BID PO ciprofloxacin 25mg/kg
(total of 4 doses) --25-34kg: 3 tablets; erythromycin 10mg/kg TID PO for 3 days if < 8 yr. BID PO for 10-14 days
- If positive: repeat procaine penicillin5 and • Or give chloramphenicol 25mg/kg QID
and primaquine --≥ 35kg: 4 tablets PO for 7 days for children <8 years. or amoxicillin 10mg/
0.25mg/kg daily --Also give single dose primaquine monitoring as above, every 12 hours until blood kg TID PO for 14 days.
PO for 14 days. 0.25mg/kg PO. film negative.
• Advise family members to wash well, reduce
crowding and wash clothes. • If none of above, advise cold compresses and review after 2 days.
Advise patient to return if no better. • If no overnight facilities, refer to hospital. • If cause uncertain, refer.
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. 2If 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). 3Do a peripheral blood film examination or a malaria rapid diagnostic test. 4If 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 134
Headache
Give urgent attention to the child with headache and any of:
• Sudden severe headache • Neck stiffness/meningism • Vision problems (e.g. double vision)
• Headache/vomiting on awakening or waking from sleep • Head tilted to one side (torticollis) • Head trauma in last week 132
• Headache getting worse and more frequent • Pupils different size • Abnormally large head
• Temperature ≥ 38°C • Weakness of arm or leg • Elevated BP1
• Decreased level of consciousness

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?

Yes No

Migraine likely Pain over cheeks, thick nasal (or postnasal) discharge, recent common cold, headache worse on bending forward?
• Give immediately and then as needed:
paracetamol 15mg/kg (up to 1g) QID PO
Yes No
or if ≥ 20kg and able to swallow tablet,
ibuprofen2 200mg TID PO with meals.
Advise to return if no better after 24 hours Sinusitis likely Consider tension headache and muscular neck pain
and refer to hospital. • Give paracetamol 15mg/kg (up to 1g) QID
• Advise child/caretaker with migraine: PO as needed for up to 5 days.
--Recognise migraine early and rest in dark, Tightness around head or Constant aching neck pain, tender neck muscles
• Give normal saline drops into nostrils as
quiet room. generalised pressure-like pain
needed.
--Draw up a headache calendar to identify • If no better, give oxymetazoline 0.025% Muscular neck pain likely
and avoid triggers like lack of sleep, stress, 2 drops TID into each nostril for up to 5 days. Tension headache likely • Give paracetamol 15mg/kg (up to 1g) QID PO as
prolonged screen time, hunger and some • If symptoms > 10 days: give amoxicillin3 • Give paracetamol 15mg/kg (up to 1g) needed for up to 5 days.
food or drink. 50mg/kg (up to 1g) BID PO for 10 days. QID PO as needed for up to 5 days. • Advise sleeping on different pillow, avoid
--Migraine may occur at start of menstrual • If > 1 episode, test for HIV. • Do vision test, if problem, refer to hospital. prolonged screen time (TV, cellphones and
period. Reassure. • If poor response to antibiotic or > 4 episodes computers) and correct posture.
--Give letter with advice on care if migraine per year, refer to hospital.
occurs at school. • If swelling around sinus/eye or tooth
• If ≥ 2 attacks/month or no response to infection, refer same day to hospital.
treatment, refer to hospital.

If unsure or poor response to treatment refer to hospital.

1
Do a peripheral blood film examination or a malaria rapid diagnostic test. 2Avoid if asthma, heart failure or kidney disease. 3If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give instead erythromycin 12.5mg/kg (up to 500mg) QID PO
for 5 days.
Child 135
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
Yes No

Bacterial lymphadenitis likely • Look for likely cause: check face, skin, gums/teeth and throat. If sore throat 139.
• If painful neck • If lymph node in groin and if sexually active, treat child and partner for lymphogranuloma venereum 36.
lymphadenopathy with sore If child abuse suspected, refer to hospital.
throat, tonsillitis likely 139.
• Give amoxicillin 30mg/kg (up
to 500mg) TID PO for 5 days. If local cause found: If no cause found:
If penicillin allergy (previous • Treat the cause. • If close TB contact or TB symptoms (cough or fever ≥ 2 weeks, not growing well/losing weight, tired/less playful), exclude TB.
anaphylaxis, urticaria or • Advise to return in 4 weeks if • If status unknown, test for HIV. If HIV positive, manage according to national HIV programme guidelines.
angioedema), give instead no better on treatment and • If none of the above:
erythromycin 12.5mg/kg (up refer to hospital.
to 500mg) QID PO for 5 days. Localised lymphadenopathy Generalised lymphadenopathy
• If poor response to treatment Any of: weight loss, fever, night sweats, lymph node growing quickly, weakness, pallor1?
after 2 days, change amoxicillin
to cephalexin 12-25mg/kg (up
to 500mg) QID for 7 days. No Yes
• Review in 2 weeks: if no better,
refer to hospital. • If lymph node > 1cm persists for > 2 weeks, refer to hospital. Refer to hospital.
• Advise to return if new symptoms or lymph nodes grow.

1
If child’s palm significantly less pink than your own.
Child 136
Pallor
This refers to the child with pale palms1 and/or conjunctiva. If possible, check Hb: if Hb < 11g/dL, child has anaemia.

Give urgent attention to the child with a low Hb and/or pallor and any of:
• Hb < 7g/dL • Increased pulse rate
• Jaundice • Palpitations or chest pain
• Swollen legs • Bone or joint pain
• Widespread/easy bruising • Lethargy or decreased level of consciousness
• Increased respiratory rate • 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.

Approach to the child with pallor not needing urgent attention

Are laboratory services available to take blood for complete blood count (CBC)?

No Yes

Take blood for complete blood count (CBC) and manage further according to MCV3 result:

MCV3 low MCV3 normal MCV3 high

Iron deficiency anaemia likely Systemic disease or Folate and/or vitamin B12
• Deworm: give single dose albendazole 400mg PO every 6 months. long-term health condition likely deficiency likely
• Give ferrous gluconate or ferrous lactate or ferrous sulphate according to weight TID PO with food. • Exclude TB and HIV. Start treatment and refer to hospital:
Check Hb monthly. Continue treatment until Hb ≥ 11g/dL: • If no cause found, refer to hospital. give folic acid 5mg daily PO and
vitamin B12 500mcg IM monthly.
Weight (kg) Ferrous gluconate elixir Ferrous lactate drops Ferrous sulphate tablets
(30mg iron per 5mL) (25mg iron per 1mL) (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.

1
If child’s palm significantly less pink than your own. 2Test for malaria with parasite slide microscopy or if unavailable, rapid diagnostic test. 3MCV: 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.
Child 137
Ear symptoms/difficulty hearing
Is ear itchy, painful, discharging or is there difficulty hearing?

Itchy ear Painful ear Discharge from ear3 Difficulty hearing

Ear canal red/swollen • Ear canal not red/swollen. Discharge Discharge ≥ 2 weeks or • If on drug resistant TB medication, discuss with TB health worker.
(pus may be present) • Able to view eardrum? for hole in eardrum • If itchy or painful ear or discharge from the ear, see left algorithm/s.
≤ 2 weeks • Look in ear for foreign body, wax or fluid behind eardrum. If normal
No Yes looking ear, refer to hospital for hearing test.
Pain > 2 days or pain waking at night?
Foreign body Wax Fluid behind eardrum
No Yes
Has temperature been • Syringe ear4 Syringe ears4 Otitis media with effusion
≥ 38°C in last > 2 days? with warm with warm likely
water. water unless • Keep ear dry.
No Yes Red bulging eardrum • Avoid child has • Advise that this usually
© University of Cape Town © University of Cape Town syringing grommets/ resolves on its own.
and refer to uncooperative/ • If communication problem,
• Give
Otitis externa likely Chronic suppurative hospital if: has chronic refer to hospital for hearing
paracetamol
• Clean ear1. otitis media likely --Hole in suppurative test.
15mg/kg
• Apply hydrogen • Clean ear1. eardrum otitis media. • If concerns about hearing
QID PO for
peroxide solution • Apply hydrogen --Grommets remain after 3 months or if
5 days as
1.5% 5-10 drops BID peroxide solution 3% --Battery/ child clumsy/poor balance,
needed.
topically to affected 5-10 drops BID topically food in ear. refer to hospital.
• Review in
ear for 5 days. to affected ear for 5 days. --Recent
2 days if no
• Give paracetamol • Give amoxicillin2 trauma to
better. © University of Cape Town
15mg/kg (up to 1g) 50mg/kg (up to 1g) TID head or
QID PO for 5 days as PO for 7-10 days. ear
Acute otitis media likely
needed. • If poor response to --Neck
• Give paracetamol 15mg/kg (up to 1g) QID PO for
• If severe pain, firm treatment, test for HIV stiffness
5 days as needed.
red swelling behind • Give amoxicillin2 50mg/kg (up to 1g) TID PO for and TB.
ear or temperature 7-10 days. • Refer to hospital if: • Stop and refer to hospital if
≥ 38°C, give • Clean ear1 if discharge and avoid getting ear wet. --No better after 4 weeks unsuccessful after 3 attempts/
amoxicillin2 • If > 1 episode, test for HIV. --Large hole in drum causes pain or if foreign body 4
How to syringe an ear: fill a
50mg/kg (up to 1g) • Refer to hospital same day if: --Difficulty hearing remains in ear. 50-200mL syringe with warm
TID PO for 7-10 days. --No response to treatment or > 5 episodes per year. • Refer to hospital same • If no better, refer to hospital for water. Ask child/caretaker to
• If blisters on ear, hearing test. hold container under ear to
• Refer same day if: day if: catch water. Pull ear upwards
herpes zoster likely, --Painful swelling behind ear, mastoiditis likely --Neck stiffness and backwards to straighten
refer to hospital. --Neck stiffness --New pain in or behind ear canal. Place tip of syringe at
ear opening (no further than 8mm
• If treated above but communication problem into canal) and spray water
present, refer to hospital for hearing test. --Yellow/white upwards into canal. Check after
deposit on eardrum, syringing to see if wax cleared.
cholesteatoma likely
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. 2If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give instead erythromycin 12.5mg/kg QID PO for 7-10 days. 3If child has grommets (small tubes in eardrum) and purulent discharge persists > 2 weeks, refer to hospital.
Child 138
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 White patches on cheeks, Groups of painful blisters on Painful ulcer/s with central
Pus or white patches on tonsils? gums, tongue, palate, or lips/mouth white patch
cracks in corners of mouth.
No Yes Herpes simplex likely Aphthous ulcer/s likely
Oral thrush/candida likely • Apply vaseline® to blisters on • Give paracetamol 15mg/
• Give nystatin suspension outside of mouth to prevent kg (up to 1g) QID PO as
Any of runny nose, cough, hoarseness, conjunctivitis or diarrhoea?
1mL QID PO after meals for spread. needed for up to 5 days.
7 days. Keep inside mouth • Give paracetamol 15mg/kg • Rinse with salt water1 for
Yes No for as long as possible. (up to 1g) QID PO as needed 1 minute BID.
• Give paracetamol 15mg/kg for up to 5 days. • If recurrent, consider HIV.
(up to 1g) QID PO as needed • If HIV or extensive herpes • If large (> 1cm) or not
Viral tonsillo- Bacterial tonsillopharyngitis likely (and < 72 hours from onset), healed within 3 weeks,
for up to 5 days.
pharyngitis likely • Give paracetamol 15mg/kg (up to 1g) QID PO as needed for up give aciclovir 20mg/kg (up refer to hospital.
• If status unknown, test for
• Give paracetamol to 5 days. to 800mg) QID PO for 7 days.
HIV. If HIV positive, manage
15mg/kg (up to 1g) • Give single dose benzathine benzylpenicillin2,3 < 30kg, • If extensive/recurrent or no
according to national HIV
QID PO as needed up give 600 000 units IM or ≥ 30kg, give 1.2 million units IM or better after 2 weeks, refer to
programme guidelines.
to 5 days. phenoxymethylpenicillin2 250mg BID PO for 10 days. hospital.
• Salt water gargle1 may • If mild, fine red rash after antibiotic, glandular fever likely. • If status unknown, test for
help. --Stop antibiotic. Reassure will resolve spontaneously. If difficulty/painful HIV. If HIV positive, manage
• Explain that antibiotics --Child may return to school when better but can only resume swallowing or refusing to eat, according to national HIV
are not necessary. sporting activities > 3 weeks from onset of illness. oesophageal candida likely. programme guidelines.
• If ≥ 5 episodes per year or persistent snoring, refer to hospital. Refer to hospital.

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.

Give bland, soft foods and advise to keep mouth and teeth clean by brushing and rinsing regularly.

1
Mix ½ teaspoon of salt in ½ cup of lukewarm water. 2If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give instead erythromycin 12.5mg/kg (up to 500mg) QID PO for 5 days. 3For benzathine benzylpenicillin 1.2 million units injection:
dissolve benzathine benzylpenicillin 1.2 million units in 3.2mL lidocaine 1% without adrenaline.
Child 139
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 • Grunting • Oxygen saturation ≤ 92% • Decreased level of consciousness/ lethargy • Restless or irritable
• Nasal flaring • Blue lips/tongue • Stridor (noisy, high-pitched breathing) • Recent episode of choking • 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.

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:

1 episode of cough (or breathing problems) < 2 weeks Repeated episodes or

Is respiratory rate increased (≥ 25 breaths/minutes if 5-12 years old or ≥ 20 breaths/minute if ≥ 12 years old)? cough (or breathing problems) ≥ 2 weeks

Yes No • Exclude TB.

• If recent common cold:
Pneumonia likely Runny/blocked nose Barking cough, may be hoarse --If wet cough ≥ 4 weeks, chronic bronchitis likely, refer
• Give amoxicillin2 30mg/kg (up to 1g) to hospital.
TID PO for 7 days. --If dry cough, post-infectious cough likely: should
Common cold likely Viral croup likely resolve by 8 weeks.
• Give paracetamol 15mg/kg (up to • Check ears 138, throat 139. • Give single dose dexamethasone 0.6mg/kg
1g) QID PO as needed for 5 days. • If persistent snoring with poor sleep/apnoea3, refer to
• Reassure caretaker antibiotics not needed. PO or prednisolone 2mg/kg (up to 40mg) PO. hospital.
• Advise to return if condition worsens. • Advise to drink warm liquids to relieve • Advise to return immediately if worse or
• Review after 2 days: if respiratory rate symptoms. stridor develops.
still increased, refer to hospital. 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.
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). 2If penicillin allergy (history of anaphylaxis,
urticaria or angioedema), give instead erythromycin 12.5mg/kg (up to 500mg) QID PO for 5 days. 3Episodes where breathing stops > 10 seconds.
Child 140
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.

Approach to the child with wheeze not needing urgent attention

Manage according to severity of symptoms:
• Oxygen saturation 91-94% • Wheeze with reduced breath sounds
• Moderate accessory muscle use1 • Able to talk only in phrases

None of the above ≥ 1 of above

Mild asthma likely

• Give salbutamol via spacer 1200mcg (12 puffs) every 20 minutes.
• Assess response after 20 minutes, repeat for 3 doses if needed:

Poor response after 1 hour (3 doses), reclassify.

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.

Good response Poor response after 1 hour

Wheeze improved, no accessory muscle use1, oxygen saturation ≥ 94% and able to drink and talk
• Refer to hospital while continuing oxygen and salbutamol via spacer 1200mcg
• Discharge on salbutamol 2-6 puffs inhaled every 4-6 hours as needed. (12 puffs) every 20 minutes.
• If known asthma, also give prednisolone 1mg/kg (up to total daily dose 40mg) BID PO for 4 days. • If child’s condition deteriorates despite treatment, consider adrenaline (1:1000)
• If respiratory rate ≥ 25, also give amoxicillin2 30mg/kg TID PO for 5 days. 0.01mL/kg (up to 0.4mL) IM/SC every 15-20 minutes. If pulse rate ≥ 180 beats/minute,
• If not known with asthma and wheeze recurrent 142. avoid repeating adrenaline.
1
Accessory muscle use is any of: subcostal recession, intercostal recession, tracheal tug, use of neck muscles. 2If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give erythromycin 12.5mg/kg (up to 500mg) QID PO for 5 days.
Child 141
Recurrent wheeze or cough
Approach to the child with recurrent wheeze or cough
First exclude TB. While excluding TB, ask about the following:
• History of eczema/allergic rhinitis • Wheeze episode needing hospital admission • Symptoms triggered by: smoking, pets, pollen, perfume,
• Parents with history of eczema/allergic rhinitis/asthma • Symptoms worse at night and in early morning paint, hairspray, cleaning agents, change in weather or
• > 3 episodes wheeze per year season, exercise, emotion, laughter or stress

≥ 1 of above None of above: are symptoms triggered by common colds?

Yes No

Do symptoms persist for > 10 days after a common cold or are there symptoms between colds?

Yes No

Give a trial of treatment for 2 months: Does child have recurrent wheeze?
• Give inhaled corticosteroid: beclomethasone 200mcg BID inhaled and
• Give salbutamol via spacer 100-200mcg (1-2 puffs) QID inhaled as needed. Yes No
• Demonstrate inhaler technique as below and encourage child/caretaker to identify and avoid triggers.
• Assess response to treatment after 2 months:
Recurrent virus-induced wheeze likely Refer to hospital.
• If wheeze is bronchodilator responsive2 give
Symptoms improve with trial of treatment and worsen when treatment is stopped. Symptoms remain salbutamol via spacer 100-200mcg (1-2 puffs)
the same. QID inhaled when needed for 5 days.
Asthma likely • Check ears 138, throat 139.
• Continue beclomethasone 200mcg BID inhaled and Refer to hospital.
• Give salbutamol via spacer 100-200mcg (1-2 puffs) QID inhaled as needed.
• If symptoms controlled1 reduce beclomethasone to 100mcg BID inhaled.

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.
• Remove cap Put spacer into mouth Press pump Remove inhaler Rinse mouth after
from inhaler and close lips around it down once and spacer using inhaled
and spacer. and form seal with lips and allow and wait for 30 corticosteroids
• Shake inhaler around mouthpiece. 6 deep seconds before (beclomethasone).
for 5 seconds If needed, make a breaths repeat. Repeat
and insert into spacer from a plastic before for each puff
1 spacer. 2 bottle 81. 3 continuing. 4 prescribed. 5

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. 2Wheeze improves 15 minutes after salbutamol via spacer 600mcg (6 puffs). If no better, child is not bronchodilator responsive.
Child 142
Abdominal symptoms
Give urgent attention to the child with an abdominal symptom:
• Guarding, rebound tenderness or rigidity of abdomen1, peritonitis likely • Tender, elevated testes Decide on maintenance fluid3 rate
• Tender in right lower abdomen and vomiting, appendicitis likely • Painful groin/umbilical swelling Weight 24 hour fluid need
• Cramping pain and jelly-like stool • Rash and joint pain
• No stool/wind for 24 hours and vomiting • Vomiting, deep sighing respiration, fatigue, 10-20kg 1000mL + (50mL for every kg body weight
• Bile-stained vomiting acidosis likely over 10kg)
Manage and refer urgently: e.g.: if 14kg: 1000mL + (50 x 4)
• Check fingerprick glucose: = 1200mL/24 hours
--If ≥ 200mg/dL, diabetic ketoacidosis likely. Assess fluids needs 129 and refer urgently. ≥ 20kg 1500mL + (20mL for every kg body weight
--If < 45mg/dL (or < 54mg/dL if malnourished), give 10% glucose2 5mL/kg IV/IO. Recheck glucose after 30 minutes. If still low, over 20kg)
repeat 10% glucose2 bolus. Up to 2000mL in girls and 2500mL in boys
• Assess and manage child’s fluid needs 129. e.g.: if 23kg: 1500mL + (20 x 3)
• Keep nil per os. Give maintenance fluid3 IV according to table. = 1560mL/24 hours
• 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?

Yes No

Is swelling localised or generalised? • 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?
Localised Generalised
• If bulge • Exclude TB.
on crying/ • Do urine dipstick: Yes No
coughing/ --≥ 3+ protein, nephrotic
passing stool syndrome likely, refer to
• Advise a high fibre diet (vegetables, fruit, • If girl and pain around time of period, dysmenorrhoea likely:
in groin or hospital.
wholemeal cereals and bran). --Give ibuprofen5 400mg TID PO for 3 days.
umbilical area, • Assess growth (weight,
• If no better despite diet change, refer to hospital. --Reassure that is common and encourage to carry on with everyday activities.
hernia likely, height, MUAC):
• If girl and sexually active:
refer to hospital. --If growth problem 150.
--If lower abdominal pain and/or vaginal discharge, pelvic infection likely 36.
• If mass felt in --If growth normal, refer to
--If lower abdominal pain with amenorrhoea or vaginal bleeding 6-8 weeks after last
abdomen, refer hospital.
period, ectopic pregnancy likely, refer to hospital.
to hospital.
--If child abuse suspected, refer to hospital.

If cause unclear or not resolved, 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. 2If 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). 3To 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). 4If child’s palm significantly less pink than your own. 5Avoid if peptic ulcer, asthma or kidney disease.
Child 143
Diarrhoea
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 • Shock or severe dehydration • Swelling of legs/ wasting
• Unable to drink • Distended abdomen • 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.

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.

Review stool microscopy result.

Positive Negative

RBC/WBC Amoebic trophozoite Ova or parasite only seen Diarrhoea Diarrhoea for > 2 weeks
only seen and RBC/WBC seen for Knowing child’s HIV status helps in the management. Test for HIV.
• If amoebiasis, give ≤ 2 weeks
Give • Give metronidazole metronidazole 7.5mg/kg (up to HIV positive HIV
ciprofloxacin 7.5mg/kg (up to 500mg) TID PO for 5-7 days. Avoid • Give routine HIV care according to national HIV programme guidelines. negative/
6-10mg/kg 500mg) TID PO for • If giardiasis, give single dose antibiotics. • Lopinavir/ritonavir can cause ongoing diarrhoea. unknown
(up to 400mg) 5-7 days. tinidazole 50mg/kg (up to 2g) PO. • If ART not started or ART failed, treat for possible Isospora belli and microsporidiosis
BID PO for • If no response • If strongyloidiasis, give with co-trimoxazole 20mg/kg BID PO for 21 days and albendazole 400mg BID PO Avoid
5 days. after 2 days, add albendazole 400mg BID PO for for 14 days. antibiotics.
ciprofloxacin 3 days.
6-10mg/kg (up to • If other parasites, albendazole
400mg) BID PO for 400mg daily PO for 3 days. • Check ears 138, check urine 145. Assess growth (weight, height, MUAC): if growth problem 150.
5 days. • 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.
If diarrhoea for > 2 weeks, test for HIV. • Give zinc 20mg daily PO for 14 days.

Review in 2 weeks if diarrhoea still present. If diarrhoea persists despite treatment or cause is not clear, 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. 2If 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 144
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.

Give urgent attention to the child with urinary symptoms and any of:
• Passing little amounts or unable to pass urine • Swelling of face/feet and either blood in urine or
• Temperature ≥ 38°C/rigors/flank pain, pyelonephritis likely 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.

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 Leucocytes/nitrites on dipstick No blood or leucocytes/nitrites

Is bed-wetting a problem?
Is there protein on urine dipstick? Urinary tract infection likely
• Send urine for microscopy. No Yes
• Give amoxicillin1 15mg/kg (up to
No Yes 500mg) TID PO for 5 days.
• Advise to wipe from front to back. Reassure and • If previously dry, ask about recent stressful
• Encourage child to drink frequently. reassess in events. Discuss possible solutions. If
Has child been in a bilharzia area? one week if daytime incontinence, to finger prick
• Avoid irritant soaps and bubble baths.
• If no response to treatment after not better. glucose to exclude diabetes and refer.
Yes No 2 days, refer to hospital. • Give advice:
• Recurrent urinary tract infections --Reduce fluid intake during evening:
might indicate an abnormal urinary avoid fluids 1 hour before bedtime.
Schistosomiasis likely Refer to hospital. --Teach child to wake with urination urge
• Send urine for S. haematobium ova. tract, if ≥ 2 urinary tract infections,
refer to hospital for investigations by initially waking him/her to urinate.
• Give single dose praziquantel 40mg/kg (up to 3g) PO. --Suggest a reward system like a star chart
• Advise to avoid contaminated water to prevent once antibiotic complete.
for a dry bed.
re-infection. --Advise to avoid punishing child.
• Review results in 3 days, repeat dipstick and refer if: --Refer if above measures unhelpful.
--Urine schistosomiasis test negative
--Blood not cleared
--Symptoms not resolved. Ask caretaker if aware of abuse of child. Ask child if anyone hurts or upsets him/her.
• Advise to return if swelling of face or feet and refer to If yes to either, child abuse likely, refer to hospital.
hospital.

1
If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give erythromycin 12.5mg/kg QID PO for 7 days.
Child 145
Leg symptoms/limp/walking problems
Give urgent attention to the child with leg symptoms with any of:
• Sudden refusal to sit, stand or walk • Leg pain and temperature ≥ 38°C • Unable to bear weight after • Any of: strange movements of limbs or face, lumps over joints/tendons
• Sudden onset weakness in leg/s • Limping and weight loss/lethargy leg injury 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.

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 Abnormal leg Leg pain Leg swelling

Is child limping? shape
• If injury 132. • If swelling of 1 leg and no history of injury, refer.
Yes No • If bow-legs, look • If well and • If swelling of both legs, do urine dipstick:
for forehead leg pain only
prominence, at night and
Ask about duration of limp. < 3+ protein ≥ 3+ protein
bowing of arms, active during
bony lumps along day, growing
Limp < 48hrs Limp ≥ 48hrs ribcage. If present, pains likely, Assess growth Nephrotic
rickets likely: refer reassure pain (weight, height, MUAC). syndrome
Sprain/strain likely Refer to hospital. to hospital. will resolve. Is there a growth problem? likely.
• Ensure can bear weight on leg, otherwise refer to • If shape otherwise • If leg pain Refer to
hospital. not normal, refer occurs in day hospital.
No Yes
• Rest and elevate leg. to hospital. and night, refer
• Apply pressure bandage. to hospital.
• If skin marks, bruises of different ages or poor Heart failure Severe acute
growth, suspect neglect and refer to hospital. likely. malnutrition
• Advise child to move leg after 2-3 days if not too Refer to likely. Manage
painful. hospital. and refer
• Give paracetamol 15mg/kg (up to 1g) QID PO as urgently
needed up to 5 days. If pain not responding to 150.
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.

1
If penicillin allergy (history of anaphylaxis, urticaria or angioedema), refer. 2For benzathine benzylpenicillin 1.2 million units injection: dissolve benzathine benzylpenicillin 1.2 million units in 3.2mL lidocaine 1% without adrenaline. 3Avoid if peptic
ulcer,asthma or kidney disease.
Child 146
Generalised rash
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.

Bumps become weeping blisters and Hyper-pigmented bumps, A widespread very itchy rash with Red raised wheals that appear suddenly,
crusts on face, scalp, trunk and limbs. surrounding skin often hyper- burrows in web-spaces of hand disappear and then reappear elsewhere.
pigmented (not on face) and feet, axillae and genitalia.

© University of Cape Town © University of Cape Town © St. Paul's Hospital Millennium Medical College © St. Paul's Hospital Millennium Medical College

Chicken pox likely Papular pruritic eruption (PPE) Scabies likely Urticaria likely
• Apply calamine lotion and give paracetamol likely • Apply benzyl benzoate lotion
15mg/kg (up to 1g) QID PO for up to 5 days. If • If HIV unknown, test for HIV. If HIV 25% to whole body from neck to
very itchy, give cetirizine, according to weight, positive, manage according to feet after hot bath and dry well. If sudden onset (few hours) of generalised itchy rash
until itch controlled (up to 2 weeks): 12-21kg: national HIV programme guidelines. Wash off next day and repeat next or face/tongue swelling and 1 or more of: 1) difficulty
give 5mg daily PO, ≥ 21kg: give 10mg daily PO. • Exclude scabies. night. Repeat treatment after breathing, 2) fainting/ dizziness/collapse, 3) abdominal
• If rash extensive or child has HIV, give aciclovir • Apply hydrocortisone 1% cream in 1 week. pain/vomiting, anaphylaxis likely:
20mg/kg (up to 800mg) QID PO for 7 days. morning and moisturise with liquid • Give cetirizine, according to • Give adrenaline (1mg/mL, 1:1000) 0.3mL IM into mid-
• If rash and surrounding skin red, painful and paraffin at night until improvement. weight, until itch controlled (up to outer thigh. If no better, repeat every 5 minutes.
swollen with temperature ≥ 38°C, impetigo • Give cetirizine, according to weight, 2 weeks): 12-21kg: give 5mg daily • Give normal saline 20mL/kg IV bolus.
likely 148. until itch controlled (up to 2 weeks): PO, ≥ 21kg: give 10mg daily PO. • Also give diphenhydramine 1mg/kg IM/IV (up to 50mg).
• Refer to hospital if any of: 12-21kg: give 5mg daily PO, ≥ 21kg: --12-21kg: 5mg, ≥ 21kg: 10mg
--Does not resolve by 10 days. give 10mg daily PO. • Treat all house members at same
--Difficulty breathing • Advise child/caretaker: time. • If recently started new medication, consider drug reaction.
--Signs of meningitis (≥ 2 of: temperature ≥ 38°C, --Explain that PPE may be long- • Wash linen and clothes in hot • Consider possible triggers1.
headache, decreased level of consciousness, standing. water and expose bedding to • Give cetirizine, according to weight, for itch (until 72 hours
neck stiffness) --May temporarily worsen on direct sunlight. after resolution of wheals): 12-21kg: give 5mg daily PO,
• If recurrent, test for HIV. starting ART. • Keep finger nails short and clean. ≥ 21kg: 10mg daily PO.
• Highly contagious (spreads in air). --Reduce exposure to insect bites. • If blisters and yellow crusts appear, • If not better after 24 hours, refer to hospital within one
--Allow return to school once blisters crusted. impetigo likely 148. month.
--Avoid contact with pregnant women. • If repeated episodes, allergy likely. Refer to hospital.
• Advise to return immediately if any symptoms of anaphylaxis
occur.
If no response to treatment, refer to specialist for review.

1
Possible triggers can be a viral infection, food (commonly peanuts, eggs milk, fish), medication or insect sting.
Child 147
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:

Scaling moist lesions between Ring shaped patches, red, scaly edge Look for blisters/honey coloured crusts and flaky/greasy crusts, flaky pink raised plaques
toes and on soles of feet
Vesicles, pimples (pustules) in centre Pus-filled blisters which dry to form Flaky or greasy crusts with
honey coloured crusts underlying red base on face,
forehead, behind ears, eyebrows,
eyelids and nasal creases.
May be itchy.

© University of Cape Town

Tinea (ring worm) likely

• If multiple or large lesions, test for HIV.
• If HIV positive, manage according to national © St. Paul's Hospital Millennium Medical College
programme guidelines.
ProjectManhattan/Wikimedia Commons
• Apply clotrimazole 2% cream 8 hourly for 2 weeks.
• Avoid sharing towels/clothes. Impetigo likely © St. Paul's Hospital Millennium Medical College
Athlete’s foot likely • Wash skin well before applying treatment. • Keep nails short. Wash and soak sores in soapy water to
Encourage open shoes/sandals. • If lesions on scalp or hair loss: soften and remove crusts. Cover draining lesions with saline-
soaked gauze dressing. Seborrhoeic dermatitis likely
• Apply clotrimazole 2% cream
BID topically for 2 weeks. • Apply povidone iodine 5% cream TID topically and give • Reassure caretaker that it will
• Avoid sharing towels/clothes. cephalexin1 12-25mg/kg (up to 500mg) QID PO for 7-10 days resolve without treatment in few
• Wash skin well before applying or cloxacillin1 12.5-25mg/kg (up to 500mg) QID PO for 7 days. weeks/months.
• If rash does not resolve completely, repeat treatment. • If extensive and HIV status
treatment and dry well
• Look for cause: if scabies 147. Also consider eczema and unknown, test for HIV. If HIV
between toes.
insect bites. positive, manage according to
• Advise caretaker that impetigo is contagious: national HIV programme.
--Ensure regular hand-washing to prevent spread. • Advise caretaker to:
--May return to school 1 day after starting antibiotic. --Trim nails and avoid scratching.
© University of Cape Town • Refer if: --Wash body with aqueous cream
--Extensive lesions and avoid perfumed soap.
--Cellulitis or abscess • If in > 1 area, apply
Tinea capitus likely
--Temperature ≥ 38°C hydrocortisone cream 1% BID
Look hair and scalp symptoms page 149.
--No better after the above treatment topically until improved.
• Advise to return immediately if blood in urine or limb/face/ • If extensive and no response to
If rash extensive, recurrent or responds poorly to treatment, refer. feet swelling and refer to hospital same day. hydrocortisone cream, refer.

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.
Child 148
Hair and scalp symptoms
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 Patches of hair loss Itchy scalp Pimples/pustules
• If flaky or greasy crusts with underlying
red base, consider seborrhoeic
Is there scaling? Look for lice or nits.
dermatitis 148.
If no lice/nits seen, exclude tinea capitus.
• If patches of hair loss:
Yes No
Lice/nits likely
• Apply malathion 1% shampoo to scalp
Alopecia areata likely
after bath at night: Comb into hair
• Give betamethasone 0.1%
repeatedly until whole scalp is covered: © University of Cape Town
gel to apply topically daily
--Dip a fine-toothed comb in vinegar
for 3 months.
and remove lice by combing entire Folliculitis likely
• If no response to
head twice. • Keep area clean and dry.
treatment, refer to
--Then rinse hair with lukewarm water • If extensive or redness/pain/
hospital.
and wash malathion out with normal swelling/temperature ≥ 38°C,
shampoo. give cloxacillin2 12.5-25mg/
• Advise to: kg (up to 500mg)QID PO or
--Avoid broken skin and contact with cephalexin2 12-25mg/kg (up to
© University of Cape Town
eyes. 500mg) QID PO for 5 days.
--Wash bed linen in very hot water. • Wash hands regularly to prevent
--Treat all household contacts. spread.
Tinea capitus likely --If lice/nits persist, shave hair.
• Give griseofulvin 20-25mg/kg daily PO for 6-8 weeks or • Consider child abuse if lice on pubic,
fluconazole 4-6mg/kg daily PO for 4 weeks. peri-anal areas or eyelashes /eyebrows,
--Use ketoconazole 2% shampoo twice a week to refer to hospital.
reduce sheddin of spores
• Advise child/caretaker to avoid:
--Shaving head.
--Sharing combs and hairbrushes.

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. If penicillin allergy (history of anaphylaxis, urticaria or angioedema), give instead erythromycin 12.5mg/kg QID PO for 5 days.
2

Child 149
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.

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).

Does child have swelling of both feet?

Yes 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)?
Severe acute
malnutrition Yes: severe acute malnutrition (SAM) likely No
(SAM) likely

Does child have any of: Moderate acute malnutrition

• Vomits everything • Glucose < 54mg/dL • Diarrhoea (> 3 watery stools/ 24 hours) Eye Signs of Vitamin (MAM) likely
• Unable to eat/drink • Hb < 10g/dL • Weeping skin lesions A deficiency Do appetite test (see below).
• Temperature < 35.5°C or > 39°C • Increased respiratory rate • Lethargy or decreased level of consciousness
Fails the
Yes No: severe acute malnutrition (SAM) without medical complications. Do appetite test (see below). Passes the appetite test appetite
Is outpatient care available, test
Fails the appetite test home circumstances reliable and
caretaker willing?

Give urgent attention to the child with severe acute malnutrition (SAM) with medical complications:
Yes No
• 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. Give routine Refer to hospital for
• Feed at least 2 hourly until transfer. If refusing, give sugar water3 via NGT. malnutrition care inpatient care.
• Treat infection: give ceftriaxone 80mg/kg (up to 1.5g) IV/IM. 153.
• Give vitamin A: 200 000IU PO.
• Keep warm: cover with blanket.
• Refer urgently.

How to do an appetite test Minimum amount to be given to child

Body weight (kg) RUTF Imunut® Sachet (92g) F75® 10% dextrose2
• 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. 15 -30 70g 200mL 200mL
• If child finishes minimum amount of feed, s/he passes the appetite test. ≥ 30 92g 250mL 250mL
• If child does not finish minimum amount of feed: s/he fails the appetite test.

1
Mid upper arm circumference. 2If 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). 3Dissolve 4
teaspoons of sugar (20g) into 200mL water.
Child 150
Girl's BMI chart
5 to 19 years (z-scores)

36 3 36

34 34

32 32

30 30
2
28 28

26 26
BMI (kg/m²)

1
24 24

22 22
0
20 20

-1
18 18

16
-2 16

-3
14 14

12 12

Months 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
Years 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Age (completed months and years)
World Health Organization. BMI-for-age Girls 5-19 years (z-scores). 2007
Child 151
Boy's BMI chart
5 to 19 years (z-scores)
36 36
3
34 34

32 32

30 30
2
28 28

26 26
1
BMI (kg/m²)

24 24

22 0 22

20 20
-1
18 18
-2
16 16
-3

14 14

12 12
Months 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
Years 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Age (completed months and years)
World Health Organization. BMI-for-age Boys 5-19 years (z-scores). 2007
Child 152
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.

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.

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 albendazole 400mg or Mebendazole 500mg PO and give therapeutic dose Vitamin A if therapeutic food is not as per WHO specification or has eye
sign or had recent measles.
• 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. If child’s palm significantly less pink than your own. 3Protein-rich foods: chicken, fish, cooked eggs, beans, lentils (shiro watt/thick soup), soya. 4Iron-rich foods: liver, kidney, dark green leafy vegetables like spinach,
2
5 6 7
cooked egg, beans, peas, lentils, fortified cereals. Vitamin A-rich foods: vegetable oil, liver, yellow sweet potatoes, dark green leafy vegetables like spinach (imifino), mango, full cream milk. Vitamin C-rich foods: oranges, melons, tomatoes. If penicillin
allergy (history of anaphylaxis, urticaria or angioedema), give erythromycin 12.5mg/kg (up to 500mg) QID PO for 5 days instead. 8Growing well: MUAC ≥ 14 cm in a child 5-9 years old or ≥ 18 cm in a child 10-14 years old.
Child 153
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.

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.

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).

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 40mg/kg/day in • Choose if generalised tonic/clonic seizures, Urgent: jaundice, vomiting, abdominal pain: stop medications
• Increase to: 15-20mg/kg/dose 8-12 hourly divided doses absence seizures, on ART. and refer urgently. Self-limiting: nausea, diarrhoea, constipation.
• Maintenance dose: 20-30mg/kg/dose 8-12 hourly • Avoid if liver disease.
Carbamazepine3 • Start dose: 2mg/kg/dose 8-12 hourly 10mg/kg/day in • Choose if focal seizures/convulsion. Urgent: skin rash, refer. Self-limiting: drowsiness, dry mouth,
• Increase to: 5-10mg/kg/dose 8-12 hourly divided doses • Avoid in absence, myoclonic seizures or if dizziness, ataxia, nausea, loss of appetite, constipation, abdominal
• Maintenance:10-20mg/kg/day in divided doses child on ART. 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. 2If unable to swallow tablet, give crushable formulation (100mg tablets) TID. If able to swallow, give controlled release (CR) formulation BID. 3Give syrup
formulation TID and tablet formulation BID.
Child 154
Quick reference chart
Decide if respiratory rate is normal for age Estimate weight according to age Decide on maintenance fluid rate
Age Respiratory rate (breaths/minute) 5-12 years Weight (kg) = (3 x age in years) + 7 Weight 24 hour fluid need
Respiratory rate Respiratory rate < 10kg 120mL/kg
decreased if: increased if:
10-20kg 1000mL + (50mL for every kg body weight over 10kg)
5-12 years < 20 ≥ 25 e.g.: if 14kg: 1000mL + (50 x 4)
Decide if blood pressure is normal for age
≥ 12 years < 15 ≥ 20 = 1200mL/24 hours
Age Blood pressure Blood pressure
decreased if: increased if: ≥ 20kg 1500mL + (20mL for every kg body weight over 20kg)
Up to 2000mL in girls and 2500mL in boys
DBP SBP DBP SBP e.g.: if 23kg: 1500mL + (20 x 3)
Decide if pulse rate is normal for age 6-10 years old < 57 < 97 > 76 > 115 = 1560mL/24 hours

Age Pulse rate (beats/minute) 10-12 years old < 61 < 102 > 80 > 120
Pulse rate decreased if: Pulse rate increased if: 12-15 years old < 64 < 110 > 83 > 131
5-12 years < 80 ≥ 120
≥ 12 years < 60 ≥ 100

Assess level of consciousness (LOC) with the AVPU scale:

Is child alert and awake? Assess level of consciousness with AVPU
A Alert
Yes No V responds to Voice
P responds to Pain
Child has normal LOC Try to rouse child by talking to him/her or shaking his/her arm: U Unresponsive/Unconscious
(A on AVPU scale)
Child responds Child does not respond
Child is lethargic Check if child responds to pain by firmly rolling a pen over child’s nailbed:
(V on AVPU scale)
If this is main presenting Child responds Child still does not respond
symptom. Child has a decreased LOC Child is unresponsive/unconscious/comatose
(P on AVPU scale) (U on AVPU scale)

Child 155
 Eastern Sub-Saharan Africa
Instructions for using WHO CVD risk (non-laboratory-based) charts
Risk Level 0 <5% 5 5% to <10% 10 10% to <20% 20 20% to <30% 30 ≥30%

Non-laboratory based risk chart Action

Age Men Women SBP
(years) Non-smoker Smoker Non-smoker Smoker (mmH Select the regional chart covering your country:
g)
24 25 27 29 30 30 32 34 36 38 18 18 19 20 20 25 26 26 27 28 ≥180 • REGION NAME is printed at the top of the charts.
20 21 22 24 25 25 26 28 30 32 15 15 16 16 17 21 22 22 23 24 160-179
• Countries included in each region can be found in Annex 1.
70-74 16 17 18 20 21 21 22 23 25 27 12 13 13 14 14 18 18 19 19 20 140-159
13 14 15 16 17 17 18 19 21 22 10 11 11 11 12 15 15 16 16 17 120-139
Have the following information ready:
11 11 12 13 14 14 15 16 17 18 9 9 9 10 10 12 13 13 14 14 <120
• age
19 20 22 23 25 25 27 29 31 34 14 14 15 16 16 21 22 23 24 24 ≥180 • sex
15 16 17 19 20 20 22 24 26 28 11 12 12 13 13 17 18 19 20 20 160-179
• smoker* or non-smoker
65-69 12 13 14 15 16 16 18 19 21 23 9 10 10 10 11 14 15 15 16 17 140-159
9 10 11 12 13 13 14 15 17 18 8 8 8 8 9 12 12 13 13 14 120-139 • systolic blood pressure
8 8 9 10 11 10 11 12 14 15 6 6 7 7 7 10 10 10 11 11 <120 • BMI (body mass index) = weight (kg) ÷ height (m)2

14 16 17 19 21 21 23 25 28 30 11 11 12 12 13 18 19 20 20 21 ≥180 Using the charts

11 12 14 15 16 17 18 20 22 24 9 9 9 10 10 15 15 16 16 17 160-179
60-64 9 10 11 12 13 13 14 16 17 19 7 7 7 8 8 12 12 13 13 14 140-159
7 7 8 9 10 10 11 12 14 15 5 6 6 6 6 9 10 10 11 11 120-139 STEP 1: Select the table for men or women, as appropriate.
5 6 6 7 8 8 9 10 11 12 4 4 5 5 5 7 8 8 8 9 <120

11 12 14 15 17 17 19 22 24 27 9 9 9 10 10 15 16 17 18 19 ≥180 STEP 2: Select smoker or non-smoker column.

8 9 11 12 13 13 15 17 19 21 7 7 7 8 8 12 13 13 14 15 160-179
55-59 6 7 8 9 10 10 11 13 15 16 5 5 6 6 6 9 10 10 11 11 140-159
5 5 6 7 8 8 9 10 11 13 4 4 4 4 5 7 8 8 8 9 120-139
STEP 3: Select age-group.
4 4 5 5 6 6 7 8 9 10 3 3 3 3 4 6 6 6 7 7 <120

9 10 11 12 14 14 16 18 21 24 7 7 7 8 8 13 14 14 15 16 ≥180
6 7 8 9 11 11 12 14 16 18 5 5 5 6 6 10 10 11 12 12 160-179
STEP 4: Within the selected box find the cell where the person’s systolic
50-54 5 5 6 7 8 8 9 11 12 14 4 4 4 4 5 8 8 8 9 9 140-159
blood pressure and body mass index (BMI) intersect.
3 4 4 5 6 6 7 8 9 10 3 3 3 3 3 6 6 6 7 7 120-139
Green <5%
3 3 3 4 4 4 5 6 7 8 2 2 2 2 3 4 5 5 5 6 <120
STEP 5: The colour of the cell indicates the
7 8 9 10 11 12 14 16 18 21 5 5 6 6 6 11 12 12 13 14 ≥180
10-year risk of a fatal or non-fatal CVD Yellow 5% to <10%
5 5 6 7 8 9 10 12 14 16 4 4 4 4 5 8 9 9 10 10 160-179 event. The value within the cell is the risk
45-49 3 4 5 5 6 6 7 9 10 12 3 3 3 3 3 6 6 7 7 8 140-159 percentage. Colour coding is based on Orange 10% to <20%
2 3 3 4 4 5 5 6 7 9 2 2 2 2 3 4 5 5 5 6 120-139 the grouping.
2 2 2 3 3 3 4 5 5 6 1 2 2 2 2 3 4 4 4 4 <120 Red 20% to <30%

5 6 7 8 9 10 11 13 16 19 4 4 4 5 5 9 10 11 11 12 ≥180 Deep red ≥30%

4 4 5 6 7 7 8 10 11 14 3 3 3 3 4 7 7 8 8 9 160-179
40-44 2 3 3 4 5 5 6 7 8 10 2 2 2 2 3 5 5 6 6 6 140-159
2 2 2 3 3 3 4 5 6 7 1 2 2 2 2 3 4 4 4 5 120-139
STEP 6: Record CVD risk percentage in person’s chart.
1 1 2 2 2 2 3 4 4 5 1 1 1 1 1 3 3 3 3 3 <120
20-24

25-29

30-35

20-24

25-29

30-35

20-24

25-29

30-35

20-24

25-29

30-35
≥ 35

≥ 35

≥ 35

≥ 35
<20

<20

<20

<20

STEP 7: Counsel, treat and refer according to risk level

Body mass index (kg/m^2)

Adult | 157
Risk Level 0 <5% 5 5% to <10% 10 10% to <20% 20 20% to <30% 30 ≥30% Risk Level 0 <5% 5 5% to <10% 10 10% to <20% 20 20% to <30% 30 ≥30%

People without Diabetes People with Diabetes

Age Men Women SBP Age Men Women SBP
(years) Non-smoker Smoker Non-smoker Smoker (mmHg) (years) Non-smoker Smoker Non-smoker Smoker (mmHg)
22 24 27 29 32 28 30 33 36 39 16 17 17 18 19 22 23 24 25 26 ≥180 30 32 35 38 42 37 40 43 47 51 24 25 25 26 28 32 33 34 36 37 ≥180
18 20 22 24 26 23 25 28 30 33 14 14 15 15 16 19 20 20 21 22 160-179 25 27 29 32 35 31 34 37 40 43 20 21 22 23 24 27 28 30 31 32 160-179
70-74 15 17 18 20 22 19 21 23 25 28 12 12 13 13 14 16 17 17 18 19 140-159 70-74 20 22 25 27 30 26 28 31 34 37 17 18 19 19 20 24 24 25 26 28 140-159
12 14 15 16 18 16 17 19 21 23 10 10 11 11 12 14 14 15 15 16 120-139 17 19 20 23 25 21 23 26 28 31 15 15 16 16 17 20 21 22 23 24 120-139
10 11 12 14 15 13 14 16 17 19 8 9 9 10 12 12 12 13 14 <120 14 15 17 19 21 18 19 22 24 26 12 13 13 14 15 17 18 19 19 20 <120

18 19 21 23 26 23 26 28 31 34 12 13 14 14 15 19 19 20 21 23 ≥180 25 27 30 33 36 33 36 39 43 47 20 21 22 23 24 29 30 31 33 34 ≥180
14 16 17 19 21 19 21 23 25 28 10 11 11 12 13 15 16 17 18 19 160-179 20 22 25 27 30 27 30 33 36 40 16 17 18 19 20 24 25 27 28 29 160-179
65-69 11 12 14 15 17 15 17 19 21 23 9 9 9 10 10 13 13 14 15 16 140-159 65-69 16 18 20 22 25 22 24 27 30 33 14 14 15 16 17 20 21 22 24 25 140-159
9 10 11 12 14 12 14 15 17 19 7 7 8 8 9 11 11 12 12 13 120-139 13 15 16 18 20 18 20 22 25 27 11 12 13 13 14 17 18 19 20 21 120-139
7 8 9 10 11 10 11 12 14 15 6 6 6 7 7 9 9 10 10 11 <120 11 12 13 15 17 14 16 18 20 23 9 10 10 11 12 14 15 16 17 18 <120

14 15 17 19 21 19 21 24 27 30 10 10 11 11 12 15 16 17 18 20 ≥180 21 23 25 28 32 29 32 35 39 44 16 17 18 19 20 26 27 29 30 32 ≥180
11 12 13 15 17 15 17 19 21 24 8 8 9 9 10 13 13 14 15 16 160-179 16 18 20 23 26 23 26 29 32 36 13 14 15 16 17 21 22 24 25 27 160-179
60-64 8 9 10 12 13 12 13 15 17 19 6 7 7 8 8 10 11 12 12 13 140-159 60-64 13 14 16 18 21 19 21 23 26 30 11 11 12 13 14 17 18 20 21 22 140-159
7 7 8 9 10 9 11 12 14 15 5 5 6 6 7 8 9 9 10 11 120-139 10 11 13 15 17 15 17 19 21 24 9 9 10 11 11 14 15 16 17 19 120-139
5 6 6 7 8 7 8 9 11 12 4 4 5 5 5 7 7 8 8 9 <120 8 9 10 12 13 12 13 15 17 19 7 8 8 9 9 12 12 13 14 15 <120

11 12 13 15 17 16 18 20 23 26 7 8 8 9 10 13 14 15 16 17 ≥180 17 19 22 24 27 26 29 32 36 40 13 14 15 16 18 23 24 26 28 30 ≥180
8 9 10 11 13 12 14 16 18 20 6 6 7 7 8 10 11 12 13 14 160-179 13 15 17 19 22 20 23 26 29 33 11 11 12 13 14 18 20 21 23 25 160-179
55-59 6 7 8 9 10 10 11 12 14 16 5 5 5 6 6 8 9 9 10 11 140-159 55-59 10 12 13 15 17 16 18 20 23 26 8 9 10 11 11 15 16 17 19 20 140-159
5 5 6 7 8 7 8 9 11 13 4 4 4 5 5 6 7 8 8 9 120-139 8 9 10 12 13 12 14 16 18 21 7 7 8 8 9 12 13 14 15 16 120-139
4 4 5 5 6 6 6 7 8 10 3 3 3 4 4 5 6 6 7 7 <120 6 7 8 9 10 9 11 12 14 17 5 6 6 7 7 10 10 11 12 13 <120

8 9 10 12 13 13 15 17 19 22 6 6 7 7 8 11 12 12 14 15 ≥180 15 16 18 21 23 23 26 29 33 37 11 12 13 14 15 20 22 24 26 28 ≥180
6 7 8 9 10 10 11 13 15 17 4 5 5 6 6 8 9 10 11 12 160-179 11 12 14 16 18 18 20 23 26 30 9 9 10 11 12 16 17 19 21 23 160-179
50-54 5 5 6 7 8 8 9 10 11 13 3 4 4 4 5 6 7 8 8 9 140-159 50-54 8 9 11 12 14 13 15 17 20 23 7 7 8 9 9 13 14 15 16 18 140-159
3 4 4 5 6 6 6 7 9 10 3 3 3 4 5 5 6 7 7 120-139 6 7 8 9 11 10 12 13 16 18 5 6 6 7 7 10 11 12 13 14 120-139
3
3 3 3 4 5 4 5 6 7 8 2 2 2 3 3 4 4 5 5 6 <120 5 5 6 7 8 8 9 10 12 14 4 4 5 5 6 8 9 9 10 12 <120

6 7 6 9 11 11 12 14 16 19 4 5 5 6 6 9 10 11 12 13 ≥180 12 14 15 17 20 21 23 26 30 34 9 10 11 12 13 18 20 22 24 26 ≥180
5 5 6 7 8 8 9 11 12 14 3 4 4 4 5 7 7 8 9 10 160-179 9 10 11 13 15 15 17 20 23 27 7 7 8 9 10 14 15 17 19 21 160-179
45-49 3 4 5 6 6 7 8 9 11 2 3 3 3 4 5 6 6 7 8 140-159 45-49 6 7 8 10 12 11 13 15 18 21 5 6 6 7 8 11 12 13 15 16 140-159
2 3 3 4 4 4 5 6 7 8 2 2 2 2 3 4 4 5 5 6 120-139 5 5 6 7 9 8 10 11 13 16 4 4 5 5 6 8 9 10 11 13 120-139
2 2 2 3 3 3 4 5 6 1 2 2 2 2 3 3 4 4 5 <120 3 4 5 5 7 6 7 8 10 12 3 3 4 4 5 6 7 8 9 10 <120

5 6 7 9 9 9 10 12 14 16 3 4 4 4 5 7 8 9 10 11 ≥180 10 11 13 15 17 18 21 23 27 32 7 8 9 10 11 16 18 20 22 24 ≥180
3 4 4 5 6 6 7 9 10 12 2 3 3 3 4 5 6 7 8 8 160-179 7 8 9 11 13 13 15 17 20 24 5 6 7 7 8 12 13 15 17 19 160-179
40-44 2 3 3 4 5 5 5 6 7 9 2 2 2 2 3 4 5 5 6 6 140-159 40-44 5 6 7 8 9 10 11 13 15 18 4 4 5 6 6 9 10 11 13 15 140-159
2 2 2 3 3 3 4 5 5 7 1 1 2 2 2 3 3 4 4 5 120-139 4 4 5 6 7 7 8 9 11 14 3 3 4 4 5 7 8 9 10 11 120-139
1 1 2 2 2 2 3 3 4 5 1 1 1 1 2 2 3 3 3 4 <120 3 3 4 4 5 5 6 7 8 10 2 3 3 3 4 5 6 7 8 9 <120
4-4.9

5-5.9

6-6.9

4-4.9

5-5.9

6-6.9

4-4.9

5-5.9

6-6.9

4-4.9

5-5.9

6-6.9

4-4.9

5-5.9

6-6.9

4-4.9

5-5.9

6-6.9

4-4.9

5-5.9

6-6.9

4-4.9

5-5.9

6-6.9
≥7

≥7

≥7

≥7

≥7

≥7

≥7

≥7
<4

<4

<4

<4

<4

<4

<4

<4
Total cholesterol (mmol/l) Total cholesterol (mmol/l)

Adult | 158
 STEP 1: Select the section of the chart for people with or without diabetes.
Action

Select the regional chart covering your country:

• REGION NAME is printed at the top of the charts.
• Countries included in each region can be found in Annex 1.
STEP 2: Select
the table for men
Have the following information ready: or women,
• age as appropriate.
• sex
• smoker* or non-smoker
• presence or absence of diabetes†
• systolic blood pressure STEP 3: Select
• total blood cholesterol‡ the column for
non-smoker
Using the charts or smoker.

STEP 1: Select the section of the chart as relevant for people with or without diabetes.

STEP 2: Select the table for men or women, as appropriate.

STEP 3: Select smoker or non-smoker column.

STEP 4: Select age-group. STEP 4: Select

the relevant
age group.
STEP 5: Within the selected box find the cell whe e the person’s systolic blood pressure and total
blood cholesterol intersect.

Green <5%
STEP 6: The colour of the cell indicates the STEP 5: Within
10-year risk of a fatal or non-fa
10- Yellow 5% to <10% the selected box,
CVD event. The value within the cell is find the cell where
the risk percentage. Colour coding is Orange 10% to <20% the person’s
based on the grouping. systolic blood
Red 20% to <30%
pressure and
Deep red ≥30% serum cholesterol
intersect.

STEP 7: Record CVD risk percentage in person’s chart.

STEP 8: Counsel, treat and refer according to risk level Adult | 159
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]

Adult 157
Co-funded by the
European Union