Treatment Guide New

Botswana Primary Care Guideline
FOR ADULTS
2016
Foreword
The Alma Ata Declaration of 1978 has identified Primary Health Care as the key to the attainment of the goal of Health for All. Some of the activities outlined in the Declaration are: education
concerning prevailing health problems and the methods of preventing and controlling locally endemic diseases; appropriate treatment of common diseases and injuries and provision of
essential medicines.
Botswana, as a member state of the United Nations, has over the years striven to implement the recommendations of the Alma Ata Declaration, and has made Primary Health Care a
cornerstone of its health care delivery system. This has seen great improvement in major health care indicators for the country, at least until the advent of HIV/AIDS epidemic in the early
1980’s which eroded most of these gains. However, with the brave response mounted and successes achieved against this epidemic, time has now come to reverse the losses and put the
country back on track to use the strengthened system of the response to deliver services in line with the Declaration once again.
Primary care, which is the integral component of primary health care strategy, plays a pivotal role in involving communities in the widest scope of health care. Therefore, a primary care
practice serves as the patient's first point of entry into the health care system. It is with this in mind that Botswana Health Care System strives to provide better care to its people by
acknowledging and utilizing primary care at all levels of health care services.
Botswana, as a country therefore needed to come up with primary care guideline to address the issues of management of diseases at different levels of care. This primary care guideline for
adults is a symptom based integrated clinical guideline that uses algorithmic approach to address some of the priority diseases in the country that are gaining prominence worldwide and
in Botswana, such as chronic diseases of lifestyle (cardiovascular diseases, diabetes, chronic respiratory diseases), mental health, musculoskeletal disorders, women’s health. It provides basic
management principles to deal with these diseases at a primary level. The availability of this document and the capacity building of our health care providers will improve the quality of health
services we offer to our clients.
May I take this opportunity to encourage all health care workers in health sectors to maximally utilize this document in the provision of quality health care.
Shenaaz El- Halabi

Permanent Secretary
Ministry of Health
BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 ii

Acknowledgements
DRAFT
The development of Primary Care Guidelinesfor the countryprovides a unique opportunity of having such a complex area of care provision put together in a comprehensive and simplified
format to ease the provision of care for the respective disease entities dealt with in the document. The Guidelines seeks to improve the knowledge base for care providers and also a
systematic symptom based approach to screening and evaluating these conditions for appropriate management.
Botswana has adopted the WHO Package of Essential Non-communicable Diseases interventions for primary health (WHO-PEN) approach and it is with this understanding that this Guideline
is developed to address non-communicable and other prevailing diseases.
The Ministry of Health acknowledges the noble work done by University of Botswana, School of Medicine for coordinating, providing expertise and soliciting funds for developing the
document; World Health Organization, Regional and Country Offices for providing us with WHO-PEN Package and their in-puts during the review process ofthe guideline.
Finally, I wouldlike to thank all experts from different Departments and Divisions of the Ministry of Health, the private sector and individuals consulted for diligently participating in coming up
with this first edited important document.
Dr. Haruna B. Jibril

Deputy Permanent Secretary, Preventive Health Services
Ministry of Health
BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 iii

Introduction
Botswana Primary Care Guideline for Adultswas compiled by the Knowledge Translation Unit, University of Cape Town, Lung Institute in collaboration with the University of Botswana
Family Medicine Department and the Botswana Ministry of Health, Department of Public Health, Non-Communicable Diseases Programme. The initial work has been funded by the Medical
Education Partnerships Initiative (MEPI) to UB, School of Medicine to strengthen and expand medical education to enable deliver quality health care by improving the standard operating
system and building the capacity of health care providers through the introduction of evidence based guideline.
The guideline has been developed in consultation with government and privatclinicians, health managers and patients in 2013 and reviewed in 2015 and 2016. It is aligned with the existing
policies and clinical protocols of the Botswana Ministry of Health as indicated in the references.
The guideline is divided into two main sections: symptoms and chronic conditions. In patients presenting with symptoms, one can start by identifying patient’s main symptom to find the
relevant page for details as indicated by a number at its end. Then follow the algorithms to manage that symptom or chronic condition appropriately.
BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 iv

Table of Contents
FOREWORD ii Positive syphilis result 28 The Asthma: routine care 68 Health education and counselling on tobacco 102
ACKNOWLEDGEMENT iii Abnormal vaginal bleeding 29 Chronic obstructive pulmonary disease 69 Classification of pure alcoholic drink intake on 00
INTRODUCTION iv Sexual problems 30 (COPD): routine care average/day
TABLE OF CONTENTS v Urinary symptoms 31 CARDIOVASCULAR DISEASE (CVD) risk: 70 Cervical Screening – PAP smear/VIA 103
CONTENTS: CHRONIC CONDITIONS vi Body/general pain 32 diagnosis Assessment of Suspected Cervical Cancer 104
SYMPTOMS INDEX vii Joint symptoms 33 HOW DO YOU USE THE CHARTS TO ASSESS 71 Assessment of Suspected Breast Cancer 105
Back pain 34 CARDIOVASCULAR RISK? End of life: routine care 106
The unconscious patient 1 Neck pain 35 10 YEAR RISK OF CARDIOVASCULAR EVENT 72-73 Prep room assessment of the patient 107
Seizures/fits 2 Arm symptoms 35 Cardiovascular disease (CVD) risk: routine care 74 Protect yourself from occupational infection 108
Weight loss 3 Leg symptoms 36 Diabetes: diagnosis 75 Protect yourself from occupational Stress 109
Fever 4 Foot symptoms 37 Diabetes: routine care 76-77 Communicating effectively 110
Lymphadenopathy (enlarged lymph node/s) 5 Injured patient 38 Hypertension: diagnosis 78 Adult Primary prevention visit 111
Weakness and/or tiredness 6 Bites 39 Hypertension: routine care 79
Collapse 7 Burns 39 Heart failure: routine care 80 ANNEX 1 112
Dizziness 8 Skin symptoms 40 Stroke: routine care 81 −Diagnostic Algorithm for TB (a) 112
Headache 9 Painful skin 41 Ischaemic heart disease (IHD): diagnosis 82 −Diagnostic Algorithm for TB (b) 113
Eye/vision symptoms 10 Itch with localised rash 42 Ischaemic heart disease: routine care 83 −Diagnostic Algorithm for TB (c) among 114
Face symptoms 11 Itch with no rash 42 Peripheral vascular disease (PVD): 84 patients > 12 years old
Ear symptoms 12 Generalised itchy rash 43 diagnosis and routine care
Nose symptoms 13 Lumps 44 Mental Disorders 85 ANNEX 2 115
Mouth and throat symptoms 14 Generalised non itchy red rash 45 Depression and anxiety: diagnosis 86 −RECOMMENDED ADULT TREATMENT 115
Chest pain 15 Ulcers and crusts 46 Depression and anxiety: routine care 87 REGIMENS FOR TB
Cough and/or difficult breathing 16 Changes in skin colour 47 Substance abuse: diagnosis and routine care 88 −FIXED - DOSE COMBINATION DRUGS 115
Wheeze/Tight Chest 17 Nail symptoms 48 Psychosis and/or mania: diagnosis and routine 89 −Treatment for New Cases in Adults 116
Breast Symptoms 18 Suicidal patient 49 care −Treatment for New Cases in Children 116
Abdominal pain with or without swelling 19 Aggressive/violent patient 50 Advise the patient with psychosis 90
(no diarrhoea) Confused patient 51 Dementia: diagnosis and routine care 91 ANNEX 3 Treatment of Malaria 117
Vomiting 20 Stressed or miserable patient 52 Epilepsy: diagnosis and routine care 92 a. Uncomplicated malaria species 117
Diarrhoea 21 Traumatised/abused patient 53 Chronic arthritis: diagnosis and routine care 93 b. In pregnants 117
Constipation 22 Difficulty sleeping 54 Gout: diagnosis and routine care 94 c. In severe malaria 117
Anal Symptoms 22 TB: diagnosis 55 Contraception 95
Genital Symptoms 23 TB: The routine care 57 Contraception: routine care 96 CONTRIBUTORS 118
Genital symptoms in a man 24 HIV: diagnosis 60 The pregnant patient 97 REFERENCES 119
Vaginal Discharge 25 HIV: routine care 61-66 Routine antenatal care 98-99
Genital ulcer 26 Using inhalers and spacers 00 Postnatal care 100
Other genital symptoms 27 Asthma and COPD: diagnosis 67 Menopause: diagnosis and routine care 101
BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 v

Contents: chronic conditions
An approach to the diagnosis and routine care of the patient with a chronic condition
TB Mental Health
TB: diagnosis 55 Mental health care 85
TB: routine care 57 Depression and/or anxiety: diagnosis 86
Depression and/or anxiety: routine care 87
HIV Substance abuse 88
HIV: diagnosis 60 Psychosis and mania: diagnosis 89
HIV : routine care 61 Psychosis and mania: routine care 90
Dementia 91
Chronic respiratory disease
Asthma and COPD: diagnosis 67 Epilepsy 92
Using inhalers and spacers 68
Asthma: routine care 69 Musculoskeletal disorders
COPD: routine care 70 Chronic arthritis 93
Gout 94
Chronic diseases of lifestyle
Cardiovascular disease risk assessment 72-73 Women’s health
Cardiovascular disease risk management 74 Contraception 95
Diabetes: diagnosis 75 Contraception: routine care 96
Diabetes: routine care 76-77 The pregnant patient 97
Hypertension: diagnosis 78 Routine antenatal care 98-99
Hypertension: routine care 79 Postnatal care 100
Heart failure 80 Menopause 101
Stroke 81
Ischaemic heart disease: diagnosis 82 End-of-life 97
Ischaemic heart disease: routine care 83
Peripheral vascular disease 84 Prep room assessment 107
Protect yourself from occupational infection 108
Protect yourself from occupational stress 109
Communicating effectively 110
BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 vi

Symptoms Index
Assess and manage the patient using his/her symptom/s as a starting point
A F P
Abused patient 00 Face symptoms 00 Pain 00
Abdominal pain 00 Fatigue 00 Pap smear 00
Abnormal vaginal bleeding 00 Fever 00
Aggressive patient 00 Fits 00 R
Anal symptoms 00 Foot symptoms 00 Rape 00
Arm symptoms 00 Foot care 00
S
B G Seizures 00
Back pain 00 General body pain 00 Sexually transmitted infections 00
Bites 00 Genital symptoms 00 Sexual problems 00
Blackout 00 Skin symptoms 00
Body pain 00 H Difficulty sleeping 00
Breast symptoms 00 Headache 00 Stressed patient 00
Burns 00 Heartburn 00 Suicidal patient 00
Syphilis 00
C I
Cervical screening 00 Injured patient 00 T
Chest pain 00 Throat symptoms 00
Collapse 00 J Tiredness 00
Coma 00 Jaundice 00 Traumatised patient 00
Confused patient 00 Joint symptoms 00
Constipation 00 U
Cough 00 L Unconscious patient 00
Leg symptoms 00 Urinary symptoms 00
D Lymphadenopathy 00
Diarrhoea 00 V
Difficult breathing 00 M Abnormal vaginal bleeding 00
Dizziness 00 Miserable patient 00 Violent patient 00
Dyspepsia 00 Mouth symptoms 00 Vision symptoms 00
Vomiting 00
E N
Ear symptoms 00 Nail symptoms 00 W
Eye symptoms 00 Neck pain 00 Weakness 00
Nose symptoms 00 Weight loss 00
O
Overweight patient 00
BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 vii

The unconscious patient
Give urgent attention to the unconscious patient:
Clear airway Glasgow Coma Scale
• Clear mouth and throat and insert oropharyngeal airway if available. Eye opening
• 4 Spontaneous
Give oxygen via face-mask. Intubate if: • 3 To speech
• Patient centrally cyanosed (blue tongue/lips) and/or • 2 To pain
• Respiratory rate < 10 breaths/minute and/or • 1 None
• Coma score < 9 (to assess Glasgow Coma Scale see chart to the right) Best motor response
If equipment or skills unavailable give mask-bag ventilation. • 6 Obeying commands
• 5 Localises purposefully to pain
Establish IV access • 4 Withdraws to pain
• Use as large bore venous access as possible. • 3 Flexing
• If patient bleeding, give Ringer’s lactate; if no bleeding, give sodium chloride 0.9% solution. • 2 Extending
• 1 None
Check BP Best verbal response
• If systolic BP < 90, give 500mℓ IV fluids rapidly. Repeat until systolic BP > 90. Stop if respiratory rate increases by > 10. • 5 Orientated
• 4 Confused
Check glucose • 3 Inappropriate words
• If glucose < 3.5 or unable to measure, give 50mℓ of 50% glucose IV. • 2 Incomprehensible
• If glucose ≥ 15, give sodium chloride 0.9% IV 1ℓ in first hour and then 1ℓ over the next 2 hours and 10U short-acting insulin IM. • 1 None
Add scores to give a single score
Manage according to likely cause:
Temperature ≥ 38˚C Soft tissue swelling of eyes/lips/wheeze Signs of trauma Recent seizure/fit
Pneumonia or meningitis likely Anaphylaxis likely • Stop bleeding. 2.

• Give Ceftriaxone 2g IV/IM. • Give Adrenaline 1mℓ (1:1000) IM every 10 minutes until • Stabilise cervical spine.
• If recently in a malaria area, better. • Stabilise fractures.
also give quinine 4. • Give Hydrocortisone 100mg IV.
• Give Promethazine 50 mg IM/slow IV.
Write a clear referral letter and refer urgently to hospital.

Record history from relatives and emergency staff:
• Onset of coma and details of how found.
• Known chronic disease/s and medication. Ask about diabetes, hypertension, asthma, HIV, cancer, epilepsy. Send medication with patient to hospital.
• Known substance abuse or depression. Was a suicide note found?
• Any recent trauma.
• Recent travel to a malaria area and any prophylaxis taken.
Document level of consciousness, blood pressure and pulse and any treatment given.
BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 1

Seizures/fits
Give urgent attention to the patient who is unconscious and fitting:
• Ensure the patient is safe. Place in a lateral lying (recovery) position. Do not place anything in the mouth.
• Give facemask oxygen.
• Check glucose. If < 3.5 or unable to measure, give 50mℓ of 50% Glucose IV.
• Continue IV Dextrose 5% in Sodium Chloride 0.9% slowly (30 drops per minute).
• If ≥ 20 weeks pregnant up to 1 week postpartum 93 for treatment of fit.
• If < 20 weeks pregnant or not pregnant, give Diazepam 10mg IV slow infusion over at least 5 minutes or Lorazepam 4mg IM/IV stat.
• Repeat after 10 minutes if fit continues.
• Treat for status epilepticus if:
--Fits do not respond to 2 doses of diazepam/lorazepam or
--Fits last longer than 30 minutes or
--Patient does not recover consciousness between fits.
Patient has status epilepticus: Patient does not have status epilepticus and fit stops:
• Give Phenytoin 20mg/kg IV (through different line Refer patient same day if:
to diazepam) over 60 minutes. • Temperature ≥ 38˚C: give Ceftriaxone 2g IM/IV (if none • New weakness, numbness, visual disturbance, facial
• If fits continue repeat phenytoin 10mg/kg IV available, Benzypenicillin 4M units IV) asymmetry, unable to name 3 out of 3 objects (like hand,
(through different line to diazepam) over 30 minutes. • Neck stiffness/meningism nose, pen) or recent headaches
• If IV phenytoin unavailable, give Phenytoin 20mg/ • HIV patient • BP ≥ 180/110 one hour after fit has stopped
kg crushed tablet via nasogastric tube. • Reduced level of consciousness more than 1 hour after fit • Substance abuse: overdose or withdrawal
• Refer urgently to hospital. • Glucose still < 3.5 after 1 hour or patient on glibenclamide • Head injury within past 6 weeks
or insulin • Pregnant or up to 1 week postpartum
Approach to patient who is not fitting now and does not need same day referral
Confirm that patient indeed had a fit: jerking movements of part of or the whole body, with/without tongue biting, incontinence, post-fit drowsiness and confusion.
Yes No
Is patient known with epilepsy? Episode/s of weakness or disturbance of speech for < 24 hours?
Yes No Yes No
Previous TB meningitis, stroke or head trauma? Stroke or Episodes of acute anxiety?
transient
Yes No ischaemic No Yes
Chance of recurrent fit is 50%, even 2 Refer for specialist attack likely Collapse following hot feeling, nausea, prolonged Panic attack likely
years after the event. assessment. 82, 83. standing or intense pain with rapid recovery? 87.
Syncope/blackout likely 7.

Treat for epilepsy 93.
Refer for specialist assessment if diagnosis uncertain.

Weight loss
Give urgent attention to the patient with weight loss on ART:
• Weight loss in the patient on ART associated with one or more of: nausea, vomiting, sore muscles, shortness of breath, abdominal pain or distension
Management:
• Patient needs same day lactate measurement 64.
• Check that the patient that says s/he has unintentionally lost weight has indeed done so. Compare current weight with previous records and ask if clothes still fit.
• Unintentional weight loss of > 5% of body weight is significant and must be investigated.
First check for TB, HIV and diabetes
Exclude TB Test for HIV Check for diabetes

• Start workup for TB 55. • If status is unknown, test for HIV 60. • Check random finger-prick blood glucose
• At the same time test for HIV 60 and diabetes 76 • The HIV patient with weight loss ≥ 10% and diarrhoea or fever • To interpret result 76.
• and consider other causes below. > 1 month needs ART 61.
Ask about symptoms of common cancers:
Abnormal vaginal discharge/ Breast lump/s or nipple Urinary symptoms in man Change in bowel habit Cough ≥ 2 weeks, blood-stained
bleeding discharge sputum, long smoking history
Consider cervical cancer. Consider breast cancer. Consider prostate cancer. Consider bowel cancer. Consider lung cancer.
Do a speculum examination Examine breasts/axillae for Hard and nodular prostate on Mass on abdominal or rectal Do chest X-Ray.
27. lumps 18. rectal examination 31. examination, occult blood positive.
If food intake inadequate, look for a cause:
Nausea and/or Loss of appetite Ask, ‘Are you stressed? No money for food The patient has an incurable Sore mouth or difficulty
vomiting illness and you would not swallowing
If yes, 52. If available, refer to be surprised if s/he died
• Eat small frequent meals. 20
social worker. within the next year.
20. • Drink high energy drinks (milk, mageu, soup, Oral/oesophageal thrush
sweetened fruit juice). likely 14
• Increase energy value of food by adding sugar, Give end-of-life care 107.
milk powder, peanut butter or oil.
Check thyroid function (TSH, T3, T4) if none of the above and patient has any of pulse > 80, tremor, irritability, dislike of hot weather or thyroid enlargement.
Refer within 1 month for further investigation the patient with persistent documented weight loss and no obvious cause.

Fever
Give urgent attention to the patient with fever (temperature ≥ 38˚C now or in the past 3 days) and one or more of the following:
• Confusion or agitation • Unable to drink • BP < 90/60 How to give IV/IM quinine
• Difficulty breathing; RR > 30 breaths/minute • Jaundice • Easy bleeding/ bruising/ • If patient had choloroquine, quinine or mefloquine in past
• Unable to walk unaided • Seizures 2 blood in urine week, give 10mg/kg, otherwise 20mg/kg, up to 1.2g.
Management: • IV infusion: dilute quinine in 5% dextrose, give over 4 hours.
• Establish IV access and give5% Glucose in 1/2 Strength Darrows. If unavailable give ORS. • IM: combine 5ml normal saline and 300mg (1mℓ) quinine in
• Give Ceftriaxone 2mg IV/IM stat. syringe = 50mg/ml. Give maximum 4ml per injection site.
• If a Malaria area and rapid diagnostic test is Positive also give Artemether-Lumefantrine(AL) with a single • Monitor blood glucose 4 hourly: if < 3.5, give IV dextrose.
• Dose of Primaquine (Refer to Annex 3 for appropriate treatment) and
• Refer same day to hospital.
Approach to the patient with fever (temperature ≥ 38˚C now or in the past 3 days) not needing urgent attention:
• Ask about other symptoms: if cough 16; sore throat ± blocked/runny nose 13; lower abdominal pain ± vaginal discharge 23.
• If above symptoms are not present and client has been in a malaria area recently, check a rapid diagnostic test for malaria:
Malaria test positive Malaria test negative Client was not in a malaria area.
Do a malaria parasite slide to confirm diagnosis. After 6 hours, repeat a rapid diagnostic test and do a malaria parasite slide.
Positive Negative
Treat same day for malaria and consider another cause of fever:
• Give 6 doses of Artemether/Lumefantrine 20/120mg: 4 tablets stat, after 8 hours, then 12 hourly.
• If pregnant in 1st trimester give instead Quinine Sulphate 600mg orally 8 hourly with food for 7 days.
• Advise patient to return for review after 3, 14 and 28 days.
Fever persists
Repeat malaria parasite slide and treat depending on duration of fever.
Fever persists within 2 weeks Fever persists after 2 weeks

• Give Quinine Sulphate 600mg orally • If malaria slide positive, retreat with Artemether/Lumefantrine
8 hourly with food for 7 days and 20/120mg: 4 tablets immediately, after 8 hours, then 12 hourly.
• Consider other cause for fever: • If negative, consider other cause of fever:
Consider other cause for fever

• If patient has any other symptoms, manage symptom on symptom page.
• Exclude TB in the client with fever ≥ 2 weeks 55.
• If status unknown, test for HIV 60. If HIV positive and temperature ≥ 39˚C, refer for workup. Give routine HIV care 61.
• If fever persists after 3 days, repeat/do malaria test, exclude TB and refer for further investigation.

Lymphadenopathy (enlarged lymph node/s)
Approach to patient with enlarged lymph nodes
• Lymphadenopathy is common in HIV. If status unknown, test for HIV 60 and
• Ask about associated symptoms, especially TB symptoms 55 (weight loss, cough ≥ 2 weeks, chest pain, night sweats) and manage on relevant page.
Are nodes equally enlarged < 2cm or 1 or more ≥ 2cm?
All lymph nodes enlarged equally but < 2cm in size 1 or more lymph node/s ≥ 2cm in size
Check for secondary syphilis with RPR or if unavailable, look for signs: rash especially palms and Is there a nearby infection (skin, throat) or Kaposi’s sarcoma lesion?
soles, mouth ulcers, genital wart-like lesions. 45.
No Yes
RPR positive or signs of HIV positive HIV and/or RPR negative
secondary syphilis
Inguinal/groin swelling • Sore throat 14
• Skin infection 40
• Kaposi’s sarcoma lesion 44
Treat syphilis 28. Give routine HIV care • Advise repeat test after 3 month No Yes
61. window period.
• If asymptomatic, reassure and
advise to return if symptoms occur. Confirm that this is a lymph node:
discrete, movable and rubbery.
Yes No
Refer for further investigation if after 2 weeks patient is unwell with lymphadenopathy
and no obvious cause.
Swelling hot, painful Refer to exclude
and/or red? hernia, aneurysm.
No Yes
How to aspirate lymph node for TB and cytology
• Clean skin over largest node with alcohol or povidone iodine.
• Insert 16 or 18 gauge needle into node, partially withdraw and reinsert at different angles • Patient needs lymph Treat patient and partner for bubo
several times. node aspirate for TB First assess and advise the patient and partner 23.
• Withdraw needle, attach to syringe filled with 2–3mℓ air, and gently spray needle contents and cytology. • Look for genital ulcer. If present 23.
over glass slide. • If patient is • Doxycycline 100mg 12 hourly for 14 days
• Thinly spread material across slide with a second slide. coughing, also • Pregnant/breastfeeding: Erythromycin 500mg 6
• Fix one slide for cytology with cytology spray. exclude TB with hourly for 14 days instead
• Allow second slide to air-dry (TB). sputa 55. • Aspirate fluctuant lymph node through intact skin to
• If the aspirate is unsuccessful, repeat. If again unsuccessful, refer to surgeon. relieve pain.

Weakness and/or tiredness
Recognise the patient with weakness and/or tiredness needing urgent attention:
• Possible stroke or TIA: sudden onset of weakness on 1 or both sides perhaps with vision problems, dizziness, difficulty speaking or swallowing 82.
• Difficulty breathing 16.
• Chest pain 15.
• Patient on ART with other signs of lactic acidosis: nausea, abdominal pain or swelling, weight loss, fatigue, shortness of breath 68.
• Diarrhoea and/or vomiting with reliable signs of dehydration:
--Postural hypotension (systolic BP drop > 20mmHg between lying and standing)
--Poor urine output
--Confusion
Management:
• If dehydrated give oral or IV rehydration. Reassess after 2 hours and refer if no improvement.
Approach to patient with weakness and/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:
First check patient’s temperature.

• If ≥ 38˚C 4. If < 38˚C but had a fever in past 3 days and recently in a malaria area, exclude malaria 4.
Then exclude TB, HIV, pregnancy and stress.

• Ask about TB symptoms. Exclude TB 55.
• If status unknown, test for HIV 60. The HIV patient needs routine HIV care 61.
• Exclude pregnancy. If pregnant 98.
• Ask ‘Are you stressed?’ If yes 52.
• If patient has difficulty sleeping 54.
If patient has an incurable disease and you would not be surprised if s/he died within the next year, give end-of-life-care 107
If none of the above, test for anaemia, diabetes, kidney and thyroid disease.
• Check Hb for anaemia: if < 11 (woman) or < 12 (man), refer to doctor same week.
• Exclude diabetes with random finger prick blood glucose. To interpret result 76.
• Look for kidney disease on urine dipstick: check eGFR if patient has proteinuria, diabetes, hypertension, or is > 60 years.
• Check TSH,T3,T4 if any of weight gain, dry skin, constipation, cold intolerance. If TSH abnormal refer to doctor.
• Serum electrolytes Na,K+, ca+, urea, creatinine, vit.B12
Refer the patient with persistent weakness/tiredness and no obvious cause.

Collapse
Give urgent attention to the patient who has collapsed if one or more of:
• Unconscious 1 • Pulse rate < 40
• Fit 2 • BP < 90/60
• Sudden onset of weakness which may not have resolved on 1 or both sides 76 • Recent trauma
• Difficulty breathing 16 • Family history of collapse or sudden death
• Chest pain 15 • Abnormal ECG
• Loss of consciousness for > 2 minutes • Known heart problem
Management:
• Check blood glucose: if < 3.5mmol/ℓ, give oral Glucose if conscious, or if unconscious, 40–50mℓ Glucose 50% IV. If known with diabetes 77.
Approach to the patient who has collapsed but not needing urgent attention
• Ensure patient has had an ECG. Refer same day if abnormal or unavailable.
• Check for postural hypotension: Measure BP lying and repeat after standing for 3 minutes.
Systolic BP drops by No change in systolic BP or change < 20mmHg

≥ 20mmHg. Ask patient to breathe rapidly for 2–3 minutes. Are symptoms reproduced?
No Yes
• This is common if elderly • Before the collapse did patient experience flushing, light-headedness, nausea?
or pregnant 98. • Did patient recover rapidly following collapse?
• Measure pulse on Hyperventilation likely
standing: if > 100/minute,
patient is dehydrated. Give Yes
No
oral rehydration solution. Was collapse associated with coughing, swallowing, head turning? • Advise re-breathing into a
• Check Hb: if <11 (woman) paper bag.
Simple faint likely
or <12 (man), refer to • Assess and manage patient’s
doctor same week. No Yes stress 52.
• Review medications to • There may be twitching of limbs, Is there known epilepsy or diabetes?
identify likely drug or drug face, eyes that last < 12 seconds
interactions. (not a fit). Refer for medical
• Advise patient to stand up • Advise to avoid overheating and Yes No specialist assessment.
slowly. prolonged standing.
• Epilepsy care 93.

• Diabetes care 77-78.
Refer the patient > 70 years with possible heart disease, or who collapses repeatedly, or where no cause for collapse is obvious.

Dizziness
Give urgent attention to the patient with dizziness if one or more of:
• Dehydration due to vomiting/diarrhoea (systolic BP drop ≥ 20mmHg between lying and standing) with poor response to IV or oral rehydration
• Consider stroke if sudden onset of dizziness is associated with vision problems, weakness on 1 or both sides, difficulty speaking or swallowing 82.
• BP < 90/60
• Pulse < 40 and/or irregular
Management:
Approach to the patient with dizziness not needing urgent attention

• Ask about ear symptoms. If present 12.
• Screen for substance abuse: if > 21 drinks/week (man) or > 14 drinks/week (woman) and/or > 5 drinks/session or misuse of illicit or prescription drugs 89.
• Review patient’s medication. Anti-hypertensives, sedatives, efavirenz, oral hypoglycaemics, anti-convulsants can all cause dizziness. Refer to doctor.
• If diabetic, check finger prick blood glucose for hypoglycaemia 71.
• Check for anaemia with Hb. If < 11 (woman) or < 12 (man), refer doctor same week.
• Check BP. If > 130/80 73 to interpret result. Assess for postural hypotension: Measure BP lying and repeat after standing for 3 minutes.
Systolic BP drops ≥ 20mmHg No drop or drop in systolic BP < 20mmHg

between lying and standing
Ask patient to breathe rapidly for 2–3 minutes. Are symptoms reproduced?
Postural hypotension likely
Yes No
Ask about associated features
• This is common if elderly or
pregnant 99. Hyperventilation likely
• Advise patient to stand up slowly. Dizziness precipitated by sudden head Recent flu-like illness
• Doctor must review if patient on movements
any medication. • Advise re-breathing into a paper bag.
• Assess and manage patient’s stress 52. Vestibular neuronitis likely
Positional vertigo likely
• Mobilize as soon as possible.

• Patient needs Epley manoeuvre. Refer to • Refer to ENT if:
doctor. --Symptoms > 2 weeks
--Tinnitus
--New deafness
• If none of the above, check TSH. If abnormal, refer to doctor.

• Refer if no cause is found or dizziness persists.

Headache
Give urgent attention to the patient with headache and one or more of the following:
• Sudden onset of severe headache • Decreased level of consciousness
• New onset, persistent, different to usual headache • Confusion
• Headache that wakes or is worse in the morning • Vision problems (e.g. double vision, photophobia)
• Vomiting • Following a first seizure
• Temperature ≥ 38˚C • Sudden weakness on one or both sides
• Neck stiffness/meningism • Speech disturbance
• BP ≥ 180/110, or if pregnant, diastolic BP ≥ 90. • Pupils different in size
Management:
• If temp ≥ 38˚C and neck stiffness, treat for meningitis. Give Ceftriaxone 2g IM/IV (if none available, give Benzylpenicillin 4MU IV stat).
• If BP ≥ 180/110 give Nifedipine SR 10mg orally stat. If unavailable give Enalapril 5mg orally stat.
Approach to the patient with headache not needing urgent attention

Is headache recurrent with nausea and/or vomiting and/or visual disturbance that resolves completely?
Yes No: Pain or pressure over forehead or cheek/s worse on bending forwards, recent common cold, runny nose?
Yes No
Migraine likely
• Give immediately and then as
needed Paracetamol 1g 6 hourly or • Check patient’s medication
Ibuprofen1 400mg 8 hourly with food Sinus infection likely
--ART: Look for meningitis. Refer if headache persists for more than 6 weeks after starting ART.
and Prochlorperazine 10mg 6 hourly. • Give Paracetamol 1g 6 hourly.
--Overuse of analgesics can cause headaches. Advise to avoid regular use and to cut down on
• If ≥ 2 attacks/month, give amitriptyline • If nasal discharge for > 6 days, give
amount used.
25mg at night to prevent migraines. Amoxycillin 500mg 8 hourly for
• If patient not on above medication consider tension headache, temporal arteritis or neck pain:
• Advise patient to recognise and treat 5 days. If penicillin allergic, give
migraine early, rest in a dark, quiet Erythromycin 500mg 6 hourly for
room, avoid precipitants like loud noise, 5 days. Tightness of scalp > 50 years, pain over temples
• Refer if poor response to treatment, Pain mainly
stress, flashing lights, missing meals, Tension headache likely in neck with Temporal arteritis likely
alcohol, chocolate, cheese. meningism, tooth infection,
swelling over sinus or around eye. muscle
• Avoid oestrogen-containing stiffness.
contraceptives 96 . • If patient has recurrent sinusitis, • Give Paracetamol 1g 6 hourly. • Give Paracetamol1g 6 hourly.
test for HIV 60. • Go to neck
• Refer if poor response to treatment. • Amitriptyline 10–25mg at pain page • Check ESR and review next day:
night may help. 35. if > 30, give Prednisolone 40mg
• Discuss stress 52. and refer same day.
• Warn patient to avoid overusing analgesics.

• Refer if the diagnosis is uncertain or headaches are not responding to treatment.
Avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure, kidney disease.
1

Eye/vision symptoms
Give urgent attention to the patient with eye or vision symptoms and one or more of the following:
• Single painful red eye
• Shingles involving the eye (or if eyelid swollen closed, the tip of the nose)
• Sudden loss or change in vision, including blurred or reduced vision
• Consider stroke if sudden onset of vision problems is associated with dizziness, weakness on 1 or both sides, difficulty speaking or swallowing 82.
• Metallic foreign body or foreign body associated with welding or grinding
• Chemical burn to one or both eyes: wash the eye continuously for at least 20 minutes with clean water or saline.
• Whole eyelid swollen, red and painful: possible orbital cellulitis. Give Ceftriaxone 2g IV/IM stat.
Management:
Approach to patient with eye/vision symptoms not needing urgent attention
Both eyes are discharging/watery Gradual change in Red or swollen Foreign body
Is there prominent itch? vision eyelids
Yes No • Wash the eye with

Associated with hayfever, allergic rhinitis? Is the discharge clear or pus? • Exclude diabetes • Give clean water or
76. Chloramphenicol saline.
• Exclude hypertension 1% ointment 6 • Remove foreign
No Yes Pus Clear 79. hourly for 7 days. body with cotton-
• If status unknown, • Wash crusts on lid tipped stick or bud.
Localised cause Allergic Bacterial Viral conjunctivitis test for HIV 60. margin twice a day
(makeup) likely conjunctivitis likely conjunctivitis likely likely with warm water.
Refer to eye OPD if:
• Wash out eye • Treat with • Give • Give 0.9% saline eye • Refer for next • Damage to eye
with clean water. Oxymetazoline eye Chloramphenicol washes. available eye OPD Refer to eye OPD • Abnormal vision or
• Remove the drops 1–2 drops 6 1% ointment 6 • Give Oxymetazoline appointment. if symptoms do movement of eye
cause. hourly for 7 days. hourly for 7 days. eye drops 1–2 drops 6 • Refer HIV patient not improve with • No improvement
• Treat with • If symptoms persist • Advise patient to hourly for 7 days. Avoid same week. treatment. after 2 days
Oxymetazoline > 4 weeks, give avoid rubbing eyes using > 7 days as this
eye drops 6 Chloropheniramine and to wash hands may result in rebound
hourly for 3 days. 4mg at night. Avoid regularly. conjunctivitis.
steroid eye drops.
Refer to eye clinic if symptoms do not

improve within 2 days.

Face symptoms
Give urgent attention to the patient with face symptoms and:
• Possible stroke/TIA: sudden onset of one sided facial weakness with minimal or no involvement of the forehead usually with weakness of arm/leg 83.
• Facial swelling and difficult breathing: check urine dipstick:
--Abnormal urine dipstick: kidney disease likely
• Normal urine dipstick: anaphylaxis likely: give adrenaline 1mℓ (1:1000) IM every 10 minutes until better and Hydrocortisone 100mg IV and Promethazine 50 mg IM/slow IV
• Painful facial swelling and temperature ≥ 38°C: facial cellulitis likely
Refer urgently same day.
Approach to patient with facial symptoms not needing urgent attention
Face pain Sudden weakness of 1 side of face Swelling of face
Pain of cheek or jaw with/without Pain over forehead or cheek/s worse on Unable to wrinkle forehead; Ensure patient has no difficult breathing,
swelling and on tapping involved tooth bending forwards and/or pressure over cannot close eye fully RR < 30, otherwise manage urgently as
sinuses and/or purulent nasal or post above.
nasal discharge
Gum/tooth infection likely Idiopathic (Bell’s) palsy likely
• Rarely may be painful. Is patient on enalapril?
Sinus infection likely • Sagging mouth, dribbling, taste
• Give Paracetamol 1g 6 hourly. impairment, watering or dry eyes
• Patient cannot wrinkle forehead, blow Yes No
• Give Amoxycillin 500mg 8 hourly
for 5 days. If penicillin allergic, give forcefully, whistle or pout out cheek.
• Give Paracetamol 1g 6 hourly.
Erythromycin 500mg 6 hourly for 5 • If symptoms for > 6 days, give Patient has Refer to doctor
days and Metronidazole 200mg 8 Amoxycillin 500mg 8 hourly for 5 days. angioedema and for review.
hourly for 5 days. • Protect eye with aqueous eye drops 5
If penicillin allergic, give Erythromycin times a day. Close eyelid with surgical must stop enalapril
• Refer to dentist same week. 500mg 6 hourly for 5 days. even if well tolerated
tape if cornea is exposed.
• Salt water washes or steam inhalation • Reassure patient that most people until now and never
may relieve symptoms. recover completely within 10 days. start it again.
• Refer if: • Refer if: • Give
--Associated tooth infection --No improvement after 10 days chlorpheniramine
--Poor response to treatment --Patient has otitis media 4mg 8 hourly for 1–2
--Swelling over sinus or around eye --Any change in hearing days until swelling
--Meningism --Recent head trauma resolved.
--If sinusitis is recurrent and status --Damage to cornea • Refer to doctor for
unknown test for HIV 60. --Unsure of diagnosis review of medication.
--Recurrent sinusitis is a stage 2 HIV • Advise patient to
diagnosis. Patient needs routine HIV return urgently
care 61. should difficult
breathing occur.

Ear symptoms
Itchy ear Painful ear Discharge from ear Difficulty hearing
Redness and/or pus of ear canal Normal drum and canal Symptoms < 2 weeks Symptoms ≥ 2 weeks
Red or bulging eardrum • If wax in ear, syringe ear
Perforated eardrum
with warm soapy water.
• If patient using
streptomycin, stop
streptomycin.
• Refer unless hearing
improves on removal of
wax.
Otitis externa likely Referred pain likely Acute otitis media likely Chronic otitis media likely
• Give pain relief. Check teeth, temporo- • Give pain relief. • Clean ear1. The ear can heal
• Clean ear1. mandibular joint and throat. • Clean ear if discharge is only if dry.
• Instill spirit 50% 4 drops in ear present.1 • Refer if:
4 times a day for 5 days. • Amoxicillin 500mg 8 hourly --No improvement after 4
• If severe pain or temperature for 5 days. If penicillin allergic weeks
≥ 38°C, give cloxacillin give Erythromycin 500mg 6 --Foul-smelling discharge
500mg 6 hourly for 5 days. hourly for 5 days instead. --A large hole in eardrum
If penicillin allergic give • Refer if: --Hearing loss
erythromycin 500mg 6 hourly --No response to --Pain in or behind ear
for 5 days instead. antibiotics after 5 days. --Consider TB and HIV
• Refer if infected and no --Recurrent otitis media in chronic otitis media
response to treatment within --Painful swelling behind that responds poorly to
48 hours ear treatment.
--Neck stiffness/
meningism
Cleaning the ear: Make a wick by twisting a tuft of cotton wool, paper towel or absorbent cloth onto a thin wooden stick. If using cotton wool, it should adhere tightly onto the stick but be fluffy and absorbent on the other end. Insert into ear and remove once
1
wet, continue until wick is dry. Never leave wick or other object inside the ear.

Nose symptoms
Runny or blocked nose Bleeding nose
Ask about duration and associated symptoms.
Sore throat Body aches/muscle Purulent nasal and/or post nasal discharge Recurrent episodes of sneezing and
• Pinch nose wings together for 10 minutes.
and/or fever pains and/or fever and/ and/or headache worse on bending forward itchy nose most days for > 4 weeks
• Check BP.
or cold chills and/or pressure over sinuses
• If < 90/60, elevate legs and give IV
Sodium Chloride 0.9%.
Common cold likely Influenza (flu) likely Sinusitis likely Allergic rhinitis likely --If ≥ 130/80 73.
• If still bleeding:
--Syringe nose with saline
• Advise the patient with influenza: • Give Paracetamol 2 tablets 4 times a day • Chlorpheniramine 4mg 3 to 4 --Pack nose with ribbon gauze
--bed rest • If pus from nose or symptoms > 6 days: times a day only when symptoms impregnated with liquid paraffin or
--avoid contact with others to prevent spread give Amoxicillin 500mg worsen (side effect is sedation). nasal packs soaked in adrenaline.
--use tissues when sneezing/coughing and 8 hourly for 5 days. If penicillin allergic, • Refer if no improvement with --Refer for further management if
dispose of these carefully. Erythromycin 500mg above treatment and symptoms bleeding persists.
• Pain and fever relief (Paracetamol 1g 6 hourly) 6 hourly for 5 days instead. debilitating. • If patient has recurrent episodes:
• Regular oral fluids • Salt water washes or steam inhalation may • If persistant (≥ 4 days per week), refer --Advise patient to avoid nose-picking,
• Reassure patient that antibiotics are not necessary. relieve symptoms. for beclomethasone nasal spray long contact sport and trauma to nose.
Use antibiotics only if pus on examination. • Refer if: term 2 sprays in each nostril daily. --Educate patient to pinch the soft
• Colds and flu should improve within 3–7 days. --Associated tooth infection nose wings when bleeding.
--Poor response to treatment
--Swelling over a sinus or around eye
--Meningism
• If sinusitis is recurrent and status unknown,
test for HIV 60.
• Recurrent sinusitis is a stage 2 HIV diagnosis.
Patient needs routine HIV care 61.

Mouth and throat symptoms
Give urgent attention to the patient with mouth/throat symptoms:
• Unable to open mouth
• Unable to swallow at all
Management:
• Refer same day
Approach to the patient with mouth and throat symptoms not needing urgent attention:
Examine the mouth and throat for redness, white patches, blisters or ulcers. Ask about dry mouth and difficulty or pain on swallowing.
Red throat White patches on cheeks, Painful blisters on lips/ Painful ulcer/s in Difficulty or pain on Dry mouth
gums, tongue, palate, mouth mouth/throat swallowing
Are there pus or white patches on tonsils? may have cracks in
• Exclude diabetes if thirst,
corners of mouth
Herpes simplex likely Aphthous ulcer/s If patient also has urinary frequency, weight
No Yes likely oral thrush, then loss 70.
Bacterial tonsillitis Oral thrush/candida likely oesophageal thrush • Review medication:
Viral pharyngitis • 0.5% gentian violet
likely likely solution painted in likely furosemide, amitriptyline,
• Miconazole oral gel apply • Rinse with hyoscine, morphine may
mouth 3 times a day
8 hourly or suck 1 nystatin Chlorhexidine cause this.
• Give Aciclovir 400mg 8 • Give Fluconazole
• Give • Give Paracetamol 1g tablet 6 hourly. 20% Solution • Assess if patient is
hourly for 7 days if: 200mg daily for 14
Paracetamol 6 hourly. 10ml twice a breathing through his/
--Blisters for ≤ 72 hours days. If no response
1g 6 hourly. • Salt water mouthwash day or crushed her mouth.
• If patient uses inhaled or new blisters forming or no oral thrush,
• Salt water • Give Benzathine Prednisolone 5mg • Look for and treat oral
corticosteroids, ensure --Ulcers are extensive or refer to determine
mouthwash Penicillin 1.2MU tablet 12 hourly thrush on this page.
s/he uses spacer and recurrent cause.
• Reassure patient IM single dose or until healed. • Advise on mouth care
rinses mouth after use --Severe pain • If status unknown,
that antibiotics Phenoxymethyl- • Rinse with aspirin below.
65. --Ulcers present for >1 test for HIV 60.
are not Penicillin 500mg 12 600mg in water • Advise patient to sip
• If status unknown, test for month • If HIV, also give ART
necessary. hourly for 10 days. 6 hourly for pain fluids frequently. Sucking
If penicillin allergic HIV 60. relief. 61. on oranges, pineapple,
give Erythromycin • For routine HIV care 61. If status unknown, test • If status unknown, • If the client has an lemon or passion fruit
500mg 6 hourly for 10 • If the client has an for HIV 60. test for HIV 60. incurable illness and may help.
days instead. incurable illness and you • For routine HIV care • Refer if: you would not be • If the client has an
would not be surprised if 61. --Not healed surprised if s/he died incurable illness and you
s/he died within the next • Herpes > 1 month is within 2 weeks within the next year, would not be surprised if
Refer for ENT
year, give end-of-life care a stage 4 HIV disease. --Larger than 1cm give end-of-life care s/he died within the next
assessment if > 4
97. Patient needs ART 61. in diameter 97. year, give end-of-life care
episodes per year.
107.
• Advise the patient with a sore mouth/throat to avoid spicy, hot, sticky, dry or acidic food and to eat soft, moist food or to soften food with margarine or gravy, or dip in tea/coffee or soup.
• Advise to keep mouth clean by brushing teeth and rinsing with a solution of water and a pinch of salt or ½ teaspoon of sodium bicarbonate after eating and before going to sleep.

Chest pain
Give urgent attention to the patient with chest pain and one or more of:
• Respiratory rate ≥ 30 breaths/minute • Pain spreads to the neck, arm or back
• BP ≥ 180/110 or < 90/60 • Sweating, nausea, vomiting
• Pulse irregular, > 100 or < 60 • Pale
• Severe pain • At risk of heart attack (diabetes, smoker, hypertension, known CVD risk > 10%)
• New onset of central chest pain • Known with ischaemic heart disease
Management:
• If unconscious 1. If conscious, sit patient up.
• Give oxygen by face mask.
• If BP < 90/60, give 200mℓ Sodium Chloride 0.9% IV.
≥ 38˚C • Manage according to temperature: < 38˚C
Do an ECG
Chest infection likely
• Give Ceftriaxone 1g IV/IM stat.
• If BP still < 90/60, give 500mℓ Sodium Chloride 0.9% IV ECG normal or unavailable or uncertain ECG abnormal
over 30 minutes. Is chest pain worse on lying down, palpation or breathing deeply?
• Repeat if BP persists < 90/60. Stop fluids if respiratory rate
increases. Yes No
• Refer patient same day.
Heart attack unlikely: refer urgently. Heart attack likely 83
Approach to the patient with chest pain not needing urgent attention
First exclude pain related to heart and lungs.
Recurrent episodes of central chest pain, brought on by exertion and relieved by rest: angina likely 83. Pain on coughing and breathing deeply: 16.
Once heart and lung conditions excluded, consider heartburn, musculoskeletal problem or shingles.
Retrosternal or epigastric pain with eating, hunger or lying down: heartburn or indigestion likely Tender at costochondral junction, Burning pain on
• Avoid spicy/acidic food, fizzy drinks, eat small frequent meals and prop up head of bed. no fever or cough 1 side with or
• If waist circumference > 88cm (woman), 102cm (man), assess patient’s CVD risk 71. Musculoskeletal problem likely without rash for
• Give Aluminium Hydroxide 250mg/Magnesium Tricilicate 500mg 1–2 tablets as needed (up to 16 in 24 hours) for 7 days. • Give Ibuprofen 400mg 8 hourly 1–2 days
• Refer same week if any of: no response to treatment, new onset and > 45 years, pain on swallowing, vomiting, weight loss, loss with food. Shingles likely
of appetite, feeling of early fullness, occult blood positive, abdominal mass. • Refer if pain persists > 4 weeks. 41.
Refer same week if uncertain of diagnosis.

Cough and/or difficult breathing
Give urgent attention to the patient with cough and/or difficult breathing and 1 or more of the following:
• Breathlessness at rest or while talking • Coughing up ≥ 1 tablespoon of fresh blood
• Respiratory rate ≥ 30 breaths/minute • Agitation or confusion
• Prominent use of breathing muscles • BP < 90/60
• Swelling of eyes/lips: anaphylaxis likely • Oxygen saturation < 92% (if available)
Management:
• If available, give oxygen by face mask.
• If temperature ≥ 38°C, give 1 dose Ceftriaxone 1g IM/IV. Avoid Ringer’s lactate for 48 hours after IV administration. If unavailable, give 1 dose Amoxicillin 1g orally. Refer urgently with continuous oxygen.
• If anaphylaxis, give Adrenaline 1mℓ(1:1000) IM every 10 minutes until better, Hydrocortisone 100mg IV and Promethazine 50mg IM/slow IV. Refer urgently.
• If wheeze and difficult breathing, no leg swelling, and if 1st episode of wheeze, patient < 50 years, treat wheeze 17.
• If difficult breathing worse on lying flat especially with leg swelling or 1st episode of wheeze in patient ≥ 50 years, heart failure likely 85.
Approach to the patient with cough and/or difficult breathing not needing urgent attention:
• If HIV status unknown, test for HIV 60. If HIV, consider chest infection, TB and PCP as below, no matter the duration of symptoms.
• If patient has leg swelling or 1st episode of wheeze and ≥ 50 years, heart failure is likely. Assess symptoms as below and manage for heart failure 85.
Cough and/or difficult breathing < 2 weeks Cough and/or difficult breathing ≥ 2 weeks
Exclude TB 55. While looking for TB, consider other cause for cough and/or difficult breathing:
If wheezing, If sputum, chest pain and fever, treat for
no leg chest infection: If HIV with dry cough, worsening breathlessness on Smoker If recent upper
swelling, if exertion and CD4 < 200, PCP likely. Has patient lost weight? respiratory tract
1st episode • Advise bed rest and regular fluids. infection, no difficulty
of wheeze • If sputum is new, increased or changed in • Doctor to diagnose on history/x-ray: give Co-Trimoxazole Yes No breathing, post-
and patient colour, treat depending on risk of severe 1920mg 6 hourly for 21 days. Consider If coughing sputum infectious cough
< 50 years infection (HIV, > 65 years, severe lung, heart, • Start workup for ART 61. lung most days of at least 3 likely.
treat liver disease, diabetes or alcohol abuse): • Review weekly to assess response and TB culture result: if cancer months for ≥ 2 years and
wheeze positive, treat for TB while completing PCP treatment 57. 3 no difficult breathing,
17. • Refer if atypical x-ray, patient was adherent to co- chronic bronchitis likely. Advise that the cough
• If risk of severe • If no risk of severe trimoxazole prophylaxis and/or ART, or if no better on should resolve within
infection, give infection, give treatment. Advise patient to stop smoking. 8 weeks.
Amoxicillin/ Amoxicillin1 1g 8
Clavulanic Acid hourly for 5 days.
500/125mg (625) If TB and above conditions excluded, consider asthma or COPD 68, 69.
• If no better
and Amoxicillin after 2 days add
250mg 8 hourly for Doxycycline 100mg Alleviate cough and/or difficult breathing in the patient needing end-of life care 107:
5 days1. 12 hourly for 5 days. • If thick sputum, give steam inhalations. If more than 30ml/day, try deep fast breathing with postural drainage.
• If HIV, exclude TB no if not already on it or • If excess thin sputum in patient who is terminally ill, give hyoscine 10mg 8 hourly.
matter duration of refer same day. --For annoying dry cough, give Codeine 5-10mg 6 hourly. If no response, try oral Morphine 2.5-5mg.
symptoms 55. • For breathlessness when terminally ill:
• If no better after 2 --If not on oral Morphine, give 2.5mg 6 hourly. If already on it, increase dose by 25%. Repeat if no better.
days, refer same day. --Doctor to consider giving small doses diazepam.
1
If allergic to penicillin, give Doxycycline 100mg 12 hourly for 5 days./Erythromycin for pregnant women

Wheeze/tight chest
Manage the patient with wheeze (no leg swelling, if first episode, patient < 50 years) from page 16:
• Give salbutamol (beta-agonist) via:
--Large-volume spacer: 4–8 puffs every 20 minutes for 1 hour then reassess, or
--Nebuliser (oxygen-driven nebuliser is preferable)1: 1mℓ of 0.5% Salbutamol Solution in 3mℓ of Sodium Chloride 0.9% solution every 20 minutes for 1 hour. 68
-- Give first dose of oral Prednisolone2 40mg if no immediate response, or If prednisolone unavailable or patient unable to take it, give Hydrocortisone 100mg IM/IV.
After 1 hour assess if patient still needs urgent attention 16.
No change or worse Better or no symptoms

Refer immediately. While waiting for transport: F ollow discharge plan below if:
--Add 2mℓ Ipratropium Bromide to salbutamol nebuliser solution. • Symptoms have resolved and
• Continue nebulisation every 20 minutes with oxygen in between.3 • Oxygen saturation (if available) > 95% and
• Respiratory rate < 20 breaths/minute.
Discharge plan for the patient who has responded to treatment

• Start, or increase dose and frequency of inhaled Salbutamol to a maximum of 2 puffs 4 times a day until condition improves. Check inhaler technique 68.
• If patient received oral prednisolone or IV hydrocortisone above, give oral Prednisolone 40mg daily for 6 more days.
• If patient has fever, increased sputum production or a change in sputum colour give Amoxicillin 1g 8 hourly for 5 days. If penicillin allergic, give Erythromycin 500mg 6
hourly for 5 days instead..
• Ask about allergic rhinitis/hayfever (sneezing, itchy or runny nose): treating hayfever effectively improves asthma symptoms 13.
• People are more likely to stop smoking if advised to do so by a health professional. Urge your patient to stop smoking. For tips on communicating effectively 101.
• Book follow-up visits before medicines are expected to run out.
• Treat according to known diagnosis (see below). If the cause of wheezing is not known 68.
Known asthma Known copd

• Start inhaled corticosteroid 66 if 2nd emergency visit for asthma in 6 months • Give oral Prednisolone 40mg daily for 7 days if:
or previously using inhaled corticosteroid. --Breathlessness has improved but remains worse than usual.
• If already on inhaled corticosteroid, adjust dose 69. • Refer to doctor same week for review.
• Give oral Prednisolone 40mg daily for 7 days if: • Follow up the COPD patient 67.
--Recent/frequent emergency visits or previous hospital admission for asthma.
--Worsening of symptoms in the months or weeks leading up to the exacerbation.
• Refer same week to doctor for review.
• Follow up the asthma patient 69.
Tell patient to return before follow-up appointment if no improvement after completing a short course of oral prednisolone.
1
If an oxygen-driven nebuliser is not available, use an air-driven nebuliser instead and give facemask oxygen between nebulisation. 2Oral prednisolone is an important component in the management in all but the mildest exacerbations. 3Continuous
nebulisation is better if there is an inadequate response to initial treatment.

Breast symptoms
Approach to the patient with a breast symptom who is not breast feeding
Breast lump/s Breast Pain Nipple Discharge Breast enlargement

One or both breasts?
• Reassure patient that breast Is the discharge blood stained, One sided Both breasts
Both breasts One breast cancer rarely causes pain. on 1 side, in patient > 50 years,
• Advise a well-fitting bra. or in a man? Refer same • Confirm that this is not obesity. If
Patient > 35 years or a • If pregnant, reassure and give
This is likely to be week. BMI > 25 assess CVD risk 75.
family history of breast antenatal care 98-99.
cyclical. • Give Paracetamol 1g 6 hourly Yes No • Look for drugs that cause breast
• Reassure cancer? 106 enlargement: efavirenz (reassure
as needed.
• Change hormonal • May be a side effect of patient that it often resolves by
contraception to No Yes hormonal contraceptive. If Refer • If pregnant, 2 years), cimetidine, nifedipine,
non-hormonal no better after 3 months on same reassure and give amlodipine, fluoxetine. Discuss
method 97. contraception, change method week to antenatal care with doctor.
Re-examine Refer breast 98.
same 96.
breast 7 days clinic. • If on hormonal
after starting week. contraceptive,
menses. Refer reassure. Change
same week if to non-hormonal
lump persists. method if
distressing 96.
Approach to the patient with a breast symptom who is breast feeding
Painful/cracked nipple/s Painful breast/s Breast lump

Usually in first few days of breastfeeding Is temperature ≥ 38˚C? Is temperature ≥ 38˚C?
due to poor latching.
No Yes Yes No
• Avoid soap on washing nipples.
• Help patient to latch properly. Engorgement likely Mastitis likely Breast abscess likely Blocked duct likely
• Advise patient to apply breastmilk onto nipples
and areola after feeding and expose to the air.
• Advise HIV patient to stop feeding from the Advise frequent • Give Cloxacillin 500mg 6 hourly for 5 days. • Refer same day for incision and Advise frequent
breast, express and heat-treat1 the milk, and breastfeeding and • Paracetamol 1g 6 hourly drainage. breastfeeding, warm
cup-feed baby until cracks have healed. cold compresses. • Advise HIV patient to stop feeding from the • Advise HIV patient to stop feeding compresses and to
breast, express and heat-treat1 the milk, and from the breast, express and heat- massage lump.
cup-feed baby until mastitis resolves. treat1 the milk, and cup-feed baby
until abscess resolves.
1
Heat-treat milk to rid it of HIV and bacteria: place breastmilk in sterilized peanut butter jar. Close lid and place in pot. Fill pot with water 2cm above level of milk and heat water. Remove jar when water is rapidly boiling.

Abdominal pain with or without swelling (no diarrhoea)
Give urgent attention to the patient with abdominal pain and one or more of:
• Peritonitis (guarding, rebound tenderness or rigidity of abdomen)
• Jaundice
• Temperature ≥ 38°C
• No stool or flatus for last 24 hours and vomiting
• On ART
• Nausea, vomiting, fatigue, sore muscles or difficulty breathing, consider acidosis. Check blood glucose 76. If on ART, patient needs lactate check 61-67.
• No urine passed for last 12 hours and swelling of abdomen.
• Pregnant woman with lower abdominal pain
• Refer same day.
Approach to the patient with abdominal pain not needing urgent attention
• If women with lower abdominal pain and/or vaginal discharge, treat for likely pelvic infection 23.
• If the patient has urinary symptoms 31.
• If the patient is constipated 22.
If patient has none of the above, try to identify cause of pain: is the pain in the upper abdomen and related to eating?
Yes - dyspepsia likely No

Has patient lost weight?
Refer same week if any warning signs:
• Weight loss Yes No
• Loss of appetite Is there fever, night sweats, Does patient have difficulty breathing, abdominal or leg swelling?
• Early fullness cough and/or HIV?
• Blood in stool or occult blood positive
• Abdominal mass Yes No
• Persistent vomiting or vomiting blood Yes No Heart Does the patient report worms?
• New episode in patient ≥ 55 years Exclude TB Consider failure
55. cancer. likely 81.
Refer same Yes No
Approach to the patient with no warning signs week. • Tapeworm: give Mebendazole If the pain is recurrent with
• If associated with chest pain on exertion 15. 100mg daily for 6 days. constipation and/or diarrhoea
• Assess patient’s CVD risk 71. • Other worm or unsure: give and bloating, irritable bowel
• Advise patient who smokes and drinks alcohol to stop 103. Mebendazole 100mg 12 hourly syndrome likely. Refer to
• Avoid spicy, hot or acidic foods, carbonated drinks. for 3 days. doctor.
• Stop non-steroidal anti-inflammatory drugs, aspirin. • Educate on personal hygiene.
• If pregnant, give antenatal care 98-99.
• Give Antacid Tablets 250mg 2-4 tablets as needed, up to
16 tablets a day for 7 days. • Give Paracetamol 1g 6 hourly as needed.
• Refer if no response. • Review regularly until pain resolves or a cause is found.

Vomiting
Give urgent attention to the patient with vomiting and one or more of:
• Reliable signs of dehydration:
--Postural hypotension (systolic BP drop > 20mmHg between lying and standing)
--Poor urine output
--Confused or drowsy
• Peritonitis (guarding, distension or rigidity of abdomen)
• Vomiting blood
• Jaundice
• Abdominal pain and no stools or flatus/wind
• Headache 9
• Patient on ART with other signs of lactic acidosis: nausea, abdominal pain or swelling, weight loss, fatigue, shortness of breath
Management:
• Oral or IV rehydration
• Check blood glucose 76.
• If on ART with signs of lactic acidosis, stop ART.
Approach to the patient with vomiting not needing urgent attention:

• Advise the patient to eat small frequent meals, avoid lying down after meals, avoid hot greasy food and to eat lightly salted dry food before getting out of bed.
• Exclude pregnancy. If pregnant 92.
• What is duration of vomiting?
< 24 hours Vomiting continuously for ≥ 24 hours

Is patient on TB medication or ART?
•M ost vomiting is due to a viral infection and resolves within

24 hours. No Yes
• If ≥ 21 drinks/week (man), 14 drinks/week (woman) or binge
drinks 89, 104. • Assess for dehydration as above.
• Give oral rehydration solution.
• If patient is dizzy 8. • Stop all medication and refer same day.
• If patient has an incurable illness, is receiving end-of-life
• Give oral rehydration.
care 107 and does not need urgent attention above,
• Review in 24 hours if still vomiting.
give Prochlorperazine 5mg orally 8 hourly before food.
• Review in 2 days or earlier if still vomiting.
If still vomiting, refer same day, or discuss with doctor.

Diarrhoea
Give urgent attention to the patient with diarrhoea and one or more of:
• Blood or mucus in the stool
• Temperature ≥ 38°C
• Reliable signs of dehydration
--Postural hypotension (systolic BP drop > 20mm Hg between lying and standing)
--Poor urine output
--Altered mental state (confused or drowsy)
Management:
• Oral rehydration (IV if unable to keep fluids down)
• If patient has had diarrhoea for ≥ 2 weeks send stool sample for ‘ova, cysts and parasites’. Indicate on the request form if the patient has HIV.
• Refer same day.
Approach to the patient with diarrhoea not needing urgent attention:

• Confirm that this is in fact diarrhoea: 3 or more watery stools per day.
• Routine antibiotics are unnecessary and increase the likelihood of antibiotic resistance and side effects.
• Knowing the patient’s HIV status helps in the management. If status unknown, test for HIV 60.
• Advise patient to increase fluid intake, eat small frequent meals and avoid milk products, caffeinated drinks and high-fat, high-fibre foods.
• Ask about duration of diarrhoea.
Diarrhoea for < 2 weeks Diarrhoea for ≥ 2 weeks

• The HIV patient with diarrhoea for most days > 1 month has stage 3 HIV 61.
• Has the patient lost weight?
• Give oral rehydration.
• If bed-bound or receiving end- Yes No
of-life care, check for faecal
impaction.
• Give oral rehydration • Give Loperamide 4mg initially,
• Give Loperamide 4mg initially,
• Send stool for ‘ova, cysts and parasites’. Indicate on request form if patient has HIV. then 2mg after each loose stool
then 2mg after each loose stool
• The HIV patient needs ART if weight loss > 10% body weight and diarrhoea for ≥ 4 weeks 61. (up to12mg/24 hours).
(up to 12mg/24 hours).
• Review symptoms and stool result in 1 week. • ddI and lopinavir/ritonavir can
• Record current weight in
patient notes. cause loose stools which are
• Provide routine HIV care 61. Stool result negative Cryptosporidium Isospora belli ongoing.
• Review in 2 weeks if diarrhoea • Review weight and symptoms
still present. Give Co-Trimoxazole 1920mg regularly.
Give Loperamide afer each loose Give Loperamide afer each loose
stool (up to12mg/24 hours). stool (up to12mg/24 hours). (4 tablets) 12 hourly for 10 days.
Then 2 tablets daily.
HIV patient needs ART 61.
• If diarrhoea persists despite treatment, refer for specialist review.

• If patient has an incurable illness and you would not be surprised if s/he died within the next year, give end-of-life-care 107.

Constipation
Give urgent attention to the patient with constipation and:
• No stools or wind in the last 24 hours plus abdominal pain and vomiting
Refer same day to hospital.
Approach to the patient who is constipated and not needing urgent attention:
• Review diet, fluid intake and medication (amitriptylline, codeine/morphine and antacids can cause constipation). Ask about chronic use of enemas or laxatives.
• Exclude pregnancy. If pregnant 98.
• If patient is bed-bound and/or has an incurable illness and you would not be surprised if s/he died within the next year, also give end-of-life care 107.
• Check for impaction on rectal examination. If impacted, apply petroleum jelly or soapy water into the rectum.
• Give Liquid paraffin if the client is impacted, bed-bound or using codeine/morphine. Otherwise, try non-drug approaches before prescribing laxatives:
--Advise a high fibre diet (vegetables, fruit, coarse mielie meal, bran and cooked dried prunes), adequate fluid intake and moderate regular exercise (20 minutes walk daily).
--Stop chronic use of laxatives or enemas.
• If no better after non-drug approaches, give Liquid paraffin at night for 3 days. Avoid long-term use.
• Refer if no response after 1 week, recent change in bowel habits or uncertain cause for constipation.
Anal symptoms
Give urgent attention to the patient with an anal symptom and one or more of:
• Unable to sit because of anal symptoms
• Unable to pass stool because of anal symptoms
Refer same day.
Anal pain and/or bleeding Anal Itch
Crack/s or lump/pile Ulcer/s Perianal warts Worms Dermatitis

Is there chronic diarrhoea?
• Treat constipation as above. Treat as for Give • Advise good hygiene

Yes No Mebendazole • Wash with Aqueous Cream.
• Apply Bismuth Subgallate Compound genital warts
• Apply Zinc and • Treat as for genital 100mg 12 hourly • Apply 1% Hydrocortisone
Ointment 2–4 times a day after each bowel 27.
Castor Oil Cream. ulcer 26. for 3 days. Cream twice a day for 5 days.
action. • To manage diarrhoea • Refer if no
• Refer if pile cannot be reduced or is thrombosed. 21. improvement.

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 partners, uses condoms unreliably or substance abuse 89.
Abuse Ask about rape/sexual assault or if patient unhappy in relationship. If yes 53. Manage and refer the recently raped/sexually assaulted patient urgently 53.
Family planning Assess patient’s family planning needs 96. Exclude pregnancy. If pregnant 98.
Examination • In the woman, examine abdomen for masses, look for genital discharge, rash or lumps. Do a bimanual palpation for cervical tenderness or pelvic masses.
• In the man look for discharge, inguinal lymph nodes, ulcers, scrotal swelling and/or masses.
HIV If status unknown test for HIV 60. The HIV patient needs routine HIV care 61.
Pap smear Do a Pap smear every 5 years if HIV negative and age 30–49 104. If HIV positive do Pap smear yearly regardless of age 27. If cervix looks abnormal/suspicious of cancer, refer same week.
Advise the patient with genital symptoms and his/her partner/s

• Educate patient about the cause of symptoms and if a sexually transmitted infection (STI), that this increases the risk of HIV transmission.
• Urge the patient to adhere to treatment and to abstain from penetrative sex for the duration of treatment.
• Stress the importance of partner treatment and issue 1 notification slip with the patient’s diagnosis for each partner. Advise patient to stick to one partner at a time.
• Promote and demonstrate male and female condom use and provide condoms.
Treat the patient with genital symptoms
Discharge Dysuria Scrotal swelling Itch Ulcer/s Lump/s
Man 24 Woman 25 Man 24 Woman 31 24 Discharge in woman 25 Glans penis 24 Pubic area 27 26 Groin 5 Skin 27
Treat the patient’s partner/s according to the patient’s diagnosis as well as the partners’ symptoms (if any)
Patient’s diagnosis Partner treatment
Vaginal discharge syndrome Ceftriaxone 250mg IM stat and Doxycycline 100mg 12 hourly for 7 days. If available, give Azithromycin 1g stat instead of doxycycline.
Lower abdominal pain in woman Ceftriaxone 250mg IM stat and Doxycycline 100mg 12 hourly for 7 days. If available, give Azithromycin 1g stat instead of doxycycline.
Urethral discharge syndrome Ceftriaxone 250mg IM stat and Doxycycline 100mg 12 hourly for 7 days. If available, give Azithromycin 1g stat instead of doxycycline.
Scrotal swelling Ceftriaxone 250mg IM stat and Doxycycline 100mg 12 hourly for 7 days. If available, give Azithromycin 1g stat instead of doxycycline.
Genital ulcer disease Benzathine penicillin 2.4MU IM stat and Ceftriaxone 250mg IM stat
RPR positive Benzathine penicillin 2.4MU IM stat
Persistent balanitis Clotrimazole Vaginal Pessary 100mg inserted at night for 6 nights and Metronidazole 400mg 12 hourly for 7 days
Bubo without genital ulcer Doxycycline 100mg 12 hourly for 14 days

Genital symptoms in a man
First assess and advise the man with genital symptoms 23 and his partner/s.
Urethral discharge or Scrotal swelling or pain Pain or itchiness of glans or inability to retract
dysuria/burning urine or reduce foreskin
Treat for urethral discharge: Does patient have any of: Can foreskin can be retracted?
• Ceftriaxone 250mg IM stat and • Sudden onset of severe pain
• Doxycycline 100mg 12 hourly for 7 days or if available, • Affected testicle is higher or twisted
• A history of trauma Yes No
Azithromycin 1g orally stat instead.
• Metronidazole 2g stat. Avoid alcohol for 24 hours.
• Treat patient's partner/s 23.
No Treat for balanitis: Treat as for
Advise patient to return in 7 days if symptoms persist. Yes
Treat for scrotal swelling: • Wash with weak salt solution, avoid genital ulcer
Torsion of
• Ceftriaxone 250mg IM stat and soap. disease 26.
testicle likely.
If ongoing urethral discharge or dysuria, ask if possible Refer to doctor • Doxycycline 100mg 12 • Retract foreskin while washing.
reinfection or poor adherence. same day. hourly for 7 days or if available, • Apply Clotrimazole Cream or
Azithromycin 1g orally stat. Gentian Violet solution 12 hourly for If no
• Treat patient's partner/s 23. 7 days. response to
Yes No • If no better after 7 days:
Refer if no improvement after treatment,
Repeat treatment: 7 days. --Give patient and partner refer same
• Ceftriaxone 250mg IM stat and Metronidazole 2g orally stat. week to
• Doxycycline 100mg 12 hourly for 7 days --Also give female partner doctor.
Clotrimazole Vaginal Pessary
Refer if not resolved. 100mg at night for 6 nights.
--Test for HIV 60 and diabetes 76.
--If still no better, refer to doctor.

Vaginal discharge
• It is normal for women to have a vaginal discharge. Abnormal discharges are itchy or different in colour or smell. Not all women with a discharge have an STI.
• First assess and advise the patient with vaginal discharge and her partner/s 23.
Is there lower abdominal pain or cervical tenderness?
No
Patient sexually active in last 3 months? Yes
Recognise the patient needing urgent attention
Refer same day if any of the following are present:
No Yes • Recent miscarriage/delivery/abortion
Treat for • Treat for chlamydia and gonorrhoea: • Pregnant or missed or overdue period
trichomoniasis/ --Ceftriaxone 250mg IM stat and • Peritonitis (guarding or rigidity on examination)
bacterial vaginosis: -- Doxycycline 100mg 12 hourly for 7 days (If pregnant or • Abnormal vaginal bleeding
• Metronidazole 2g breastfeeding, use amoxicillin 500mg 8 hourly for 7 days • Abdominal mass
orally stat. Avoid alcohol instead). If Azithromycin available, use 1g orally stat Management:
for 24 hours. instead (safe in pregnancy, breastfeeding and penicillin • If dehydrated or shocked: give IV fluids
allergy). • If temp ≥ 38°C, give Ceftriaxone 1g IM stat and Doxycycline 100mg orally
• Treat the patient's partner/s 23. stat (or if available Azithromycin 1g) and Metronidazole 2g orally stat.
• Treat the baby with pus in eyes born to mother 101. Refer same day.
If the vulva is red, scratched and inflamed, also treat for thrush: If patient does not need urgent attention, treat for pelvic inflammatory disease:
• Clotrimazole pessaries 100mg inserted at night for 6 nights. • Ceftriaxone 250mg IM stat and
• Avoid washing with soap. • Doxycycline 100mg 12 hourly for 14 days (If breastfeeding, use Amoxicillin
500mg 8 hourly for 14 days instead). If available use Azithromycin 1g weekly for
Advise patient to return in 7 days if symptoms persist. 2 weeks instead (safe in breastfeeding and penicillin allergy) and
• Metronidazole 2g weekly for 2 weeks. Avoid alcohol during the 2 weeks and for
24 hours after.
Persistent thrush: Ongoing discharge, no thrush: • Treat the patient's partner/s 23.
• Repeat clotrimazole. Ask if possible re-infection or poor adherence to treatment. Review within 3 days.
• Test for diabetes
76 and HIV 60. Yes
No No improvement Improved
Repeat treatment and ensure partner
Refer to doctor
is treated. If still no improvement,
same week.
refer to doctor same week. Continue treatment and refer to doctor Complete treatment.
same week.

Genital ulcer
First assess and advise the patient with a genital ulcer and his/her partner/s 23.
Are there blister/s?
Yes No
Treat for herpes Treat for herpes, syphilis and chancroid

• Give pain relief if necessary • Give pain relief if necessary
• Keep lesions clean and dry. • Keep lesions clean and dry.
• Give Aciclovir 400mg 8 hourly for 7 days. • Give Aciclovir 400mg 8 hourly for 7 days and Benzathine Penicillin 2.4MU IM stat
• Explain that herpes is an infection and that herpes transmission can occur even when there and Ceftriaxone 250mg IM stat.
are no symptoms. The likelihood of HIV transmission is increased when there are ulcers. • Review after 7 days.
• If patient has HIV and genital herpes > 1 month s/he has stage 4 HIV disease and needs
routine HIV care and ART 61.
• Review after 7 days.
If ulcer persists after 7 days, is it worse, unchanged or improved?
Ulcer still present but improved Ulcer worse or unchanged
• Continue Aciclovir 400mg 8 hourly for 7 days more. Ask if possible re-infection or poor adherence to treatment?
• Review after 7 days.
No Yes
• Repeat treatment.
• Ensure patient understands importance
of adherence to treatment and treating
his/her partner/s.
If ulcer persists, refer same week.

Other genital symptoms
First assess and advise patient and partner/s 23.
Lumps Itchy rash in pubic area
Genital warts Molluscum Pubic lice Scabies

If warts are soft, involve the skin, and < 10mm: contagiosum Treat patient and partner/s: Treat patient:
• Protect surrounding skin with petroleum jelly and apply 20% • Papules with • Apply Malathion 0.5% • Apply Malathion 0.5% lotion
Tincture of Podophyllin solution. Do not apply internally. central dent lotion from the neck from the neck down overnight.
• Wash solution off after 4 hours. • If HIV, should down overnight. Advise Advise patient to avoid
• Repeat weekly for 4 weeks. resolve with patient to avoid mucous mucous membranes, urethral
Refer if: ART. membranes, urethral opening and raw areas as it
• No response or opening and raw areas as may sting.
• If warts are > 10mm, hard, on mucosal surfaces or it may sting. Repeat after • Wash clothes and linen.
• Pregnant or 7 days. • Treat partner/s even if
• Podophyllin not available • Wash clothes and linen. asymptomatic.

Positive syphilis result
• First assess and advise the patient with a positive syphilis result and his/her partner/s 23.
• Do a RPR/VDRL test in those who are pregnant, sexually assaulted, signs of secondary or tertiary syphilis1 or recently treated for early syphilis, as well as those whose partners have positive RPR result.
• RPR and VDRL tests reflect disease activity but do not necessarily indicate syphilis infection. They are useful to measure successful response to treatment.
• TPHA or FTA tests are specific for syphilis and confirm its diagnosis. They usually remain positive for life.
RPR/VDRL positive
Not pregnant
Pregnant
Is RPR titre from last 2 years available?
No Yes • Treat for late syphilis

• Treat partner/s 23.
Does patient have a genital ulcer or signs of New titre is ≤ the last test result.
secondary syphilis1? • If penicillin allergic give Erythromycin 500mg
6 hourly for 28 days. Once the patient has
No Yes stopped breastfeeding, repeat treatment with
No Yes • New syphilis infection likely. • No further treatment needed. doxycycline 100mg 12 hourly for 28 days3.
• Treat for late syphilis. • Treat for early syphilis. • Treat for early syphilis. • Discharge.
• Treat partner/s 23. • Treat partner/s 23. • Treat partner/s 23. • If not already treated, treat
partner/s 23. Does baby have signs of congenital syphilis2?
Repeat RPR/VDRL after 3 months. Yes No
Refer same day. • If mother RPR

positive in 2nd or
3rd trimester, check
baby's RPR.
Early syphilis: Late syphilis:
• If mother received
• Benzathine Penicillin 2.4MU IM stat • Benzathine Penicillin 2.4MU IM weekly for 3 weeks
only 1 dose or
• If penicillin allergic give Doxycycline 100mg • If penicillin allergic and not pregnant give
no treatment
12 hourly for 14 days. Doxycycline 100mg 12 hourly for 28 days.
at all, treat the
baby: Procaine
Penicillin 50 000u/
kg IM daily for 10
days.
1
The signs of secondary syphilis occur 6–8 weeks after the primary ulcer and include a generalized rash (including palms and soles) 45, flu-like symptoms, flat wart-like genital lesions, mouth ulcers and patchy hair loss. Tertiary syphilis occurs many years later
and affects skin, bone, heart and nervous system. 2Signs of congenital syphilis are rash (red/blue spots or bruising especially on soles and palms), jaundice, pallor, distended abdomen due to enlarged liver or spleen, low birthweight, respiratory distress, large,
pale placenta, hypoglycaemia. 3Erythromycin does not reliably cure syphilis in either the mother or the baby.

Abnormal vaginal bleeding
Give urgent attention to the patient with vaginal bleeding and one or more of:
• BP < 90/60
• Exclude pregnancy. If pregnant 98.
• Following abortion or miscarriage
Management:
• Give IV sodium chloride 0.9%. If systolic BP < 90, give 500mℓ rapidly. Repeat until systolic BP > 90. Stop if respiratory rate increases by > 10.
• Refer same day.
Approach to the patient with abnormal vaginal bleeding not needing urgent attention
• Refer within 2 weeks the patient with vaginal bleeding who is menopausal (no periods for at least one year).
• In patient who is not menopausal determine the type of bleeding problem.
Heavy regular bleeding with/without pain Periods have irregular pattern Bleeding after sex Spotting between periods
(bleeding > 7 days, passing clots) (< 24 days or > 35 days between periods)
• Look for STI: if vaginal discharge or lower abdominal pain

Has the patient been bleeding elsewhere (gums, easy Does patient have hot flushes, mood swings and/or 23.
bruising, rash)? difficulty sleeping? • Do pap smear once bleeding has stopped 27.
• Ask about assault or abuse 53.
Yes No Yes No • If patient on oral or injectable contraception 96.
• Refer the patient within 2 weeks:
--Unsure of diagnosis
• Check full • Check Hb: if < 11 give Ferrous Salt Patient is • If there is weight gain, tiredness, --Menopausal (no periods for at least 1 year)
blood count. (60mg iron) 1 tablet 12 hourly after perimenopausal. feeling cold all the time, check --Bleeding persists after treatment of STI
• Stop warfarin, food for at least 3 months until Hb TSH. Refer to doctor if abnormal. --Abnormal cervix on speculum examination
aspirin. > 11. • Give combined oral contraceptive (suspicious of cancer)
98
• Refer to • During period, give Ibuprofen levonorgestrel and ethinyl
doctor same 400mg 8 hourly with food for 2-3 oestradiol for 6 months 96.
week. days to decrease pain and blood • Refer to gynaecologist if patient
loss. wanting to be pregnant.
• If newly started on injectable
contraceptive, give combined oral
contraceptive for 2–3 cycles 90.
• Refer the patient:
--Same week if mass in abdomen
--If no improvement after 3
months
--Same week if excessive
bleeding after IUCD insertion.

Sexual problems
Problem with erections Woman who has pain with sex Loss of libido
Was the onset of the problem gradual or sudden? Is the pain superficial or deep? • Ask: ‘Are you stressed?’ If yes 52.
• Ask about sexual assault or abuse
Gradual onset Sudden onset Superficial pain Deep pain 53.
Partial or poorly sustained erections Has erections in morning, • If low mood or sadness, loss of
but not during sex interest or pleasure, feeling tense
• Look for STI: if vaginal • Look for STI: if vaginal discharge or or worrying a lot or not coping as
discharge or ulcers lower abdominal pain 23. well as before, consider depression/
• Assess cardiovascular disease risk • Ask: ‘Are you stressed?’ If 23. • Ask about irritable bowel syndrome: anxiety 87.
71. yes 52. • Ask about vaginal dryness. recurrent abdominal pain with • Screen for substance abuse: if > 21
• Screen for substance abuse: • Ask about sexual assault If there is vaginal atrophy constipation and/or diarrhoea and drinks/week (man) or > 14 drinks/
if > 21 drinks/week or > 5 drinks per or abuse 53 and or has other menopausal bloating 19. week (woman) or > 5 drinks/session
session or misusing prescription or anxiety/fear about sex and symptoms like flushes, • Severe spasm of vagina during sex: or misusing prescription or illicit
illicit drugs 89. fertility. Refer to available problems sleeping, mood ask about sexual assault or abuse drugs 83.
• Atenolol, furosemide, HCTZ, counselor. changes, headaches 96. 53. • Ask the woman patient about pain
fluoxetine, amitriptyline, phenytoin, • Assess patient’s family • Advise use of lubricant • Refer to gynaecologist if mass in with sex.
carbamazepine, cimetidine may planning needs 96. with sex, but to avoid abdomen or periods have become • Ask about anxiety/fear about sex
cause erection problems. Doctor • Discuss condom use. using vaseline with heavy and painful. and fertility. Refer to available
can consider changing medication Ensure patient knows how condoms. counselor.
but needs to balance disease to use condoms correctly. • Assess patient’s family planning
control with possible improvement needs 96.
in erections.
• Advise the patient who smokes to
stop.
• Ask: ‘Are you stressed?’ If yes 52.
• Refer to urologist if no
improvement once treatment
optimised and chronic condition
stable.
Refer if sexual problems do not resolve.

Urinary symptoms
Give urgent attention to the patient with urinary symptoms:
• Unable to pass urine with lower abdominal discomfort
Management:
• Insert urethral catheter.
• Refer same day.
Approach to patient with urinary symptoms not needing urgent attention
Blood in urine Burning urine Flow Problem

Has patient been in bilharzia area?
Woman Man Leakage Poor stream or
Yes No of urine difficulty passing
urine
• If patient has a vaginal discharge 23. Look for discharge
• Give single dose Does patient have • If no vaginal discharge, is patient • Check dipstick to
praziquantel burning urine? catheterised, known with diabetes or exclude urinary • If on amitriptyline,
No discharge Patient has
40mg/kg. urinary tract problem? tract infection. doctor to review
Are there leucocytes and discharge
• To prevent re- nitrites on midstream urine? • If on furosemide, indication and
No
infection advise No Yes doctor to review dose.
patient to boil indication and • Refer for
water before Leucocytes Yes No dose. assessment, same
use and avoid Patient has a simple • Look for vaginal week if patient
and nitrites
swimming in urinary tract infection. atrophy 96. has weight loss or
on urine Patient has a complicated Patient has an STI 23.
contaminated dipstick? urinary tract infection. • Ask about hard and nodular
water. • Give Cefuroxime constipation prostate on rectal
500mg 12 hourly for 22. examination.
No Yes 5 days. • Give Amoxicillin/ • Advise patient to
• Encourage patient Clavulanic Acid cut down alcohol
to drink plenty of 250/125mg 8 hourly and caffeine and to
Refer for for 7 days. If pregnant, do Kegel exercises.
investigation fluids and to empty
bladder after sex. do not give amoxicillin/ • Refer if patient has
of cause of clavulanic acid and refer. vaginal prolapse
blood in urine. • Encourage patient to or no response to
drink plenty of fluids. above measures.
• Educate female patient to
empty bladder after sex.
Do a urine microscopy, culture and sensitivity if symptoms do not

resolve or patient has recurrent urinary tract infections.

Body/general pain
Approach to the patient who aches all over
• Check patient’s temperature and weight.
• Ask about a sore throat or runny/blocked nose.
Normal • If temperature ≥ 38˚C 4

Do a musculoskeletal screen to check if problem is in the joint. Ask the patient to: and/or
• Place hands behind head; then behind back. • If weight loss ≥ 5% of body
• Make a fist and open hand. weight in past 4 weeks 3.
• Press palms together with elbows lifted. • If sore throat 14.
• Walk. Sit and stand up with arms folded. • If runny/blocked nose 13.
Unable to do all actions comfortably. Able to do all actions comfortably
Examine the joints.
Joints are Joints are normal.

warm, tender, swollen
or have limited
movement. • If status is unknown, test for HIV 60.
• Ask patient: ‘Are you stressed?’ If yes 52.
• If patient has experienced recent trauma or abuse 53.
33 • If patient has an incurable illness and you would not be surprised if s/he died within the next year, give end-of-life-care 107.
• Ask about duration of generalised pain.
< 4 weeks ≥ 4 weeks
• Give Paracetamol 1g 6 • Give Paracetamol 1g 6 hourly.

hourly. • Take blood for ESR, creatinine, random blood glucose and full blood count.
• Patient to return if no • If patient has weight gain, low mood, dry skin or constipation, check TSH.
better in 2 weeks. • If sleep is poor, give amitriptyline 25mg at night.
• Review in 2 weeks.
Blood results all normal Blood results abnormal
If body pain persists, refer. Refer for further assessment.

Joint symptoms
Give urgent attention to the patient with a joint symptom:
Short history of single, warm swollen, extremely painful joint and:
• Temperature ≥ 38˚C. If known with gout 95, otherwise refer same day.
• Known haemophiliac or bleeding problem – possible bleed into the joint
• Trauma in the past 48 hours
Refer same day.
Approach to the patient with a joint symptom not needing urgent attention
Do a musculoskeletal screen to check if problem is in the joint. Ask the patient to:
• Place hands behind head; then behind back. Make a fist and open hand. Press palms together with elbows lifted.
• Walk. Sit and stand up with arms folded.
Able to do all actions Unable to do all actions comfortably.

comfortably. Recent trauma?
Joint problem No Yes

unlikely Ask about duration of joint pain.
• Rest and elevate joint.

• If general body pain < 8 weeks ≥ 8 weeks • Apply ice.
32. Does patient have a genital discharge? • Apply pressure bandage
• If localised pain see Chronic arthritis without compromising
relevant page. Yes No 94 circulation.
Painful big toe, knee or ankle with warm red overlying skin? • Give Ibuprofen 400mg 3
a day with food for 5 days.
23 Avoid if peptic ulcer, asthma,
No Yes hypertension, heart failure,
kidney disease.
• X-Ray to exclude fracture if no
• Give Ibuprofen 400mg 3 Acute gout likely better after 5 days.
times a day for 1 month. • Patient may also be
Avoid if peptic ulcer, over–weight and have
asthma, hypertension, diabetes.
heart failure, kidney disease. • Might have had similar
• If status unknown test for episode previously.
HIV 60. • For treatment of acute
• Review after 1month, gout attack and routine
sooner if joint pain worsens. gout care 95.
If no better, refer to specialist.

Back pain
Give urgent attention to the patient with back pain and one or more of:
• Bladder or bowel disturbance
• Sudden onset of leg weakness
• Recent trauma with severe pain and X-Ray unavailable or abnormal
• Temperature ≥ 38˚C and vomiting, pulse rate > 80, respiratory rate > 17, BP < 90/60, diabetes, pregnancy, menopause or male patient: pyelonephritis likely.
• Severe stabbing flank pain (one sided) with cramp-like radiation to groin and blood in urine: kidney stone likely.
Management:
• Pyelonephritis: give IV Sodium Chloride 0.9% (500mℓ rapidly if BP < 90/60) and Ceftriaxone 1g IV/IM.
• Kidney stone: give IV Sodium Chloride 0.9% and Morphine 5mg IM/slow IV. If poor response give another 5mg.
• Refer urgently to hospital.
Approach to patient with back pain not needing urgent attention

• If patient is a non-pregnant woman of reproductive age with temperature ≥ 38˚C and:
--Vaginal discharge with/without lower abdominal pain: pelvic inflammatory disease is likely 23.
• Flank pain: uncomplicated pyelonephritis is likely. Give Amoxicillin/Clavulanic Acid 500/125 8 hourly for 7 days and Paracetamol 1g 6 hourly as needed.
• Next, ask about TB symptoms: cough, weight loss, night sweats, feeling unwell.
Yes No TB symptoms
Is there any of: < 20 years, > 55 years, pain progressive or for > 6 weeks, previous cancer or oral steroid use, HIV or deformity?
Exclude TB
55 and Yes No
What is the nature of the back pain?
• Sleep not usually disturbed by pain and
• Do frontal and lateral back X-Ray. • No stiffness or stiffness on waking lasts < 30 minutes and
• Refer to doctor within 1 week. • Pain is worse with activity and improves with rest.
Yes No Unsure
Mechanical back pain likely Inflammatory

back pain likely
• Measure waist circumference: if > 80cm (woman) or 94cm (man) assess CVD risk 71.
• Ask are you stressed? If yes 52. • Check ESR.
• Advise patient to be as active as possible, continue to work and avoid resting in bed. • Do back X-Ray.
• Give Paracetamol 1g 6 hourly. • Refer to specialist.
• If poor response after 1 week add Ibuprofen 400mg 8 hourly for up to 5 days. Avoid if
peptic ulcer, asthma, hypertension, heart failure, kidney disease.
• If still a poor response add Amitriptyline 25mg–75mg at night.
• Refer to physiotherapy if pain persists > 2 weeks, or unable to cope with daily activities/work.
• Refer to specialist if pain persists > 6 weeks, urgently if bladder disturbance or leg weakness.

Neck pain
Give urgent attention to the patient with neck pain and one or more of:
• Neck stiffness with temperature ≥ 38˚C: give Ceftriaxone 2g IV/IM stat.
• New onset of hand or arm symptoms (weakness or numbness) or gait disturbance (leg weakness, stiffness or loss of balance)
• Trauma with neurological symptoms or abnormal X-Ray: immobilise neck with hard collar or sandbags on either side of the neck.
Refer same day.
Approach to the patient with neck pain not needing urgent attention
Is there any of < 20 years, > 55 years, pain progressive or for > 6 weeks, previous TB, cancer or oral steroid use, feeling unwell or weight loss? 60.
Yes No
Do X-Ray and refer. Neck pain with arm pain Neck pain without arm pain
• Give Paracetamol 1g 6 hourly. Avoid NSAIDs like ibuprofen. • Give Paracetamol1g 6 hourly. Avoid NSAIDs like ibuprofen.
• Do not refer for physiotherapy. • Refer for physiotherapy.
Refer if no response after 1 month or hand weakness develops. Refer if no response after 3 months.
Arm symptoms
Give urgent attention to the patient with arm symptoms and one or more of:
• Pain and limitation of movement following injury: refer
• Arm, elbow or hand pain with swelling and temperature ≥ 38˚C: refer
• Left arm pain with chest pain: exclude ischaemic heart disease 15.
• Sudden onset of weakness of arm perhaps with vision problems, dizziness, difficulty speaking or swallowing: consider stroke/TIA 82, 83.
Approach to the patient with arm symptoms not needing urgent attention
Screen if problem is in the joint: Place hands behind head; then behind back. Make a fist and open hand. Press palms together with elbows lifted. Walk. Sit and stand up with arms folded.
Cannot do screen Can do screen comfortably. Check for associated symptoms.

comfortably.
Painful shoulder Wrist pain worse at night and if arm hangs Elbow pain worse on gripping Pain at base of thumb relieved by rest
Joint problem likely Referred pain likely down. May be pins and needles in 1st, 2nd Tennis or golfer’s elbow likely De Quervains tenosinovitis likely
and 3rd fingers.
Ask about chest pain, difficult • Advise rest. • Rest and splint joint.
breathing, cough, abdominal Carpal tunnel syndrome likely • Give Ibuprofen 400mg 3 times a day with • Give Paracetamol 1g 6 hourly.
33.
pain, pregnancy. food for 2 weeks. • Refer if no better.
See relevant page. Refer • Refer if no better.

Leg symptoms
• If the problem is in the joint 33.
Give urgent attention to the patient with leg symptoms and one or more of:
• Unable to bear weight following injury
• Swelling and localised pain in calf : DVT likely especially if > 35 years, BMI > 25, smoker, immobile, pregnant, on oestrogen, recent surgery, TB or cancer
• Muscle pain in legs or buttocks on exercise associated with pain at rest, gangrene or ulceration: critical limb ischemia
• Sudden onset of weakness of leg perhaps with vision problems, dizziness, difficulty speaking or swallowing: consider stroke/TIA 82, 83.
Refer same day.
Approach to the patient with leg symptoms not needing urgent attention
Is there leg swelling?
No Yes
Pain in buttock Muscle pain in legs Both legs swollen One leg swollen
radiating down or buttocks on
back of leg walking or exercise Is there cough/wheeze/difficult breathing? Has there been a recent injury?
Irritation of Claudication Yes No Yes No

sciatic nerve likely
likely • Leg pulses are
weak or absent. 16. • Exclude pregnancy. Soft tissue injury likely Examine skin for discolouration, ulcers or
• Skin is cool, shiny If pregnant 98. lumps.
Refer same week. • Check for kidney
and hairless.
disease on urine • Ensure patient can bear weight
Discolouration, Purple lumps on
dipstick: if blood or on leg, otherwise refer same
ulcers or breaks legs or elsewhere
protein, check BP day.
in skin on body (mouth)
Manage for 80 and refer to • Apply firm supportive
peripheral vascular doctor. bandage.
disease 79. • Advise patient to use leg Venous stasis Kaposi’s
within limits of pain. likely sarcoma likely
If none of the above or unsure of diagnosis, • Give Ibuprofen 400mg 3
refer same week. times a day with food, or if • Advise patient • If status unknown
peptic ulcer, hypertension or to exercise daily test for HIV 60.
asthma, Paracetamol 1g 4 and raise the • Patient needs ART
times a day. leg periodically. within 2 weeks
• Review if no better after 2 • If ulcer 46. 61.
weeks or if symptoms worsen. • Refer.

Foot symptoms
• If the problem is in the joint 33.
Give urgent attention to the patient with foot symptoms and refer same day:
• Unable to bear weight following injury
• On ART with signs of lactic acidosis: nausea, abdominal pain or swelling, weight loss, fatigue, shortness of breath. Check lactate 63.
• On ART and symptoms rapidly worsening over a few weeks, sensation decreased, and/or arms involved: stop ART.
• Muscle pain in legs or buttocks on exercise associated with foot pain at rest, gangrene or ulceration: critical limb ischemia
Approach to the patient with foot symptoms not needing urgent attention
Generalised foot pain Localised pain
Constant burning pain, pins/needles and/or numbness of feet worse at night Foot pain on Ensure that shoes fit properly.
Peripheral neuropathy likely walking or exercise
with muscle pain in Heel pain Foot deformity
• If status unknown, test for HIV 60. HIV patient needs routine care 61. legs and buttocks Plantar fasciitis likely if pain is
• Exclude diabetes 76. Peripheral worse on waking Bony lump at base of big
• Give Amitriptyline 25–75mg at night and Paracetamol 1g 6 hourly. vascular disease
toe with/without callus,
• If no response, add Ibuprofen 400mg 3 times a day with food. likely
• Advise patient to avoid inflammation, ulcer
• Refer same week if one-sided, other neurological signs, or loss of function. Bunion likely
standing and to apply ice.
85. • Give Ibuprofen 400mg 3 times
On TB treatment: give Pyridoxine • If on d4T switch to TDF-based ART 63. a day with food, or if peptic • Encourage patient to go
150mg daily for 3 weeks, then 50mg • If on AZT or ddI refer. ulcer, hypertension or asthma, barefoot when possible.
daily for duration of treatment. Paracetamol 1g 6 hourly. • If severe pain or ulceration,
• Refer to physiotherapist. refer for surgery.
If no response to treatment, refer. • Refer other foot deformity.
In the patient with diabetes and/or PVD identify the foot at-risk to prevent ulcers and amputation
• Skin: callus, corns, cracks, wet soft skin between toes, ulcers. Treat athlete's foot 42. Refer the patient with ulcers for specialist care.
• Foot deformity: most commonly bunions (see above). Refer the patient with foot deformity for specialist care.
• Sensation: light prick sensation abnormal after 2 attempts
• Circulation: claudication (muscle pain in legs or buttocks on exercise with/without rest pain), absent foot pulses. Refer the patient with claudication for specialist care.
Advise patient with diabetes and/or PVD to care for feet daily to prevent ulcers and amputation
• Inspect and wash feet daily and carefully dry between the toes. Do not soak your feet. Avoid testing water temperature with the feet.
• Moisten dry cracked feet daily with aqueous cream. Do not moisturise between toes.
• Avoid walking barefoot or wearing shoes without socks. Change socks/stockings daily. Look and feel inside shoes daily.
• Clip nails straight across. Do not cut corns or calluses yourself and avoid chemicals or plasters to remove them.
• Tell your health worker at once if you have any cuts, blisters or sores on the feet.
• Do not use hot water bottles or heaters near your feet.

Injured patient
Give urgent attention to the injured patient with one or more of:
• Unconscious 1
• BP < 90/60: give IV Ringer’s Lactate or Sodium Chloride 0.9% 500mℓ rapidly. Repeat until systolic BP > 90. Check Hb.
• Difficulty breathing – may need a chest drain. Doctor to assess.
• Blood in urine
• Enlarging or pulsating swelling
• Fracture: see below
• Head injury: see below
Refer patient urgently.
Bruising Fracture/s Laceration/s Head injury
• Elevate and apply ice. • Immobilise the limb. • Clean with saline and suture if Give urgent attention to the patient with a head injury and refer same day:
• Apply supportive • Patient should be assessed same needed. • Skull fracture
bandage if severe. day by a doctor. • Avoid suturing stab wounds > • Amnesia
• If bruising extensive • Refer urgently if: 12 hours on body, > 24 hours on • Loss of consciousness or fit after injury
check for blood in urine. --Poor perfusion below a limb face/head; bullet wounds, crush • Increasing restlessness, confusion, aggression
• Give Paracetamol 1g fracture: poor capillary refill, injuries, chest stabs • Nausea and/or vomiting
6 hourly. limb colder or pale below • Give Paracetamol 1g 6 hourly • Double vision
• If blood in urine give injury as needed. • Blood or serous fluid from nose or ear
IV Sodium Chloride --Loss of function or weakness • Remove sutures after 7 days • Haematoma around eye or behind eardrum
0.9% and refer same --Loss of sensation except: • Limb weakness
day. --Overlying open wound --Face and neck: 4–5 days • Drunk patient
--Fractures of femur or pelvis --Leg: 10 days • Pupils respond slowly to light or are different size.
--Suspected spinal fracture --Below knee: 2 weeks
--Deformity --Wound under tension like
amputation: 2 weeks Approach to patient with head injury not needing urgent referral
• Clean any wound and suture if needed.
• Give Paracetamol 1g 6 hourly for pain relief. Advise patient to avoid sleeping
tablets and tranquilizers.
• On discharge home ensure a responsible person is available to keep an eye on
the patient for 24 hours.
• Advise patient to avoid drinking alcohol for 24 hours.
• Patient to go to hospital if any of the following occur: vomiting, visual
disturbances, headache not relieved by paracetamol, balance problem,
difficult to wake.
• If patient has been assaulted 53.

• Ask about substance abuse 89.
• Give the patient with a wound Tetanus Toxoid 0.5mℓ IM if not had in last 5 years.
• Advise patient to return if no improvement.

Burns
Give urgent attention to the patient with a burn:
• Carefully remove smouldering, hot and/or constrictive clothing and rings and immerse burnt area in cold water for 30 minutes. Calculate % of body surface burnt:
• Clean burn gently with clean water or Sodium Chloride 0.9%. • Head 9% • Leg 18%
• Assess the percentage of body surface burnt (see adjacent guide) and depth of the burn: • Neck 1% • Front torso 18%
--Full thickness burns: complete skin loss, dry, charred, whitish/brown/black, painless • Arm 9% • Back 18%
--Partial thickness burns: moist white/yellow slough, red, mottled, only slightly painful
• Cover full thickness and extensive burns with an occlusive dressing, other burns with paraffin gauze and dry gauze on top. If infected apply povidone iodine 5% cream daily.
• If inhalation burn with black sputum, difficulty breathing, hoarse voice or stridor apply face mask oxygen.
• Ensure hydration: if < 10% burns give oral fluids; if ≥ 10% burns, give Sodium Chloride 0.9% IV [burn% x weight (kg) x 4mℓ]: give half volume in first 8 hours, second half in the next 16 hours.
• Give Tetanus Toxoid 0.5mℓ IM if not had in last 5 years.
• Give Paracetamol 1g 6 hourly as needed.
• Ask about abuse 53 and substance abuse 89.
Refer same day the patient with:
• Full thickness burns • Circumferential burns of limbs/chest
• Partial thickness burns > 10% of total body surface • Electrical or chemical burns
• Burns of hands/face/feet/genitalia/perineum/major joints • Inhalation injury
Bites
Give urgent attention to the patient with a bite and one or more of:
• Snake bite even if bite marks not seen
• Insect bite/s and weakness, drooping eyelids, difficulty swallowing & speaking, double vision
• Suspected rabid animal (animal with strange behaviour)
• Deep and large wound needing surgery
Management:
• Snake bite: do not apply a tourniquet or attempt to squeeze or suck out the venom. Discuss with poison help line back page.
• If rabies suspected give rabies Immunoglobulin 10IU/kg injected in and around wound and 10IU/kg IM.
• Refer same day.
Approach to the patient with a bite not needing urgent attention
Human or animal bite/s Insect bites

• Remove any foreign bodies and allow a small amount of bleeding. • If very painful scorpion sting, inject Lignocaine
• Irrigate with warm water and Chlorhexidine 0.05% solution or Povidone Iodine 10% solution. 2% 2mℓ around site.
• Do not close the wound. • Remove bee sting.
• Give Tetanus Toxoid 0.5mℓ IM if not had in last 5 years. • Give Chlorpheniramine 4mg 8 hourly.
• Give Paracetamol 1g 6 hourly as needed. • Apply Calamine Lotion.
• Give antibiotic if human bite/s or animal bite/s to hand or extensive bite: Amoxycillin/Clavulanic acid 500/125mg 8 hourly • Give Paracetamol 1g 6 hourly as needed.
or Erythromycin 500mg 6 hourly and Metronidazole 400mg 8 hourly all for 5 days, or for 10 days if infected.

Skin symptoms
This is the starting page for the patient with skin symptom/s.
Give urgent attention to the patient with skin symptom/s and any of the following:
Refer urgently:
• Purple rash/purpura with headache, vomiting: give Ceftriaxone 2g IM/IV (if none available give Penicillin G 5MU
IV).
• Rash with BP < 90/60: give Sodium Chloride 0.9% IV.
• Diffuse itchy rash with respiratory rate ≥ 30 breaths/minute: treat for anaphylaxis: give Adrenaline 1 mℓ (1:1000)
IM every 10 minutes until better, Hydrocortisone 100mg IV and Promethazine 50mg IM/slow IV.
Refer same day:

• Extensive blistering
• Shingles involving the eye
• If on any medication like ART, TB drugs, Co-Trimoxazole or anticonvulsants, with 1 or more of the
following, stop all drugs:
--Temperature ≥ 38°C
--Systemically unwell (vomiting/headache)
--Any mucosal involvement (look in the mouth)
--Blistering or raw areas
--Diffuse purple discolouration of the skin
--Jaundice
Approach to the patient with skin symptom/s not needing urgent attention
Generalised, Changes in
Pain Itch Lump/s Ulcers Crusts
non-itchy rash skin colour
41 No rash Rash 44 45 46 46 47
Localised Generalised
42 43
If status unknown, test for HIV, especially if rash is extensive, recurrent and/or difficult to treat.

Painful skin
Firm, red lump which softens in the centre to Sudden onset sharply demarcated Blisters with crusting in a band along one side of the body or
discharge pus. redness of skin. face for 3 days or less.
Boil/abscess likely Cellulitis likely Shingles likely

Skin is swollen, red, hot and tender to the touch. There may be blistering. If status is unknown test for HIV 60.
• Advise patient to wash with soap and water, keep nails • Give Paracetamol 2 tablets 4 times a day for pain • Treat rash topically with Povidone Iodine cream.
short, and avoid sharing clothing or towels. relief. • If blisters are fresh, give Aciclovir 800mg 4 hourly
• Give Paracetamol 2 tablets 4 times a day for pain relief • Give Amoxicillin/Clavulanic Acid 500/125mg (miss the middle of the night dose) for 7 days.
as needed. 8 hourly for 5 days. If allergic to penicillin use • Shingles is very painful. Give regular analgesia:
• Incise and drain if larger or fluctuant. Refer if on face or Erythromycin 500mg 6 hourly x 5 days -- Paracetamol 1g 4 times a day
perianal region. • Advise patient to elevate limb. --If no response, add Ibuprofen 400mg 8 hourly.
• If enlarged lymph nodes or temperature ≥ 38˚C, give • Refer if symptoms worsen or no better after 4 days. Avoid if peptic ulcer, asthma or hypertension.
Cloxacillin 500mg 6 hourly for 5 days. If penicillin --If poor response or pain persists after rash has
allergic, give Erythromycin 500mg 6 hourly for 5 days. healed, give Amitriptyline 25mg at night,
• If recurrent boils: test for HIV 60 and diabetes 74. increase by 25mg every 2 weeks if needed to
Wash body daily for 1 week with antiseptic wash. 75mg.
• A stage 2 HIV diagnosis. HIV patient needs
routine HIV care 61.
Refer same day if:

• Eye involvement
• Features of meningitis
• Blisters elsewhere on the body

Itch with localised rash
Slow growing ring-like patch/patches Scaling moist lesions between toes and Itchy rash on back of neck Well demarcated pink raised plaques
on soles of feet covered with a silvery scale.
Ringworm likely Athlete’s foot likely Lice likely Psoriasis likely

A clearly-demarcated active, scaly or blistering edge Look for nits/eggs on hair.
is characteristic. If multiple or large lesions, test for
HIV 60.
• Give Whitfield, Soint or Providone • Dip comb in vinegar and fine comb the • Apply Emulsifying Ointment bd.
Iodine Oint twice a day and continue hair. • Expose skin to sunlight.
• Give Clotrimazole Cream twice a day for 2 for 2 weeks after lesion has cleared. • Give Malathion 0.5% Lotion: apply • Apply Coal Tar-Based Ointment
weeks after lesion has cleared. • Advise patient to wash and dry feet well. to dry scalp overnight and wash off in daily.
• Advise patient to avoid sharing towels/clothes. • Encourage open shoes/sandals. morning. • Refer if extensive or not responding or
• Give routine HIV care to the HIV patient 61. • Repeat after 1 week. coal tar-based ointment unavailable.
• Refer if rash is extensive, recurrent or responds
poorly to clotrimazole cream.
Itch with no rash

• Confirm there is no rash, especially scabies or insect bites.
• Is the skin very dry?
No Yes
Review patient’s medication. Dry skin/ichthyosis likely
All TB drugs and morphine can cause itch with • If not on any medication, refer for • Avoid washing more than once a day.
no rash. assessment of underlying cause. • Use emulsifying ointment or aqueous cream as moisturiser.
• Use aqueous cream instead of soap to wash.
• Continue TB treatment.
• Chlorpheniramine 4mg at night or up to
3 times a day if needed for itch (may cause
sedation).
• Advise patient to return if rash develops.

Generalised itchy rash
If status unknown, test for HIV, especially if rash is extensive, recurrent and difficult to treat 60.
A widespread very itchy rash with Very itchy bumps. Patches of dry, scaly skin Very itchy red raised wheals that
burrows Skin often hyper-pigmented with/without itch appear suddenly, disappear and then
that may be localised reappear elsewhere
Scabies likely Papular-pruritic eruption likely Eczema likely Urticaria likely

Commonly involves web-spaces of hands • Often co-exists with scabies. Commonly due to allergy
and feet, axillae and genitalia. • Usually seen in HIV patients 60.
• May temporarily worsen on starting ART. • Use emulsifying ointment instead of soap.
• A stage 2 HIV condition. HIV patient • Prescribe 1% Hydrocortisone cream bd. • If cough, difficult breathing or whezing,
• Give Malathion 0.5% Lotion. needs routine HIV care 61. • Use Aqueous Cream as a moisturiser bd. manage for anaphylaxis 16.
• Apply, leave to dry, wash off after 24 hrs, • Chlorpheniramine 4mg 8 hourly for itch. • Try to identify and remove allergen.
repeat after 1 week (repeat once only). • If infected, treat with Cloxacillin 500mg • Stop offending drug and prescribe
• Treat all household members and clean 6 hourly for 5 days. If penicillin allergic give alternative if necessary.
linen/clothes in hot water. • First treat as for scabies in adjacent column. Erythromycin 500mg 6 hourly for 5 days. • Calamine Lotion directly on rash as
• Chlorpheniramine 4mg at night for • If no response, give Emulsifying • If poor response doctor to give needed.
itch. Ointment and 1% Hydrocortisone Betamethasone ointment twice a day for • Chlorpheniramine 4mg or
Avoid direct sunlight until resolved Cream bd, .1% Hydrocortisone and 7 days (do not apply to face). If unavailable, Promethazine 20mg 3 times a day until
Aquouscream bd, Calamine Lotion tds or refer. 72 hours after resolution of wheals.
prn
• Chlorpheniramine 4mg 8 hourly for itch.
• If poor response doctor to give
Betamethasone ointment twice a day for
7 days (do not apply to face). If unavailable,
refer.
If no response to treatment, refer for review.

Lumps
Refer same week the patient with a lump that:
• Bleeds easily
• Is a new or changed mole
• If the diagnosis is uncertain to exclude skin cancer
Raised nodules or papules Small, skin-coloured bumps Purple lumps on skin or in mouth Small, firm lump beneath the skin, Red papules, pustules and
with pearly central dimples may discharge white material blackheads on face and perhaps on
upper back, arms, buttocks and chest
Warts likely Molluscum contagiosum likely Kaposi’s sarcoma likely Epidermal cyst likely Acne likely
• Common on hands in young • May be extensive in HIV. • These can vary from isolated
adults. • If status is unknown test for HIV lumps to florid tumours.
• Plantar warts on the soles of 60. • If status is unknown test for HIV • If not infected no treatment • Steroids, anticonvulsants, isoniazid
the feet are thick and hard 60. needed. can all worsen acne.
with a black central point. • If warm, tender and red, the • Advise to avoid squeezing lesions
• Reassurance (may disappear cyst is infected: and greasy cosmetics. Diet will not
quickly with ART). • This is an AIDS-defining illness. --Incise and drain if large or affect acne.
• Reassure patient that warts • If distressing to patient, try local • Patient needs routine HIV care fluctuant. Refer if on face • Apply Benzoyl Peroxide 5%
often disappear spontaneously. destructive treatment (open and ART 61. or perianal region. Cream at night to inflamed
• Protect surrounding skin with molluscum with sterile blade/ • If enlarged lymph nodes or pustules and give Doxycycline
petroleum jelly and apply a needle and apply Povidine temperature ≥ 38˚C give 100mg daily for at least 3 months.
Silver Nitrate Pencil. Repeat Iodine 10% Ointment. Cloxacillin 500mg 6 hourly for Doxycycline interferes with oral
as needed after 2 weeks. • Refer if no response to ART or 5 days. If penicillin allergic give contraceptive and can cause
• Refer if warts persist or are local destructive treatment. Erythromycin 500mg 6 hourly sunburn. Advise to use condoms
extensive. for 5 days. as well and to avoid the sun.
• Refer if large, symptomatic, • If woman needs contraception,
recurrent infection or diagnosis advise oestrogen-containing oral
uncertain. contraceptive 90.
• Response to treatment is usually
slow.
• Refer if severe or not responding
to treatment.

Generalised non itchy red rash
Is patient taking any medication?
Yes No
Drug reaction likely • Most likely due to infection.

• Patient may have fever, headache, lymphadenopathy, muscle pain.
• Presentation is variable, from • Ensure patient does not need urgent attention 40.
mild, patchy spots on the trunk to
widespread skin damage (like burns).
• Hand involvement is characteristic. Approach to the patient not needing urgent attention:
• May occur within 6 weeks of starting • Give pain relief if needed. Paracetamol 2 tablets 4 times a day.
or restarting anti–retrovirals especially • Check for syphilis.
nevirapine, TB drugs, anticonvulsants, • If status unknown, test for HIV 60.
penicillin or co-trimoxazole.
Syphilis test positive or unavailable HIV negative HIV positive
About one third of patients with untreated Rash may be an HIV
primary syphilis develop secondary syphilis. seroconversion illness.
Patient needs routine
Rash is often on soles and palms. HIV care 61.
Does the patient have any markers of severity: There may also be condylomata lata and Advise patient to repeat
• Temperature ≥ 38°C • Painful mouth, eyes or genitals patchy hairloss. HIV test after 3 months.
• Vomiting or nausea • Blistering or ‘raw’ areas
• Headache • Diffuse purple discolouration of skin
• Jaundice • Abdominal pain
Yes No
Patient needs urgent attention. Patient does not need urgent attention.
• Stop all drugs. • Patient must continue with medication. Do not

• Refer to hospital same day. increase nevirapine if still on once daily dose until
rash has resolved and ALT is normal.
• Check ALT.
--If ≥ 200 refer same day.
--If 50–199 and patient is well, repeat ALT after
1 week. Treat patient for early syphilis 28.
• Apply Emulsifying Ointment.
• Chlorpheniramine 4mg at night if itchy.
• Review daily until rash resolves.
• Advise patient to return urgently if markers of
severity develop.

Ulcers and crusts
Ulcer/s Blisters which dry to form
Is client usually in bed and is ulcer in common bedsore site (see below)? honey coloured crusts.
No Yes
Is ulcer/s on the leg?
No Yes
• If genital ulcer

26. Impetigo likely
• If elsewhere on • Usually starts on face, spreads
body and no to neck, hands, arms and
obvious cause like legs. May complicate bites or
trauma, refer to grazes/scrapes.
exclude skin cancer. • May be extensive in HIV. If
status is unknown test for HIV
60.
Check if foot pulses are present and if patient has muscle pain in legs or
buttocks on exercise. Bedsore likely • Use Aqueous Cream to
remove crusts.
Foot pulses are present and no muscle pain in legs or Foot pulses not present • Apply Povidone Iodine 5%
• If infected (increased fluid, poor Cream 3 times a day.
buttocks on exercise. and/or muscle pain in legs healing, swelling and heat of
or buttocks on exercise • Give Amoxycillin 500mg 8
surrounding skin) treat with hourly for 5 days if extensive
Is there darkening of skin around the ulcer, varicose veins Amoxycillin 500mg 8 hourly infection. If no response give
and/or chronic swelling of the leg? for 5 days. If smelly, also give Cloxacillin 500mg 6 hourly
Peripheral vascular Metronidazole 400mg 8 hourly
disease likely for 5 days. If penicillin allergic
for 5 days. give Erythromycin 500mg 6
No Yes • If there are black, yellow or cream hourly for 5 days. If rash does
areas in the sore, there is dead not resolve completely, give
• Patient needs specialist tissue. Refer or discuss.
• If patient has Venous stasis ulcer likely assessment. antibiotics for 5 days more.
• Give pain relief if needed.
weight loss, • Do not apply • Wash ulcer daily with salt water. If
cough or sweats, • Apply dressing under compression compression bandage ulcer is large, dress with Povidone
exclude TB 55. (ideally Hydrocolloid dressing or to ulcer/s. Iodine or saline soaked gauze.
• Refer for further Silver Sulfadiazine cream). • For PVD routine care • If patient is bed-bound with an
assessment. • Assess CVD risk 71-75. 83. incurable illness and you would
• Refer if patient has diabetes or ulcer not be surprised if s/he died within
no better after 1 month of treatment. the next year, also give end-of-life
care 107.

Changes in skin colour
Yellow skin/eyes Darkening of skin Absence of colour
Jaundice likely Is skin smooth or scaly? Is skin smooth or scaly?
Recognise and refer same day the Smooth Scaly Smooth

jaundiced patient if:
• Pregnant Dark brown patches on cheeks Scaly dark or light patches Is absence of colour generalised or patchy?
• Temperature ≥ 38˚C and upper lip usually occur on the trunk –
• Confusion they may coalesce.
• Easy bruising or bleeding Patchy Generalised
• Persistent vomiting
• Severe abdominal pain
• Hb < 10 Present from birth, hair and
• On any medication eyes are involved.
Albinism likely
Approach to jaundiced patient who
does not need same-day referral:
• If patient takes ≥ 21 drinks/week (man), • Encourage sun avoidance
14 drinks/week (woman) or binge and use of sunscreen.
Melasma likely Tinea versicolor likely
drinks, assess for alcohol abuse 87. • Monitor for the
• Check ALT and ALP/GGT. development of skin
• Review with blood results. • Avoid use of skin-lightening • Apply Clotrimazole Cream cancers.
agents. bdx 7days, Ketaconazole
ALT ≥ 120 ALP/GGT ≥ 3 times • Encourage sun avoidance 200mg bd po x 10d, Vitiligo likely
upper limit and use of sunscreen. Seleniumsulphide 2.5%
• Check for pregnancy. If shampoo to affected areas
Do hepatitis B pregnant 98-99. overnight once a week.. • Advise use of camouflage
screen. Refer for • Change oral contraceptive • Advise that colour may take cosmetics.
ultrasound liver to alternative contraception months to return to normal, • Skin colour may return but
and further 96. but that absence of scale seldom does on hands, feet,
management. • Ask about symptoms of indicates adequate treatment. lips and genitalia.
menopause 102. • Recurrence is common. • Refer to dermatologist if
• Review weekly. • Stop all topical preparations extensive.
• Check full blood count. like cosmetics, perfumes,
• Refer if Hb falls < 10, patient develops perfumed soap and
markers of severity above or jaundice moisturisers.
persists > 6 weeks. • This is often difficult to treat.
Refer if diagnosis is uncertain.

Nail symptoms
Disfigured nail with swollen nail bed Painful, red, swollen area around White/yellow disfigured nails Diffuse blue/black discolouration
the nail. of nails.
Chronic Paronychia likely Acute Paronychia likely Fungal infection HIV or drug side effect
• Often associated with working with • Often associated with trauma like nail Refer if very troublesome as culture is If status is unknown test for HIV 60.
water. Advise patient to wear gloves. biting or pushing the cuticle. Advise needed to confirm fungal infection.
• Dip finger in antiseptic drying agent patient to stop.
like methylated spirits and keep • Give Cloxacillin 500mg 6 hourly for
hands dry. 10 days.
• Apply Hydrocortisone 1% Cream • Refer for incision and drainage if no
to nailfold at night. response after 5 days.

Suicidal patient
Give urgent attention to the patient who has attempted or had thoughts of suicide/self harm and one or more of:
• Unconscious 1.
• If aggressive or violent 50.
• Intent to attempt suicide: suicidal thoughts; ongoing wish to commit suicide; plans have been made for suicide
• Suicide attempt was serious: planned, took care against discovery; violent or potentially lethal; perhaps preceded by ‘final acts’ like leaving a note or new will.
• Overdose of medication or other potentially harmful substance
• Exposure to carbon monoxide
Management:
• If patient took an oral overdose of medication and is fully conscious give 500mℓ water added to 100g Activated Charcoal via nasogastric tube.
• Avoid activated charcoal if patient ingested paraffin, petrol, corrosive poisons, iron, lithium or alcohol.
• If exposed to carbon monoxide: give 100% face mask oxygen.
• Consider admitting under the Mental Disorders Act 80 if the patient has signs of mental illness (see below) and refuses treatment or admission.
Refer same day.
Assess the patient who has no suicidal intent and has not had a serious suicide attempt not needing urgent attention
Screen for mental illness
• If low mood or sadness, loss of interest or pleasure, feeling anxious or worrying a lot or not coping as well as before, consider depression/anxiety 87.
• If hallucinations, delusions and abnormal behaviour, consider psychosis 90.
• If memory problems, screen for dementia 92.
• If patient takes > 21 drinks/week (man) or > 14 drinks/week (woman) and/or ≥ 5 drinks per session or misuses illicit or prescription drugs consider substance abuse 893.
Explore possible stressors
• Ask ‘Are you unhappy in your relationship? Has anything happened to you which changed your life?’ If yes to either 53.
Make discharge and follow-up plans according to the following factors:
If any 1 of the following are present: If all of the following are present:
• Male and/or • Female and
• ≥ 40 years and/or • < 40 years and
• Socially isolated and/or • Adequate social support and
• Previous attempts at suicide and/or • First suicide attempt and
• Known mental illness and/or • Suicide attempt was an impulsive act in context of a crisis now resolved and
• Substance abuse and/or • No evidence of mental illness or substance abuse and
• Functioning impaired and/or • Functioning not impaired and
• Chronic medical illness like HIV • Otherwise well
Refer same week to community mental health nurse or social worker. • Discharge to family/carers.
• Review within 1 week:
--Reassess for suicidal intent, mental illness, stressors.
--Consider referral to community mental health nurse.

Aggressive/violent patient
Approach to the aggressive or violent patient
Talk to the patient and understand the problem, always have one single person talking, remove spectators, involve security and police.
Ensure the safety of yourself, the patient and those around you:
• Ensure enough security personnel are present, call the police if necessary. They should disarm patient if s/he has a weapon.
• Assess patient in a safe room in the presence of other staff. Handle the patient in a calm authoritative manner. Try to talk the patient down.
• Restrain only if absolutely necessary.
Check for confusion: try to avoid sedation before assessing confusion 51.
• Varying levels of drowsiness and alertness • Unsure of the day in the week, the time of day, own name
• Unaware of surroundings/disorientated • Poor attention span
• Talking incoherently • Change in sleep pattern
Look for mental illness and substance abuse:
• Take a history from the escort for known mental illness or substance abuse.
• Consider psychosis if hallucinations, delusions, incoherent speech 84.
• Consider substance withdrawal or intoxication if alcohol on breath or history of alcohol or illicit drug use 83.
Consider detaining under the Mental Disorders Act 80 before sedation if the patient fulfils all 3 of the following:
• Has signs of mental illness and
• Refuses treatment or admission and
• Is a danger of harm to self, others, own reputation or financial interest/property
Is sedation needed?
No Yes
Give Lorazepam 2mg and Haloperidol 2–5mg IM or orally if patient accepts oral medication.
• Monitor and record BP, pulse and level of consciousness every 15 minutes.
• Reassess for mental illness.
• Is patient’s behaviour still aggressive after 60 minutes?
No Yes
Repeat Haloperidol 2–5mg IM or orally if patient accepts oral medication.
• Monitor and record BP, pulse and level of consciousness every 15 minutes.
• If necessary, repeat Haloperidol to a maximum of 20mg in 24 hours.
• Refer the mentally ill aggressive patient same day to hospital.

• Document history, details of Mental Disorders Act, and time and dose of medication given.

Confused patient
• The confused patient may be disorientated for place and time, unsure of his/her own name, and may have a poor attention span and altered sleep pattern.
• If the confused patient is also aggressive, try to assess and manage confusion before sedating the patient 50.
Give urgent attention to the confused patient with one or more of:
• Sudden onset of confusion or disturbed speech or behaviour, perhaps with weakness, visual disturbance that may have resolved: stroke likely 82
• Had a fit 2
• Sudden onset over hours or days of confusion with impaired awareness, varying levels of alertness and drowsiness and change in sleep pattern: delirium likely
• Temperature ≥ 38˚C
• Head injury within past 6 weeks
• Finger prick blood glucose ≤ 3.5
Management:
• Give face mask oxygen.
• If glucose ≤ 3.5, give Oral Glucose or 40–50mℓ Glucose 50% IV. If confusion resolves, refer only if on Dlibenclamide or Insulin. If diabetic 76.
• If temperature ≥ 38˚C: give Ceftriaxone 2g IM/IV immediately. If a malaria area, also consider treating for malaria 4.
• Alcohol withdrawal (known alcohol user who has taken less alcohol for 12 hours): give Thiamine 100mg IM and Diazepam 10mg orally and oral rehydration.
• Drunk (smells of alcohol, recent drinking): give 1ℓ Sodium Chloride 0.9% with Thiamine 100mg IV over 4 hours. Refer only if still confused when drip complete 89, 104.
• Refer same day to hospital unless confusion resolves when sober or with glucose not on Glibenclamide or insulin.
Approach to the confused patient not needing urgent attention
Is the patient psychotic?

Lack of insight with 1 or more of hallucinations (hearing voices), delusions (fixed false beliefs) and disorganized speech and behaviour.
Yes No
Psychosis or mania 90 Has patient had memory problems and been disoriented for at least 6 months?
Yes No
Dementia likely 92 Refer same day for assessment.

Stressed or miserable patient
Recognise the stressed/miserable patient needing urgent attention
• Assess the patient with suicidal thoughts 49.
Assess the stressed/miserable patient

• The patient may have headache, dizziness, fatigue, abdominal pain. S/he may have poor eye contact, cry easily, be agitated or communicate poorly.
Screen for mental problem
• If low mood or sadness, loss of interest or pleasure, feeling tense, worrying a lot or not coping as well as before, consider depression/anxiety 87.
• If > 21 drinks/week (man) or > 14 drinks/week (woman) and/or > 5 drinks/session or misuses illicit or prescription drugs consider substance abuse 89.
• If hallucinations, delusions and abnormal behaviour, consider psychosis 90.
• If memory problems, screen for dementia 92.
Identify the traumatised/abused patient
• Ask ‘Are you unhappy in your relationship? Has anything happened to you which changed your life?’ If yes to either 53.
Try to identify a cause to focus on a solution
• Ask about financial difficulty, bereavement, post-natal 101, menopause 102 or chronic ill-health (is HIV status known? 60).
• Review medication: oral corticosteroids, oestrogen-containing oral contraceptives ( 94), Theophylline, Efavirenz can cause mental side effects. Reassure patient on Efavirenz that low mood is usually
self-limiting and resolves within 6 weeks on ART. If > 6 weeks change to NVP 200mg 12 hourly.
Advise the stressed/miserable patient

• Encourage patient to take time to relax:
--Do a relaxing breathing exercise each day.
--Find a creative or fun activity to do.
--Spend time with supportive friends or family.
• Regular exercise might help.
• Advise patient to get adequate sleep. If patient has difficulty sleeping 54.
• Link patient to available psychosocial services: counsellor, psychologist, support group, social worker.
• Address bereavement issues and concerns in the patient with an incurable illness receiving end-of-life care and/or his/her family:
--Acknowledge grief reactions: denial, confusion, shock, sadness, bargaining, yearning, anger, humiliation, despair, guilt and acceptance.
-- Allow the patient and/or family to share their sorrow and to talk of memories, the meaning of the patient’s life or religious beliefs as appropriate.
-- Identify worrying issues and who can give practical support with these before and after the patient dies.
-- Connect the patient and/or family with a spiritual counsellor or pastoral care as appropriate.
• For tips on communicating effectively 111.
Offer to review the patient in 1 month.

Traumatised/abused patient
Give urgent attention to the traumatised/abused patient with any of:
• Injuries need attention 38
• Immediate risk of being harmed and in need of shelter
• At risk of harm to self 49
• Recent rape/sexual assault:
--Arrange doctor assessment ideally at a designated facility for management of rape and sexual assault (same day if patient wishes to lay a charge).
--All documentation and patient’s notes must be correctly completed and labelled. Record in a register and keep locked away all forensic specimens.
--Aim to prevent HIV, STIs and pregnancy as soon as possible after the abuse:
Prevent HIV Prevent chlamydia and gonorrhoea Prevent syphilis Prevent pregnancy (if not on contraceptive and
• If status unknown, test for HIV 60. • If asymptomatic give Ceftriaxone • Offer RPR: of child-bearing age):
• If HIV negative or unknown, start post-exposure 250mg IM single dose and --If RPR negative, • Within 72 hours: give Norgestrel/Oestradiol
prophylaxis ideally within 4 hours and no later than 72 Doxycycline 100mg 12 hourly for 7 repeat after 1 month. 0.5/0.05mg 2 tablets as soon as possible and
hours of rape: TDF/FTC/EFV 1 tablet daily for 1 month. days. --If RPR positive 28. again after 12 hours 96.
--Check ART bloods as per schedule 61. • If symptomatic, treat symptoms • Advise patient to use • Within 5 days: intrauterine device can be
--Do not delay PEP for blood tests. 23. condoms with regular inserted 96.
--Repeat HIV test at 6 weeks, 3 and then 6 months. • Advise patient to use condoms with partner for 3 months. • After 5 days: check pregnancy test 6–8 weeks
regular partner for 3 months. after last period. If pregnant 99.
Also assess and support the patient needing urgent attention as below.
Approach to the traumatized/abused patient

Listen and support 111.
• Interview the patient in a private room, supported by a trusted friend/relative if the patient wishes.
• Clearly record the patient’s story in his/her own words. Include the nature of the assault and the identity of the perpetrator.
• Help the patient to identify strengths and support structures. Do not give up if the patient fails to follow your advice.
• Offer to see the patient again. A supportive relationship with the same health practitioner helps to contain frequent visits for multiple problems.
• If low mood or sadness, loss of interest or pleasure, feeling tense, worrying a lot or not coping as well as before, consider depression/anxiety 87, 88.
• If > 21 drinks/week (man) or > 14 drinks/week (woman) and/or > 5 drinks/session or misuses illicit or prescription drugs consider substance abuse 89.
Exclude pregnancy and STIs
• Check for pregnancy. If pregnant 98. If pregnancy resulted from rape, discuss the option of termination of pregnancy.
• If status unknown, test for HIV 60. The HIV patient needs routine HIV care 61.
• Ask about symptoms of sexually transmitted infections. If present 23.
Refer to available supportive resource
• Refer to available mental health nurse, psychologist or social worker.
• Encourage patient to report case to the police and to file a Police Assault form BP73. Respect the patient’s wishes if s/he declines to do so.
• Encourage patient to apply for restraining order at local magistrate’s court. Refer to family violence NGOs for assistance.

Difficulty sleeping
Assess the patient with difficulty sleeping
• Check 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.
Check medication
• Over-the-counter decongestants, oral steroids, theophylline, fluoxetine, efavirenz may cause sleep problems. Discuss with doctor.
• Reassure patient that sleep disturbance from efavirenz is usually self-limiting and resolves within 6 weeks on ART. If > 6 weeks change to NVP 200mg 12 hourly.
Screen for substance abuse
• If patient takes > 21 drinks/week (man) or > 14 drinks/week (woman) and/or > 5 drinks/session or misuses illicit or prescription drugs 89.
• If low mood or sadness, loss of interest or pleasure, feeling tense, worrying a lot or not coping as well as before, consider depression/anxiety 87.
• Consider psychosis if hallucinations, delusions, incoherent speech 90.
• Consider dementia if memory problems 92.
Ask about associated loud snoring
• Refer the patient with difficulty sleeping who snores for further assessment.
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 (but not before bedtime).
--Avoid caffeine (coffee, tea) and smoking before bedtime.
--Avoid day-time napping.
--Encourage routine: try to get up at the same time each day (even if tired) and go to bed the same time every evening.
--Wind down/relax before bed.
--Use bed only for sleeping and sex. Spend only 6–8 hours a night in bed.
--Once in bed do not clock-watch. If not asleep after 20 minutes, do a low energy activity out of bed, like a short walk around the house.
--Keep a sleep diary. Review this at each visit.
• Review the patient regularly. A good relationship between practitioner 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:
--Give amitriptyline 12.5–25 mg at night.
--If still no improvement after 1 month on amitriptyline refer patient for further assessment.

Tb: diagnosis
Exclude TB in the patient with cough ≥ 2 weeks (or if HIV patient cough of any duration), unintentional weight loss ≥ 5% in 4 weeks, drenching night sweats, fever ≥ 2 weeks, loss of appetite, chest pain on
breathing, blood-stained sputum, feeling unwell, lymph node ≥ 2cm 2, TB contact.
Give urgent attention to the TB suspect with one or more of the following:
• Respiratory rate of ≥ 30 breaths/minute • Prominent use of breathing muscles
• Breathlessness at rest or while talking • Confusion or agitation
• Coughing up ≥ 1 tablespoon fresh blood
• Give 1 dose of Ceftriaxone 1g IM/IV (if unavailable, Amoxicillin 1g orally. If penicillin allergic give Erythromycin 500 mg orally).
• Give face-mask oxygen.
• Take 2 spot sputum specimens for AFBs 1 hour apart and arrange follow-up.
• Refer urgently with continuous oxygen to hospital.
1st Approach to the TB suspect not needing urgent attention

VISIT • Send 1 spot sputum specimen for AFBs at this visit. Only if patient is unable to return the next day, take 2 specimens 1 hour apart.
• Next day, send 1 early morning sputum for AFBs. If patient previously treated for TB for ≥ 4 weeks, known MDR/XDR TB contact or a health worker, also request culture and DST1.
• If status unknown test for HIV 60.
• If patient has chest pain on breathing or is coughing frank blood, also arrange doctor review with chest X-Ray (see below).
• Ask patient to return for sputum results after 1–2 working days.
2nd Is GeneXpert (if available) positive?

visit
Yes GeneXpert not available or negative
GeneXpert At least one sputum AFB positive Both sputum specimens AFB negative or GeneXpert negative
diagnostic
algorithm Diagnose TB • Give Amoxicillin 1g 8 hourly for 5 days. If penicillin allergic: Erythromycin 500 mg 6 hourly for 5 days and
Annex a, b, c • Give routine TB care 57. • Manage further according to HIV status. Encourage patient who has not tested to do so 60.
HIV positive HIV negative
Review in one week.
No or partial response Resolved. Advise to return

if symptoms recur.
1
Drug susceptibility testing. This specimen must be sent to the National TB Refernce Laboratory with a mycobacteriology form.

Continue workup of patient
• If GeneXpert negative, arrange chest Xray and doctor visit (see below).
• If GeneXpert not done, send 3rd sputum for AFBs, and culture and DST1 if not already sent and patient has HIV.
• Ask patient to return for AFB result after 1–2 working days.
• If patient treated previously for TB, a known MDR/XDR TB contact or health worker, and GeneXpert not done, ensure culture and DST1 were sent.
3rd 3rd sputum AFB positive and/or culture positive All sputum specimens AFB negative or GeneXpert negative and culture negative or pending
visit
Diagnose TB. Give routine TB care 57. Arrange chest X-Ray and doctor appointment. Do not wait for culture result before referring to doctor.
• Ensure patient does not need urgent attention 55.

4th • If the patient has HIV, does s/he have a dry cough, worsening breathlessness on exertion and if known, CD4 < 200?
visit:
DOCTOR
Yes No
PCP likely 16 Review chest X-Ray
Intrathoracic Miliary TB Pleural effusion Any lung opacification/s Upper lobe cavitation Pericardial effusion
lymphadenopathy can be TB in HIV patient
Chest X-Ray similar to any X-Ray above Chest X-Ray normal Chest X-Ray different to above
or unsure
Diagnose TB on basis of chest X-Ray. • Look for extra-pulmonary TB:
• Give routine TB care 57. --If patient has abdominal pain, swelling or diarrhoea Refer for specialist review.
refer for abdominal ultrasound.
--If patient has headache, refer for lumbar puncture.
--If patient has lymphnode ≥ 2cm, aspirate for TB and
cytology 5.
--If extra-pulmonary TB diagnosed give routine TB care
57.
• Look for other cause of cough 16.
1

TB
The
Tb: routine
unconscious
care patient
Assess the patient with TB at diagnosis and monthly
Assess When to assess Note
Symptoms Each visit Expect gradual improvement on TB treatment. Refer if symptoms worsen or do not improve.
Contacts At diagnosis and if symptomatic Screen household contacts who are symptomatic, < 5 years or have HIV .
Family planning At diagnosis and each visit Assess contraceptive needs 96:
--Suggest patient uses injectable contraceptive or if available an intra-uterine contraceptive device.
--Adjust oral contraceptive: at least 0.05mg ethinyloestradiol, shorten pill free day to 4 days and use condoms.
--If using hormonal implant, advise patient uses condoms too.
Adherence At diagnosis and each visit At each visit check adherence on the TB card.
Side effects At diagnosis and each visit On starting TB treatment, advise patient about possible side effects (see below) and to report these promptly.
Substance abuse At diagnosis and if adherence poor If ≥ 21 drinks/week (man), 14 drinks/week (woman) and/or ≥ 5 drinks/session or misuses illicit or prescription drugs 89.
Severely ill patient Each visit Check for signs of the patient needing urgent attention 55.
Weight At diagnosis and each visit • Expect gradual weight gain on treatment. Refer for doctor review if losing weight or not gaining weight on treatment.
• BMI is weight (kg) ÷ height (m) ÷ height (m). If < 18.5, refer for nutritional support.
Sputum According to schedule 59. Review results at • Make every effort to obtain sputum, even if early morning, by nebulisation or with brisk exercise.
each visit. If smear negative, culture negative TB, • If patient treated previously for TB, a known MDR/XDR contact or a health worker, ensure culture and DST1 were requested at diagnosis.
check only if deteriorating. • If sensitivities show resistance refer to MDR/complicated TB treatment centre.
Chest X-Ray After 1 month if pleural or pericardial effusion Routine repeat chest X-Ray is unnecessary. Do chest X-ray in the patient if frank haemoptysis or smear negative TB and symptoms not improving.
HIV If status unknown Test for HIV 60. Give the HIV patient routine HIV care 61. Start ART within intensive phase once tolerating TB treatment.
CD4 HIV patient not on ART If CD4 < 100 start ART at 2 weeks as soon as patient is tolerating TB treatment. Do not delay starting ART waiting for the CD4 result.
Advise the patient with TB

• Smoking worsens TB treatment outcomes. Urge the patient who smokes to quit.
• Discuss adherence: poor adherence leads to drug resistant TB. For treatment to be effective it is crucial to take all treatment for the correct period. Refer for adherence support and TB/HIV education.
• Advise the patient abusing alcohol and/or illicit or prescription drugs to stop. Substance abuse can interfere with recovery and with adherence to treatment.
• Educate patient about TB treatment side effects (as below) and to report these promptly should they occur.
Discuss TB treatment side effects

Jaundice and vomiting Most TB drugs Stop all drugs and refer to hospital same day. Nausea/poor appetite Rifampicin Take treatment at night.
Skin rash/itch Rifampicin Assess and manage 40. Joint pain Pyrazinamide Paracetamol or ibuprofen as needed
Loss of colour vision Ethambutol Stop ethambutol and refer same week. Orange urine Rifampicin Reassure.
Ringing in ears/deafness Streptomycin Stop streptomycin immediately and refer same week. Burning feet Isoniazid Give pyridoxine 37.
Treat the patient with TB 58.

1
Choose TB treatment regimen
Treat the patient with TB
• If patient has never been treated previously for TB or received TB treatment for less than 4 weeks s/he is a new TB case: give new treatment regimen for 6 months.
• If patient has ever been treated for TB for more than 4 weeks s/he is a retreatment TB case: give retreatment regimen for 8 months.
Start TB treatment TB treatment doses according to weight

• Treat the patient with TB 7 days a week. Ensure directly observed treatment for the entire length of treatment. Weight RHZE (150/75/400/275) Streptomycin RH E (400)
• New TB case: give new treatment regimen for 6 months: Intensive phase: RHZE for 2 months
and then change to continuation phase: RHE for 4 months. 30–37kg 2 tablets 0.5g IMI 2 (150,75) 2 tablets
• Retreatment TB case: give retreatment regimen for 8 months: Intensive phase: RHZE for 3 months 38–54kg 3 tablets 0.75g IMI 3 (150,75) 2 tablets
(including streptomycin for first 2 months) and then change to continuation phase: RHZE for 5 months.
• Determine dose according to weight in table. Adjust dose with weight gain. 55–70kg 4 tablets 1.0g IMI 2 (300,150) 3 tablets
• Give Streptomycin for the first 2 months in retreatment regimen: ≥ 71kg 5 tablets 1.0g IMI 2 (300,150) 3 tablets
--Ideally for 7 days a week, same time every day.
R – rifampicin H – isoniazid Z – pyrazinamide E – ethambutol
--Omit if patient is pregnant, > 65 years, has kidney disease, hearing loss or on TDF.
• Give Pyridoxine 25mg daily throughout TB treatment.
Manage the TB/HIV patient’s HIV

• Give Co-Trimoxazole 960mg and and routine HIV care throughout TB treatment 61. Stop co-trimoxazole after completion of TB treatment if patient has CD4 > 200 and is stage 1 or 2.
• Start ART in the first 8 weeks of TB treatment as soon as patient is tolerating TB treatment, at 2 weeks or 4 weeks if TB meningitis.
• If on ART and TB treatment, check AST/ALT monthly for 3 months. To interpret result 61.
• If patient on Lopinavir/Ritonavir, double the dose of LPV/r to 800/200mg 4 tablets 12 hourly and monitor for liver problem. On completion of TB treatment, reduce LPV/r dose to 2 tablets 12 hourly.
Approach to the patient who interrupts TB treatment

• Explore with the patient the reason for interruption. Exclude substance abuse 89, stress 52, side effects, lack of treatment support.
• Provide increased adherence support and weekly follow-up. Strengthen DOT.
• Consider restarting TB treatment according to timing and duration of interruption:
Interruption during intensive phase Interruption during continuation phase
Interrupted for < 2 Interrupted for ≥ 2 Interrupted for < 1 Interrupted for 1–2 months Interrupted for ≥ 2 months
weeks weeks month
• Send sputum for microscopy, culture and DST. • Register patient as TB treatment default.
• Continue TB • Restart TB treatment. • Continue TB • Continue treatment while awaiting results. • Send sputum for microscopy, culture and DST.
treatment. • Send sputum for treatment. • Give no treatment while waiting for results unless patient is sick.
• Prolong intensive microscopy, culture • Patient to make Negative smear and Positive smear or Negative smear and
phase to make up and DST if initially up missed doses. Positive smear or culture or
culture or EPTB culture culture or EPTB and no TB
missed doses. smear positive. patient sick
symptoms
• Continue TB Retreatment patient:
treatment. • Continue New patient: Retreatment • Doctor to decide if to start
• Patient to make retreatment. • Start retreatment. patient: retreatment or to give no
up missed doses. • Refer if MDR-TB • Refer if MDR-TB • Refer to MDR- more TB treatment and
confirmed. confirmed. TB centre. monitor monthly. Discuss
with MDR/complicated TB
treatment centre.
1
Avoid Atazanavir with ATT

TB
The unconscious patient Approach to the sputum follow-up and discharge of the smear positive and/or culture positive TB patient.
Review the patient on TB treatment monthly. Plan his/her visits according to TB treatment regimen and sputa results.
New smear positive Retreatment smear positive New smear negative culture positive Retreatment smear negative culture positive
End of month 2 • Change to continuation phase. Check culture and DST result. If resistant, register as
1
• Change to continuation phase.
• Send 2 sputa for AFB. If positive, plan to repeat 1 treatment failure and refer to MDR/complicated TB • Send 2 sputa for AFB:
sputum for AFB at 3 months. treatment centre. --If negative and well, no need for further sputa.
--If positive, send sputum for culture and DST1.
End of month 3 If month 2 sputa were positive, send 1 sputum for • Change to continuation phase. Check culture and DST1 result if sent. If resistant, • Change to continuation phase.
AFB. If positive, send sputum for culture and DST1. • Send 2 sputa for AFB. If 1 or 2 AFB positive, send register as treatment failure and refer to MDR/ • Send 2 sputa for AFB:
sputum for culture and DST1. complicated TB treatment centre. --If negative, no need for further sputa.
--If positive, send sputum for culture and DST1.
End of month 4 Check culture and DST1 result if sent. If culture Check culture and DST1 result if sent. If resistant, Check culture and DST1 result if sent. If resistant, Check culture and DST1 result if sent. If resistant,
positive, register as treatment failure and refer to register as treatment failure and refer to MDR/ register as treatment failure and refer to MDR/ register as treatment failure and refer to MDR/
MDR/complicated TB treatment centre. complicated TB treatment centre. complicated TB treatment centre. complicated TB treatment centre.
End of month 5 Send 2 sputa for AFB. Review results at the end of Send 2 sputa for AFB: Check culture and DST1 result if sent. If resistant,
month 6 to determine treatment outcome. • If negative, continue treatment. register as treatment failure and refer to MDR/
• If positive, send culture and DST1, register as complicated TB treatment centre.
treatment failure and refer to MDR/complicated
TB treatment centre.
End of month 6 Stop TB treatment and register treatment outcome: • Stop TB treatment.
• If both sputa negative: cured. • Register patient as treatment completed if
• If 1 or more sputa positive: treatment failure, patient has completed 6 months treatment.
re-register as retreatment after failure and start
regimen 2. Discuss with MDR/complicated TB
treatment centre.
• If unable to produce sputum and is well:
treatment completed.
End of month 8 • Send 2 sputa for AFB. • Stop TB treatment.
• Stop TB treatment and register treatment outcome: • Register patient as treatment completed if
--If both sputa negative: cured. patient has completed 8 months treatment.
--If 1 or more sputa positive: treatment failure.
Send culture and DST1 and refer to MDR/
complicated TB treatment centre.
--If unable to produce sputum and is well:
treatment completed.
1

HIV: diagnosis
N E
LI
Encourage your patient and partner and children to test for HIV.
D E
UI
Obtain informed consent
• Educate patient about HIV/AIDS, methods of HIV transmission, risk factors and benefits of knowing one’s HIV status.
• Explain test procedure and that it is completely voluntary.
Test
T G
Do double rapid HIV test on finger-prick blood.
E N
Discordant result
TM
1 result positive and 1 result negative
R EA
Repeat double rapid HIV test at the same visit.
Both results positive
V T
1 result positive and 1 result negative Both results negative
Patient has HIV. I

Result is indeterminate – it is uncertain what the
H
patient’s HIV status is.
HIV test result is negative.
6
01
• Advise patient to practise safe sex and to return
Give routine HIV care at this visit 61-67. • A rapid test detects HIV antibodies which may take up to 3
after 1 month for repeat test.
2
months to be formed.
• If results are still discordant, send blood specimen • Was patient at risk of HIV infection in the past 3 months?
E
to laboratory for ELISA test.
T H Yes No
TO Repeat HIV test after

the 3 month window
Patient does not have HIV.
• Encourage patient to remain
R
period. HIV negative.
E
• Offer to refer the man who is
F
not circumcised for safe male
E
circumcision.
R
• Advise patient who plans to be
sexually active to use condoms,
encourage partners to test and
to repeat HIV test once a year.
Support
Ensure patient understands test result and knows where and when to access further care.

HIV
HIV: routine care
N E
LI
Assess the patient with HIV
D E
UI
Symptoms Every visit • Manage patient’s symptoms according to symptom pages.
• Ask especially about TB symptoms 55 and genital symptoms 23.
G
TB Look for TB at every visit • Exclude TB if any of cough (any duration), weight loss, night sweats, chest pain, lymphadenopathy 55. Delay starting ART until TB excluded.
T
• if TB diagnosed and not on ART, start ART within 2 to 8 weeks as soon as tolerating TB treatment, at 2 weeks if CD4 < 100 and at 4 weeks if TB meningitis.
• If TB diagnosed on LPV/r, double LPV/r dose to 800/200mg 12 hourly.
Adherence Every visit
E N
• Check patient’s adherence with pill counts and record of attendance. Remember to give the patient a follow-up date.
• Do not start ART if adherence or attendance is poor.
M
• More than 95% of ART doses must be taken to avoid resistance to ART. If adherence poor 61-67.
T
EA
ART side effects Every visit after starting ART • Ask about ART side effects 62. Manage side effects as on symptom page. Refer if “self-limiting” side-effects persist after 6 weeks 61-67.
• Consider reporting a severe adverse drug reaction. Discuss with Drug Regulatory Unit, tel +267-363-2383/2378/2381.
• If signs of hepatitis: nausea, vomiting, jaundice, abdominal pain, stop all ART, TB treatment, co-trimoxazole and refer same day.
Mental health At diagnosis and if adherence poor R

• Look for lactic acidosis in adherent woman who gains > 10kg 6–24 months after starting d4T, AZT, 3TC/FTC or ABC 61-67.
T
• Screen for depression if patient has low mood or not coping as well as in the past 88.
H I V
• If patient takes ≥ 21 drinks/week (man), 14 drinks/week (woman), binge drinks or misuses drugs, assess for substance abuse
• If patient has problems with memory and perhaps coordination for > 6 months, consider dementia 92.
89.
6
Safe sex Every visit • Demonstrate and provide male and female condoms. Encourage patient to have only 1 partner at a time, and to encourage partner to test for HIV.
1
Pregnancy status Every visit • If needed, advise reliable contraception (injectable plus condoms) 94.
0
• If pregnant, give antenatal care 97 and ART 61-67. Discuss plans for contraception post-delivery 101.
2
• If wanting to fall pregnant and on EFV, if VL < 400, consider switch to NVP if CD4 > 250; or to LPV/r if CD4 ≤ 250.
E
End-of-life At diagnosis; if deteriorating If patient deteriorating or failing 3rd line ART and you would not be surprised if s/he died within the next year, also give end-of-life care 107.
Weight Every visit
T H
• Record weight. Investigate weight loss ≥ 5% of body weight in 4 weeks 3.
• To calculate BMI, enter into calculator: weight (kg) ÷ height (m) ÷ height (m). If < 18.5, refer for nutritional support.
O
Stage Every visit • Stage to treat HIV. Check the following to stage the patient: weight, mouth, skin, previous and current problems 62.
T
• Stage 3 and 4: give co-trimoxazole and ART. Do not wait for CD4 result before starting ART.
R
Pap smear If none in past 3 years Check Pap smear regardless of age in the HIV patient 27. If normal repeat 3 yearly.
Pre-ART CD4
F E
• Same day as diagnosis • If pre-ART CD4 ≤ 200, give co-trimoxazole.
E
• CD4 350–500: 3 monthly • If pre-ART CD4 ≤ 350, give ART.
• CD4 > 500: 6 monthly • If CD4 > 350, ensure patient has an appointment to return and understands the importance of regular follow-up.
Syphilis
ART bloods R At diagnosis
When eligible for ART and on ART
64.
• If RPR positive, treat patient and partner/s for syphilis 28.
• Before starting ART, check FBC, AST/ALT, creatinine clearance (TDF), and total cholesterol, triglycerides and glucose (LPV/r) 64.
• Check AST/ALT monthly for the first 3 months of TB treatment when on ART.
• Check hepBsAg if due to switch from TDF, 3TC or FTC.
• Check VL 4 weeks after switching/restarting ART or continuing ART after treatment failure. If VL is < 400, continue VL monitoring as usual 64. If VL ≥ 400, discuss with specialist.
Continue to assess the patient with HIV 62.

Stage 1 Stage 2 Stage 3 Stage 4: AIDS
• No symptoms • Recurrent sinusitis • Current pulmonary TB • Current extrapulmonary TB
N E
LI
• Painless swollen • Recurrent otitis media • Persistent oral thrush • Oesophageal thrush (pain on swallowing)
glands • Recurrent tonsillitis • Oral hairy leukoplakia • Weight loss ≥ 10% and diarrhoea or fever > 1 month
E
• Pruritic papular eruption 43 • Unexplained weight loss ≥ 10% body weight and/or BMI < 18.5 • Pneumocystis pneumonia
D
• Fungal nail infections • Diarrhoea > 1 month • Herpes simplex of mouth or genital area > 1 month
UI
• Shingles: 1st episode, 1 • Fever > 1 month • Kaposi’s sarcoma
dermatome • Severe recurrent bacterial infections (pneumonia, meningitis, • HIV associated dementia
• Recurrent mouth ulcers PID) • Recurrent severe pneumonia
• Seborrhoeic dermatitis
• Unexplained weight loss of
• Unexplained Hb < 8, neutrophils <0.5, or platelets < 50
• Shingles that is recurrent or involving the eye or > 1 dermatome
T G • Invasive cervical cancer

• Cryptosporidium or isospora belli diarrhoea
N
< 10% body weight
M E
T
Identify and manage ART side effects
EA
Antiretroviral Dose and frequency If repeat CrCl < 50 Side effects (refer if "self-limiting" side-effects persist after 6 weeks)
R
Nevirapine (NVP) 200mg once daily for 2 weeks, then if well Same dose Skin rash, nausea (self limiting, take with food), abdominal pain, jaundice or vomiting may be hepatitis – advise patient to
T
increase to 12 hourly return urgently and refer same day.
V
Efavirenz (EFV) 600mg once daily – same time every night Same dose Dizziness, sleep problems, depression (all self limiting), gynaecomastia
HI
Tenofovir (TDF) 300mg once daily Avoid TDF Nausea, vomiting, diarrhoea (self limiting), kidney failure (refer)
Emtricitabine (FTC) 200mg once daily Uncommon
16
Lamivudine (3TC) 150mg 12 hourly or 300mg once daily CrCl 30–50: 150mg daily Uncommon
0
CrCl 15–29: 100mg daily
2
CrCl < 15: 50mg daily
E
Zidovudine (AZT) 300mg 12 hourly CrCl < 15: 300mg daily Lactic acidosis, vomiting, nausea (self limiting, take with food), headache, fatigue (self limiting, if Hb < 7 64), body shape
TH
change (consider switch to TDF, discuss with specialist)
Lopinavir/ritonavir (LPV/r) 400/100mg (2 tablets) 12 hourly. On TB treatment, Same dose Diarrhoea, change in body shape (consider switch to TDF, discuss with specialist). Abdominal pain, jaundice or vomiting may
double the dose to 4 tablets 12 hourly. be hepatitis or pancreatitis – refer same day.
TO
R
Advise the patient with HIV
E
• Support by encouraging disclosure and referring to counselor/support group. Encourage patient to identify an adherence partner.
F
• Encourage patient to have 1 partner at a time. Advise safer sex even if partner is HIV positive or patient on ART. Demonstrate and give male/female condoms.
E
• Educate patient that treatment for HIV requires lifelong adherence and regular attendance for follow-up checks.
R
• Antiretroviral therapy may lead to increased cardiovascular risk. Help the client to assess and manage his/her CVD risk 71.
• Ensure the patient about to start ART attends adherence counselling.
• Give intensified adherence support to the patient with < 80% adherence, poor attendance (> 1 missed appointment) or viral load > 400:
--Educate on the importance of adherence and dangers of resistance. --Refer patient to adherence counselor and support group.
--Re-explain treatment schedule (including weekends). --Arrange a home visit by counselor or adherence partner.
--Consider adherence aids (pillboxes, diaries cellphone alarms). --Consider depression and/or substance abuse.
--Ask about drug-related side-effects below. --See the patient more frequently (weekly instead of monthly).

HIV
The unconscious patient Treat the patient with HIV
E
• Give co-trimoxazole 960mg daily (2 single-strength tablets) if stage 3 or 4 or CD4 ≤ 200. Adjust dose if CrCl 10-50: 480mg daily; if CrCl < 10: 480mg 3 times a week. If allergic, refer for dapsone.
N
• If the patient not on ART has CD4 > 350 and stage 1 or 2 and is not pregnant, s/he does not need ART. Otherwise start or continue ART according to the algorithm below.
LI
• If patient is > 28 weeks pregnant not on ART, start AZT 300mg 12 hourly same day while waiting for baseline blood results and adherence counselling. Once ready to start ART, switch from AZT.
Choose ART Regimen
D E
UI
• Start ART if not on ART and one or more of: CD4 ≤ 350 and/or stage 3 or 4 and/or pregnant.
• Before starting, restarting or switching ART, check baseline bloods 61, 67. If results abnormal, doctor to review and discuss with a specialist if necessary.
G
• A nurse trained in ART care may start a patient on ART if all of the following: CD4 150-350; stage 1; completely well, not pregnant, never had ART before and has normal baseline bloods.
• Has patient had any ART before (other than single dose NVP when pregnant in past 6 months)?
Never had any ART before or Patient has had ART

N T
Patient is currently on ART
had single dose NVP during
pregnancy in the past 6
before (other than single
dose NVP in past 6
M E Has s/he failed his/her current ART regimen?
T
months. months), not on ART now.
No Yes
EA
Is patient currently on a d4T-based regimen? Is patient on 2nd line ART, or did she have
• Start 1st line FTC (or 3TC) + single dose NVP during pregnancy?
TR
• If patient stopped ART
TDF + EFV unless: due to adverse drug No Yes
• Single dose NVP in past 6 reaction, discuss new Was patient started on triple antiretroviral prophylaxis No to both Yes to either
V
months: give instead TDF + ART regimen with
I
(TAP) during pregnancy with baseline CD4 > 350 and
FTC/3TC + LPV/r. specialist. stage 1 or 2 HIV?
H
• Patient wishes to be • Currently on Refer to
• If patient defaulted • Failed 1st line TDF +
d4T + 3TC/ddI
6
pregnant or is < 14 weeks explore reasons for specialist for
No Yes + EFV/NVP: if VL FTC/3TC + EFV/NVP:
ART switch.
1
pregnant: Replace EFV with stopping ART and give switch to standard
< 400 switch to
0
NVP if CD4 ≤ 250; if CD4 intensified adherence 2nd line AZT + 3TC
> 250, give LPV/r. If CD4 > TDF + FTC +
2
support 62. Restart + LPV/r.
350 and stage 1 or 2, delay • If planning Continue ART until EFV/NVP
same ART regimen
E
pregnancy and on at least 6 weeks post • Currently on • Failed 1st line AZT
ART (triple antiretroviral when patient is ready. + 3TC + EFV/NVP:
delivery if never d4T + ddI +
H
prophylaxis TAP) until > 14 • If patient was on EFV, only if VL < 400
consider switch to breastfed or 6 weeks LPV/r: if VL < switch to TDF +FTC
T
weeks pregnant. triple antiretroviral + LPV/r.
• Previous/current depression NVP if CD4 ≤ 250; or after last breastfeed. 400 switch to
prophylaxis during
O
to LPV/r if CD4 > 250. • If patient is well and TDF + FTC + • Failed 1st line ABC
87, psychosis 90 or pregnancy, restart same
T
• If new on NVP, still stage 1 or 2, LPV/r. + 3TC + EFV/NVP:
suicide attempt 49: ART regimen. switch to TDF +FTC
increase to 200mg 12 stop ART as follows:
R
Replace EFV with NVP if • If restarting NVP and + LPV/r.
hourly if well. stop EFV/NVP and
E
CD4 ≤ 250 (woman), ≤ 400 patient stopped ART • If patient on any
• Double dose of continue 3TC/FTC + Review after 1
F
(man); otherwise with LPV/r. > 2 weeks previously, other 1st line
LPV/r for duration of AZT/TDF for 1 more month.
E
• CrCl < 60 on 2 occasions. give a once daily dose regimen, refer to
TB treatment. week, then stop.
R
Replace TDF with AZT. See for 2 weeks and then specialist for ART
dose adjustments for AZT • If patient is well, • If patient was unwell
increase to 12 hourly. switch.
and 3TC 62. adherent and VL < on ART, is now stage
• On carbamazepine – refer 400, review: 3 or 4 or CD4 ≤
to change anticonvulsant. Review after 2 weeks. --3 monthly if on 350, continue ART
ART < 2 years and discuss with Review after 1 month.
--6 monthly if on specialist.
Review after 2 weeks. ART > 2 years.

The unconscious patient Once on ART, check blood according to ART regimen and review result
2 weeks on ART 1 month on ART 3 months on ART 6 months on ART 1 year on ART After 1 year on ART
N E
LI
NVP: AST/ALT AZT: FBC Viral load Viral load Viral load Viral load 6 monthly
E
NVP/EFV: AST/ALT CD4 CD4 CD4 CD4 6 monthly. If > 300 twice, then yearly
AZT: FBC TDF: CrCl TDF: CrCl TDF: CrCl 6 monthly
NVP/EFV: AST/ALT
TDF: CrCl
AZT: FBC
LPV/r: fasting cholesterol & triglycerides, glucose
UI D
AZT: FBC yearly
LPV/r: fasting cholesterol & triglycerides, glucose yearly
T G
Test
ALT/AST
Normal result
< 50
Doctor to manage an abnormal result
• If baseline ALT/AST ≥ 100, discuss with specialist before starting ART.
E N
TM
• If ALT/AST 50–200 and client well: continue ART (if only once daily NVP, do not increase to 12 hourly) and repeat ALT/AST after 1 week.
• If ALT/AST > 200 or nausea, vomiting, abdominal pain, jaundice: stop ART, co-trimoxazole and TB treatment. Discuss same day with specialist.
EA
CrCl > 60 • Calculate creatinine clearance: 140 – age (years) × weight (kg) ÷ creatinine. Multiply by 1.22 (man) or 1.037 (woman).
R
(creatinine clearance) • If baseline CrCl < 60, repeat the test and calculation. If still < 60, avoid TDF and adjust doses of ART and co-trimoxazole 61. Recheck CrCl after 3 months and if still < 60
discuss with specialist.
• Once on ART, refer urgently if CrCl < 50.
V T
I
Full blood count (FBC) Hb > 10 Platelets > 150 • If Hb < 7 discuss with specialist. Exclude TB. If pregnant, consider referring for blood transfusion.
H
WBC > 1000
6
HepBsAg negative If HepBsAg positive, do not stop TDF or 3TC/FTC. Discuss with specialist.
1
Total cholesterol, TC < 4.5 • If TC > 5, assess and manage CVD risk 72-74.
0
triglycerides • If client needs a cholesterol-lowering drug, refer for atorvastatin.
Glucose <7 • Interpret the result
276. If glucose > 7 or client diagnosed with diabetes, discuss ART with specialist.
HE
Viral load < 400 if on ART for > 6 If VL ≥ 400, recall the patient immediately (do not wait for routine visit) and do a confirmatory priority viral load. Intensify adherence support 62.
months • If client on 2nd line ART regimen: if VL still > 400, refer to specialist for further care.
O T • If client on 1st line ART regimen:

--If confirmatory VL is the same log or higher, switch to 2nd line ART 61. Do not delay switching to second line.
T
--If confirmatory VL has dropped by at least 1 log (10-fold, like from 10 000 to 1 000), continue on regimen 1 and recheck in 4 weeks.
--If repeat VL continues to drop, repeat 4 weekly until < 400. If repeat VL does not continue to drop, switch to 2nd line ART 61-67.
CD4
E R • Stop co-trimoxazole prophylaxis if client on ART has CD4 > 200 for 3 months, is well and is not on TB treatment.
F
Lactate < 2.5 • Hyperlactataemia/lactic acidosis presents with vague symptoms like weight loss, nausea, vomiting, abdominal pain, shortness of breath and fatigue.
E
• Consider lactic acidosis in the adherent woman who gains > 10kg 6-24 months after starting d4T, ddI, AZT and less often, 3TC or TDF.
R
• If available, check rapid/on-site venous blood lactate (uncuffed). If not available, refer same day:
--< 2.5: if > 1 symptom above, refer for laboratory lactate. Look for other cause. Repeat after 1 week.
--≥ 5: refer same day for further management.
--2.5–4.9: Check respiratory rate:
--RR ≥ 20 breaths/minute: Refer same day for further management.
--RR < 20 breaths/minute: Switch d4T, ddI or AZT to TDF and recheck lactate after 3 days. If lactate falls and symptoms improve, recheck weekly until normal. If symptoms
worse and/or lactate is increasing, stop ART and discuss with specialist.

HIV
Revised Guidance For Adherence Counseling With “Treat All”
N E
LI
The adoption of “Treat All” could see increases in the numbers of patients who default treatment or exercise poor adherence unless health care providers who initiate ART clearly educate patients on
the importance of both early treatment and strict adherence. Patients should be made to understand the following:
• Early initiation of ART may decrease mortality and morbidity by more than 60%
D E
UI
• Early initiation of ART will decrease the chances of contracting TB and cancer.
• Early initiation of ART will protect their sexual partners from HIV transmission
• That although they may be healthy now – initiating ART is currently the only way known to prevent the eventual decline of immune function and development of opportunistic infections.
Recommendations for “Treat All” Adherence Counseling: Cardiovascular Disease,

T G Elevated lipids can appear within the first
Educate and discuss the following topics with all patients before initiating ART:
1. For now, there is no cure for HIV.
ART & HIV
E N
All classes of ART can cause
months of initiating ART
• The most significant lipid abnormalities occur
M
2. Without taking the HIV prevention precautions, HIV-infected people can easily pass HIV to elevated total cholesterol with d4T, AZT and PIs, including LPV/r.
T
their sexual partners. (TC) and triglycerides (TG), • NNRTIs may cause relatively minor increases in
EA
3. Taking ART is a life-long commitment which may lead to serious cholesterol (EFV > NEV).
4. Although they may not be sick now, it is just a matter of time before HIV willdestroy their long term, cardiovascular • Atazanavir and integrase inhibitors (RAL & DTG)
immune system and cause opportunistic infections and/or cancers. and/or cerebrovascular
R
are most lipid friendly
5. Defaulting from treatment will decrease their chances for remaining disease free despite disease. Cardiovascular
T
• Elevated TG may cause pancreatitis
HIV infection and enjoying a normal life expectancy. relatedmorbidities,
V
6. Whenever their life circumstances change and they want to stop ART, they should first seek regardless of whether they
HI
the advice of their healthcare providers. are related to ART or not,
7. People who start ART when they are healthy with higher CD4 counts,experience less side must be addressed promptly Before initiating PI based ART
• Determine the baseline non-fasting lipid
6
effects to ART. including modification of
profile: TC, LDL-C, HDL-C and TG.
1
8. HIV-infection is a chronic disease that must be managed like any other chronic disease, vascular risk factors such as
• Inquire about any family history of heart
0
with regular medical consultations and adherence to medications. prior stroke, heart attack,
related disease, diabetes mellitus II.
2
9. Patients should seek mental health support when their circumstances cause depression, peripheral arterial disease,
self-stigma and/or the desire to stop taking ART. smoking, hypertension,
E
10. Life-long ART is only guarantee there is for HIV-infected people to live normal, happy and diabetes, BMI >25 and
H
healthy and lives. elevated weight-hip ratio
T
(Males >94cm, Females Screen all patients on PI-based ART annually
>80cm). Clinically significant LDL thresholds/goals vary
O
Ensure that all Patient Information (including cell phone numbers) according to the presence of known vascular
T
is current for purposes of tracking patients as necessary. risk factors or disease according to the following
CVD risk groups:
E R
E F
R
New Guideline for Adult and Adolescent (>40kg), Paediatric ART Regimens
Until officially notified otherwise, keep all stable patients (those who are virally suppressed without toxicities or history of poor adherence) on their current their ART
regimens. Beginning in 2017, older ART regimens will begin to be phased out. Information regarding prioritization for treatment groups and all treatment options will be
communicated by the Ministry of Health at a later date.
However, patients on older ART regimens who develop toxicities should be switched to DTG containing regimens, whenever possible. NRTI backbones for these treatment switches must be
made based upon previous treatment histories and the presence of full virological suppression. Seek advice from HIV Specialists as required.

Table 1: ART Regimens for New and Previously Initiated Adults and Adolescents
ALL ADULTS& ADOLESCENTS (>40kg) 1st Line 1st Line Modifications
N E
2nd Line
LI
Initiations Beginning 2016 Truvada + Dolutegravir TDF renal toxicity w/o CVD risk: Based on Resistance Testing Results &
E
ABC/FTC/DTG Consultation with HIV Specialist
D
(Including pregnant women)
UI
TDF renal toxicity or insufficiency withCVD risk or DTG
Toxicity:
G
Discuss w specialist
All Adults Failing 1st Line with DTG containing regimens will be resistance tested to determine 2nd line with assistance from an HIV specialist.
ALL ADULTS& ADOLESCENTS (>40kg) 1st Line 1st Line Modifications

N T 2nd Line 2nd2Line
nd Line Modifications
Initiations Prior to 2016 TDF/FTC/EFV
M E
TDF renal toxicity w/o CVD risk: CBV/ALU AZT Anemia and/or
T
TRU/NVP ABC/FTC/DTG (If CVD rish: Consult HIV specialist) TRU/ALU TDF Renal Toxicity: ABC/FTC/DTG
CBV/EFV
EA
CBV/NVP CNS Toxicity and/or Hepatic Toxicity: CBV/ATA/r AZT Anemia and/or
ABC/3TC/NVP TRU/DTG TRU/ATA/r TDF Renal Toxicity: ABC/FTC/DTG
ABC/3TC/EFV
T R
All adult 2nd Line failures (regardless of their regimens) will be resistance tested to determine 3rd line with assistance from an HIV specialist.
Notes:
H I V
Document complete treatment histories into all patient charts, noting dates of toxicities, defaults, treatment failures.
6
Diabetics on Metformin must have dosage reduced (maximum daily dose 1,000mg) discuss with HIV specialist
1
Creatinine Clearance Calculation: MALES: (140-age) x Body Wt in Kg FEMALE: Male formula x 0.85 Serum Creatinine x 72
2 0
Table 2: ART Regimens for New and Previously Initiated Children and Infants
PEDIATRICS Age Weight
H E 1st Line 1st Line Modifications for toxicities 2nd Line
T
Initiations <3 years ABC/FTC/NVP* ABC or NVP Rash: Based on R Testing Results & Consultation with HIV Specialist
Beginning 2016 CBV/ALU
TO
>3 yrs ABC/FTC/EFV ABC Rash: CBV/EFV
R
<40Kg CNS Toxicity: ABC/FTC/ALU
F E
All Pediatric Patients Failing 1stLine regardless of their regimen will be Resistance Tested to determine 2nd line with assistance of HIV specialist. *Except infants whose mothers received sdNVP – then 1st Line ABC/FTC/ALU
Initiations
Prior to 2016
E
PEDIATRICS(>40kg)
R >3 yrs
<40kg
Age Weight
CBV/EFV
CBV/NVP
1st Line 1st Line Modifications for toxicities
AZT Anemia: ABC/FTC/EFV or NVP

EFV CNS: BV/ALU
CBV/ALU
ABC/ALU
2nd Line 2nd Line Modifications
2nd Line
ABC/FTC/NVP ABC Rash: CBV/FTC/EFV or NVP CBV/ATA/r AZT Anemia and/or

ABC/FTC/EFV EFV CNS: TRU/ATA/r TDF Renal Toxicity: ABC/FTC/ATA/r
EFV CNS: CBV/ALU
All adult 2nd Line Failures regardless of their regimens will be Resistance Tested to determine 3rd line with assistance of HIV Specialist

HIV
Asthma and copd: diagnosis
• The patient with chronic cough may have more than one disease. First exclude TB, PCP, lung cancer, bronchitis, heart failure and post-infectious cough 16.
• Then consider asthma or chronic obstructive pulmonary disease (COPD) which both present with cough, difficult breathing, tight chest or wheeze. Distinguish COPD and asthma as follows:
Asthma likely if: COPD likely if:

• Onset before 20 years of age • Onset after 40 years of age
• Associated hayfever, eczema, allergic conjunctivitis, allergies • Symptoms are persistent and worsen slowly over time
• Intermittent symptoms with normal breathing in between • Cough with sputum starts long before difficult breathing
• Symptoms worse at night, early morning, with cold or stress • Patient is or was a heavy smoker (tobacco/marijuana) or miner
• Patient or family have a history of asthma • Previous doctor diagnosis of COPD
Give routine asthma care 66. Give routine COPD care 67.
Doctor to confirm diagnosis. If unsure of diagnosis, treat as asthma66 and refer to doctor within 1 month.
Using inhalers and spacers

• Add a spacer if the patient is unable to use an inhaler correctly to increase drug delivery to the lungs and/or if using inhaled corticosteroids to prevent oral thrush.
• Make a spacer from a plastic bottle that fits permanently into the inhaler mouth. Prime the spacer initially with 15 puffs of medication. When the medication is finished, replace only the canister.
• Clean the spacer weekly: remove the canister and wash spacer with soapy water. Allow it to drip dry. Do not rinse with water after each use. Prime the spacer with two puffs after washing before use.
How to make a spacer from a plastic bottle How to use an inhaler with a spacer
• Wash a 500ml plastic • Wind a steel wire around • Shake inhaler and • Breathe out. Then
cold-drink bottle with the open mouth of spacer. form a seal with lips
soapy water. inhaler to form a mould. around mouthpiece.
• Leave to air-dry for 12 • Keep some wire for a
hours. handle.
• Discard the lid. • Heat the mould with a
1 2 flame until it is red hot. 1 2
• Apply the hot mould • Insert mouth of inhaler • Press pump once and • Hold that breath and
to the bottom end immediately to create take a deep breath count up to 10.
of the bottle for 10 a tight fit. from spacer. • Then breathe out.
seconds then rotate • Apply quick-setting • Do not pump inhaler • Rinse mouth after
180˚ and reapply until glue to seal the inhaler more than once for using inhaled
the plastic melts. permanently to the each breath. corticosteroids.
3 4 spacer. 3 4

The unconscious
Asthma: patient
routine care
• Ensure that a doctor confirms the diagnosis of asthma within 1 month of diagnosis.
Assess the patient with asthma

Asthma symptoms to Every visit • Any of the following in the past month indicate uncontrolled asthma:
determine if asthma is --Daytime cough, difficulty breathing, tight chest/wheezing or using salbutamol inhaler > twice a week
controlled --Nighttime or early morning waking due to cough, difficulty breathing, tight chest or wheezing
--Limitation of daily activities due to asthma symptoms
• Peak flow measurement can be unreliable and need not be used routinely to assess asthma control. Asthma symptoms are more useful.
Other symptoms Every visit • Manage symptoms as on symptom pages.
• Ask about hayfever: sneezing, itchy or runny nose. Treating hayfever may improve asthma control 13.
• Ask the patient using inhaled corticosteroids about a sore mouth 14. See advice below.
• Ask about heartburn or upper abdominal pain on eating. Treating gastroesophageal reflux may improve asthma control 19.
Medication use Every visit • Ensure patient is adherent to treatment before adjusting or adding treatment.
• Check that patient can use inhaler and spacer correctly 65.
Advise the patient with asthma

• Ask about
BOTSWANA smoking.
PRIMARY If yes, urge
CARE GUIDELINE FORpatient
ADULTSto stop. Also advise patient to avoid other possible triggers for asthma like dust, cockroaches, burning rubbish, cooking smoke.
2016
• Ensure the patient understands the need for medication and which to use for symptoms and prevention:
--Salbutamol inhaler only relieves symptoms and does not control asthma.
--Inhaled corticosteroid (eg budesonide or beclomethasone) prevents symptoms and controls asthma, but does not give instant relief. It is the mainstay of treatment.
• Check that patient can use inhaler and spacer correctly 68. Advise patient to always carry salbutamol inhaler.
• Inhaled corticosteroids can cause oral thrush: advise patient to rinse and gargle after each dose of inhaled corticosteroid.
Treat the patient with asthma

• Give inhaled Salbutamol 2 puffs as needed up to 4 times a day.
• If asthma is uncontrolled, refer to doctor to consider adding low dose Inhaled Corticosteroid(ICS)
--Before adjusting treatment ensure patient is adherent and can use inhaler and spacer correctly 68.
--Start inhaled corticosteroid Budesonide or Beclomethasone 200μg 12 hourly if patient not already on it with salbutamol as needed for a reliever only.
--If patient already on Inhaled Corticosteroid, and not still controlled, doctor to step-up to inhaled Fluticasone/Salmeterol or Beclomethasone to maximum 400μg 12 hourly.
--Or alternatively doubling the dose of ICS. Inhaled Salbutamol to be used as needed. If again not controlled, step up to medium or high dose of ICS/LABA and Inhaled Salbutamol as needed.
• If asthma is controlled:
--Continue inhaled corticosteroid at the same dose for at least 6 months.
--If controlled for at least 6 months, decrease inhaled corticosteroid dose by half or lower dose of ICS/LABA. However one can continue with the same dose for ≥6 months if there is exacerbations.
--Stop inhaled corticosteroid if controlled for at least 6 months on 100μg daily - review in 1 month
--Inhaled corticosteroids are not needed for the patient with controlled exercise-induced asthma who has had no emergency visits for asthma in the past 6 months.
• Oral corticosteroid (OCS)
-- Prednisolone is only used for emergency visits for asthma. Refer to doctor if needing more than 2 courses of OCS within 6 months.
Review the controlled patient 3 monthly, the patient whose asthma is uncontrolled after 1 month.
Advise patient to return before next appointment if no improvement or worsening of symptoms.

CHRONIC RESPIRATORY
DISEASE
Chronic obstructive pulmonary disease (copd): routine care
• Ensure that a doctor confirms the diagnosis of COPD within 1 month of diagnosis.
Assess the patient with COPD

COPD symptoms: persistent Every visit • Assess disease severity: difficulty breathing occurs with strenuous activity like climbing stairs (mild COPD), at normal pace like walking (moderate COPD)
cough and difficult breathing or with activities of daily living like dressing (severe COPD).
• In patient with cough:
--Treat for chest infection as below if cough increases with fever and/or sputum increases or changes in colour to yellow/green.
--Investigate for TB only if patient has other TB symptoms like weight loss, sweats 55.
Other symptoms Every visit • Manage symptoms as on symptom pages.
• Ask the patient using inhaled corticosteroids about a sore mouth and look in the mouth for thrush 14. See advice below.
• If patient has leg swelling, refer to doctor for assessment.
Medication use Every visit • Ensure patient is adherent to treatment before adjusting or adding treatment.
CVD risk assessment At diagnosis • The patient with COPD is at increased risk of cardiovascular disease.
• Assess the patient’s CVD risk 71.
End-of-life care At diagnosis, every visit If patient has severe COPD, > 3 hospital admissions for COPD in 1 year and/or heart failure and you would not be surprised if s/he died within the next year,
also give end-of-life care 107.
Advise the patient with COPD

• Ask about smoking. If yes, urge patient to stop. This is the mainstay of COPD care. Also advise patient to avoid cooking smoke and dust 103.
• Exercise: 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 75.
• Inhaled corticosteroids can cause oral thrush: advise patient to rinse and gargle after each dose of inhaled corticosteroid.
Treat the patient with COPD

• Ensure patient can use inhaler and spacer correctly before adjusting treatment 65.
• Give bronchodilator inhaled Salbutamol 2 puffs when needed (up to 4 times a day).
• Add bronchodilator inhaled Ipratropium Bromide 2 puffs when needed (up to 4 times a day) if moderate or severe COPD.
• Treat for chest infection if sputum increases or changes in colour to yellow/green:
--Give Amoxicillin/Clavulanic Acid 250/125mg (375) and Amoxicillin 500mg 8 hourly for 10 days.
--If already symptomatic for > 2 weeks, give also Doxycycline 100mg 12 hourly for 10 days.
--Give oral Prednisolone 40mg daily for 7 days if severe COPD.
• Doctor to give Inhaled Corticosteroid Budesonide 100µg or Beclomethasone 400µg 12 hourly if moderate or severe COPD and ≥ 2 chest infections or emergency visits for COPD per year.
Review every 3–6 months if stable. If available offer Influenza vaccine & PCV 13, 53 for asthma and COPD

Cardiovascular disease (cvd) risk: diagnosis
Check CVD risk if the patient has any of: > 40 years, smoker, BMI > 25, hypertension and/or parent or sibling with diabetes or premature CVD (man < 55 or woman < 65)
Identify the patient with established cardiovascular disease:
• If patient has or has had chest pain, screen for ischaemic heart disease.
• If patient has or has had leg pain, screen for peripheral vascular disease.
• If patient has had sudden weakness of limb/s or face, visual disturbance, difficulty communicating, dizziness or headache, screen for stroke.
Look for risk factors for cardiovascular disease:
• Ask about smoking 103.

• Look for hypertension. Hypertension is diagnosed at different BP levels depending on risk factors. Check BP.
• Calculate BMI: on calculator enter weight (kg) ÷ height (m) ÷ height (m). More than 25 is a risk factor.
• Measure waist circumference on breathing out midway between the lowest rib and the top of the iliac crest. More than 80cm (woman) or 94cm (man) is a risk factor.
• Check random finger prick glucose for diabetes and interpret result 70.
• Check random total cholesterol, if available.
Calculate the patient’s risk of a heart attack or stroke over the next 10 years:
• Plot the patient's risk on the charts below using age, sex, systolic BP (SBP) and smoking status. If cholesterol testing available, use the cholesterol-based charts.
• Do not use these charts if the patient is known to have diabetes and/or CVD as s/he already has a CVD risk > 30%.
How do you use the charts to assess cardiovascular risk?
• The charts provide approximate estimates of CVD risk in people who do not have established coronary heart disease, stroke or other atherosclerotic disease. They are useful as tools to help identify those at
high cardiovascular risk, and to motivate patients, particularly to change behavior, and when appropriate, to take antihypertensive, lipid-lowering drugs and aspirin.
Before applying the chart to estimate the 10 year cardiovascular risk of an individual, the following information is necessary:
• Presence or absence of diabetes.

--A person who has diabetes is defined as someone taking insulin or oral hypogly¬caemic drugs or with a fasting plasma glucose concentration above 7.0mmol/l(126 mg/dl) or a postprandial
(approximately 2 hours after a main meal) plasma glucose concentration above 11.0 mmol/l (200 mg/l) on two separate occasions).
--For very low resource settings Urine Sugar test may be used to screen for diabetes if blood glucose assay is not feasible. If urine sugar test is positive a confirmatory blood glucose test need to be
arranged to diagnose diabetes mellitus.
--All current smokers and those who quit smoking less than 1 year before the assess¬ment are considered smokers for assessing cardiovascular risk.

CHRONIC DISEASES
OF LIFESTYLE
How Do You Use The Charts To Assess Cardiovascular Risk?
Age ≥40 years
Systolic blood pressure (SBP)

--Systolic blood pressure, taken as the mean of two readings on each of two occasions,
Total blood cholesterol (if in mg/dl divide by 38 to convert to mmol/l).

--The mean of two non-fasting measurements of serum cholesterol by dry chemistry, or one non-fasting laboratory measurement, is sufficient for assessing risk.
--Once the above information is available proceed to estimate the 10-year cardiovascular risk as follows:
-- Step 1 Select the appropriate chart depending on the presence or absence of diabetes
-- Step 2 Select male or female tables
-- Step 3 Select smoker or non-smoker boxes
-- Step 4 Select age group box (if age is 50-59 years select 50, if 60-69 years select 60 etc)
-- Step 5 Within this box find the nearest cell where the individuals’ sys¬tolic blood pressure (mm Hg) and total blood cholesterol level (mmol/l) cross.
THE COLOUR OF THIS CELL DETERMINES THE 10 YEAR CARDIOVASCULAR RISK.

10 Year Risk Of Cardiovascular Event
When resources are limited, individual counselling and provision of care may have to be prioritized according to cardiovascular risk.
Risk Level
<10%1 Individuals in this category are at low risk. Low risk does not mean “no” risk. Conservative management focusing on lifestyle interventions is suggested b.
10–20% Individuals in this category are at moderate risk of fatal or non-fatal vascular events. Monitor risk profile every 6–12 months.
20–30% Individuals in this category are at high risk of fatal or non-fatal vascular events. Monitor risk profile every 3–6 months.
>30% Individuals in this category are at very high risk of fatal or non-fatal vascular events. Monitor risk profile every 3–6 months
b
Policy measures that create conducive environments for quitting tobacco, engaging in physical activity and consuming healthy diets are necessary to promote behavioural change.
They will benefit the whole population. For individuals in low risk categories, they can have a health impact at lower cost, compared to individual counseling and therapeutic approaches.
b
BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016
Policy measures that create conducive environments for quitting tobacco, engaging in physical activity and consuming healthy diets are necessary to promote behavioural change.
71
They will benefit the whole population. For individuals in low risk categories, they can have a health impact at lower cost, compared to individual counseling and therapeutic approaches.
72
WHO/ISH
WHO/ISH risk prediction
risk prediction chart forAFR
chart for Sub-regions Sub-regions
E. AFR E.
Botswana, Burundi, Central African Republic, Congo, Côte d’Ivoire, Democratic Republic of The Congo, Eritrea, Ethiopia,
Botswana, Burundi, Central African Republic, Congo, Malawi,
Kenya, Lesotho, Côte d’Ivoire, Democratic Republic of The Congo, Eritrea, Ethiopia, Kenya,
Mozambique,
Lesotho, Malawi,
Namibia,Mozambique,
Rwanda, SouthNamibia, Rwanda, Uganda,
Africa, Swaziland, South Africa,
UnitedSwaziland,
Republic ofUganda,
Tanzania,United Republic
Zambia, of Tanzania, Zambia, Zimbabwe
Zimbabwe
10-year risk of a fatal or non-fatal cardiovascular event byGender, age, systolic blood pressure, total blood
10-year risk of a fatal or non-fatal
cholesterol, cardiovascular
smoking eventorbyGender,
status andpresence absence of age, systolic
diabetes blood pressure, total blood
mellitus.
cholesterol, smoking status andpresence or absence of diabetes mellitus.
AFR E People with Diabetes Mellitus
Age Male Female SBP
(years) Non-smoker Smoker Non-smoker Smoker (mm Hg)
180
160
70 140
120
180
160
60 140
120
180
160
50 140
120
180
160
40 140
120
4 5 6 7 8 4 5 6 7 8 4 5 6 7 8 4 5 6 7 8
Cholesterol (mmol/l)
AFR E People without Diabetes Mellitus
Age
Male Female SBP
CHRONIC DISEASES
OF LIFESTYLE
180
160
70 140
120
180
160
60 140
120
180

160
50 140
120
180
160
40 140
120
4 5 6 7 8 4 5 6 7 8 4 5 6 7 4 5 6 7 8
Cholesterol (mmol/l)
WHO Region of Africa, sub-region E,
b
WHO Region of Africa, sub-region E,
BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS
73
WHO/ISH
WHO/ISH risk prediction
risk prediction chart for
chart for Sub-regions AFRSub-regions
E. AFR E.
Botswana, Burundi,
Botswana, Burundi, Central
Central African
African Republic,
Republic, Congo,
Congo, CôteCôte d’Ivoire,
d’Ivoire, Democratic
Democratic Republic
Republic of The of The Congo,
Congo, Eritrea, Ethiopia, Kenya,
Eritrea, Ethiopia,
Lesotho, Malawi, Mozambique, Namibia, Kenya, Lesotho,
Rwanda, Malawi,
South Mozambique,
Africa, Swaziland, Uganda, United Republic of Tanzania, Zambia, Zimbabwe
Namibia, Rwanda, South Africa, Swaziland, Uganda, United Republic of Tanzania, Zambia, Zimbabwe
10-year risk of a fatal or
10-year risk of a fatal or non-fatal non-fatal cardiovascularevent
cardiovascularevent by gender,
by gender, age, systolic bloodage,
and presence or absence of diabetes mellitusbutNo CHOLESTEROL
systolic
pressure, bloodstatus
smoking pressure, smoking
status and presence or absence of diabetes mellitusbutNo CHOLESTEROL
AFRE People with Diabetes Mellitus – Chart 2
Male Female
Age SBP
180
70 160
140
120
180
160
60 140
120
180
160
50 140
120
180
160
40 140
120
AFRE People without Diabetes Mellitus
Male Female
Age SBP
(years)
Non-smoker smoker Non-smoker smoker (mm Hg)
180
160
70 140
120
180
160
60 140
120
180
160
50 140
120

180
160
40 140
120
This chart can only be used for countries of the WHO Region of Africa, sub-region E,
in settings where blood cholesterol CANNOT be measured
This chart can only be used for countries of the WHO Region of Africa, sub-region E, in settings where blood cholesterol CANNOT be measured
b
BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS
Cardiovascular disease (cvd) risk: routine care
Assess the patient with CVD risk
Symptoms Every visit Manage symptoms on symptom page. Ask about chest pain 15, difficulty breathing 16, leg pain 36 and symptoms of stroke/TIA 82.
Risk factors Every visit Ask about smoking, diet, exercise and activities of daily living. 103
BMI Every visit BMI is weight (kg) ÷ height (m) ÷ height (m). If BMI >25 calculate target weight:: 25 x height(m) x height(m)
Waist circumference Every visit Measure waist circumference on breathing out midway between lowest rib and top of iliac crest. Aim for women <80cm and men <94cm
BP Every visit Diagnose and treat hypertension depending on CVD risk 75. If known hypertension give routine hypertension care 79.
CVD risk At diagnosis, then depending on risk If CVD risk < 10% repeat after 3 years, if 10-20% after 1 year, if > 20% after 6 months. If CVD risk still > 30% after 6 months refer.
Glucose At diagnosis, then depending on risk 76 Timing of repeat diabetes screen depends on risk factors 76. If known diabetes give routine diabetes care 77-78.
Total cholesterol 3 monthly if baseline > 5 Treat with statin if > 8. If repeat cholesterol ≥ 5, increase statin as below. If baseline or follow-up cholesterol < 5, no need to repeat.
Total cholesterol 3 monthly if baseline > 5 Treat with statin if > 8. If repeat cholesterol ≥ 5, increase statin as below. If baseline or follow-up cholesterol < 5, no need to repeat.
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 Manage stress
• Aim for at least 30 minutes brisk • Eat a variety of foods in moderation. • Perform a relaxing breathing
exercise at least 5 days/week. Reduce portion sizes. exercise each day.
• Increase activities of daily living like • Increase fruit, vegetables and low fat • Find a creative or fun activity
gardening, housework, walking dairy. to do.
instead of riding, using stairs • Reduce fatty foods: eat low fat food, • Spend time with supportive
instead of lifts. cut off animal fat, replace brick friends or family.
• Exercise with arms if unable to use margarine/butter with soft tub • If patient is stressed 52.
legs. margarine.
• Reduce salty processed foods like
Weight gravies, stock cubes, packet soup.
• Aim for BMI < 25, and Avoid adding salt to food. Screen for alcohol/substance misuse
waist circumference • Use less sugar. • Limit alcohol intake to 2 drinks/day (man) and
Smoking < 80cm (woman) and 1 drink/day (woman). 1 drink is 1 tot of spirits,
• Urge patient who < 94cm (man). Any weight a small glass of wine or 1 can of beer.
smokes to stop. reduction is beneficial, • If patient exceeds these limits or abuses illicit
103 even if targets not met. or prescription drugs 89, 104.
• Identify support to maintain lifestyle change: health education officer or dietician/nutritionist, 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 109.
Treat the patient with CVD risk

--Give the patient with CVD risk > 30% or total random cholesterol > 8 Simvastatin for life. Start 20mg daily and if cholesterol > 5 after 3 months, increase to 40mg.(alternative: Atovastatin, rosuvastatin
Follow-up 3 monthly until targets are met then 6–12 monthly. Refer if CVD risk remains > 30% after 6 months.

CHRONIC DISEASES
OF LIFESTYLE
Diabetes: diagnosis
Check finger prick blood glucose. Give urgent attention if glucose ≥ 15 and any of:
• Nausea and/or vomiting • Temperature ≥ 38˚C • Unconsciousness 1
• Abdominal pain • Drowsiness • BP < 90/60 and/or systolic BP drop > 20mmHg between
• Deep sighing breathing • Confusion lying and standing and poor urine output
Management:
• Rehydrate urgently: give Sodium Chloride 0.9% IV 1ℓ in first hour then 1ℓ over next 2 hours.
• Give 10IU Short-Acting Insulin IM (not IV).
interpret random glucose result and manage as follows:
Random glucose normal: 4–7.7 Random glucose: 7.8–11 Random glucose 11.1–25 Random glucose > 25
Look for risk factors: Is patient pregnant? Is patient pregnant?

• family history of diabetes
• history of diabetes in pregnancy No Yes No Yes
• BMI > 25 Does patient have urinary frequency, thirst, or hunger?
• hypertension
• waist circumference > 80cm
(woman), > 94cm (man) Patient needs No Yes • Ensure patient does not need urgent
antenatal care Repeat finger prick blood attention above.
and fasting glucose after 8-hour fast. • Check urine for ketones.
No risk Risk factors are glucose 99. • Refer patient same day.
factors present <7 ≥7
Diagnose diabetes
Recheck < 15 ≥ 15:

glucose in • Ensure patient does not
5 years. need urgent attention
above.
• Check urine ketones.
• May be at risk for diabetes. 1+ or more ketones:

• Do cardiovascular disease risk assessment 71. No/trace ketones
• Give Sodium Chloride 0.9% IV 1ℓ 4
• Repeat finger-prick blood glucose in 1 month. hourly(1 litre1st hr, then 1 litre over next 2 hrs
Start routine diabetes care 77. and then 1 litre over next 4 hours.)
• Give 10IU Short-Acting Insulin IM (not IV).
• Refer same day.

Diabetes: routine care
Assess the patient with diabetes
Symptoms Every visit Ask about chest and leg pain. Manage symptom as on symptom page.
BP Every visit Diagnose hypertension if ≥ 140/90 79. Treat to target <140/90 79.
BMI At diagnosis and yearly BMI is weight (kg)/[height (m) x height (m)]. Aim for BMI < 25.
Waist circumference Every visit Aim for < 80cm in woman and < 94cm in man.
Pregnancy status Every visit Discuss family planning needs 96. Refer for specialist care if pregnant.
Eyes for retinopathy At diagnosis, yearly and if visual problems develop Refer if new diabetes diagnosis, visual problems, cataracts or retinopathy.
Feet for neuropathy At diagnosis, yearly if no neuropathy, more often if present For foot screen and foot care education 37.
Random glucose Every visit Finger prick sample is adequate. See below: aim for < 8.
Protein on urine dipstick At diagnosis and yearly If proteinuria start enalapril 5mg daily regardless of BP, up gradually to 20mg if proteinuria persists and systolic BP > 100.
Ketones on urine dipstick If glucose ≥ 15 If glucose ≥ 15 and ≥ 1+ ketones, see below.
HbA1c At least yearly if stable; 3 months after start or change of treatment Aim for HbA1c < 7%. HbA1c reflects glucose control over past 3 months. See below.
Creatinine clearance At diagnosis and yearly Give patient’s age and sex on form. If CrCl < 60, refer to doctor.
Fasting total cholesterol and triglycerides At diagnosis if not already done. Refer to specialist if total cholesterol ≥ 8 or triglycerides ≥ 15.
Check random finger prick glucose at every visit and HbA1c at least yearly if stable but 3 months after change in glucose-lowering treatment.
Glucose ≤ 3.5 Glucose 3.6–14.9 Glucose ≥ 15

With/without hunger, palpitations, Review HbA1c result from within past 3 months. Is there any of nausea, vomiting, abdominal pain, hyperventilation,
sweating, tremors, fatigue, headache, difficult breathing, dehydration, fever, drowsiness, confusion, coma?
mood changes, fits, confusion,
drowsiness, coma. HbA1c ≤ 7% or not done in past 3 months HbA1c > 7%
No - check urine for ketones
Yes
Glucose < 8 Glucose 8–14.9 • Rehydrate urgently:
• Give sugar water orally or if Sodium Chloride 0.9%
unconscious give 50mℓ 50% No/trace ≥ 1+ ketones:
ketones IV (1ℓ in first hour, 1ℓ
Dextrose Water IV. • Review in 6 No HbA1c HbA1c • Give Sodium over next 2 hours).
• Identify cause and educate about months. < 3 months ≤ 7% Chloride 0.9% • Give 10IU Short-Acting
meals and doses 76-77. • Check HbA1c • Not adherent: educate and 1ℓ 4 hourly IV Insulin IM (not IV).
• Refer same day if incomplete yearly. review in 1 month. and 10IU Short-
Check HbA1c. Review in • Refer urgently to
recovery or on glibenclamide or • Adherent: step up Acting Insulin hospital.
Review in 3 months.
long-acting insulin. Continue 5% treatment and review in 1 IM (not IV).
1 month.
Dextrose Water 1ℓ 6 hourly IV. month 77. • Refer same day.

CHRONIC DISEASES
OF LIFESTYLE
Advise the patient with diabetes
• Encourage the patient to adhere to medication and to try to eat 4-6 small meals per day.
• Ensure patient can recognise and manage hypoglycaemia:
--If palpitations, sweats, headache or tremors, drink milk with 3 teaspoons of sugar or eat a sweet or sandwich. If fits, confusion or coma, rub sugar inside mouth.
--Identify and manage the cause: missed meals, inappropriate dosing of glucose-lowering drugs, alcohol, intercurrent illness like diarrhoea.
• Educate the patient to care for his/her feet to prevent ulcers and amputation 37.
• Refer patient to available helplines or support group.
Treat the patient with diabetes

• Give Aspirin 75-150mg daily if CVD or a family history of CVD, hypertension, smoking, dyslipidaemia, albuminuria or > 40 years. Avoid if < 30 years, previous peptic ulcer or dyspepsia or BP ≥ 180/110.
• Give Simvastatin 20mg regardless of cholesterol if patient has CVD, hypertension, smoking, obesity, and/or > 40 years. Avoid in pregnancy or liver disease.
• Give Enalapril first line for hypertension. If client has proteinuria, give 5 mg increasing gradually up to 20 mg if proteiuria persists and systolic BP remains >100.
• Give glucose-lowering drugs in a stepwise fashion. Ensure patient is adherent before increasing treatment:
Step Drug/s Breakfast Supper Bed Note

1 Start Metformin 500mg • Avoid in pregnancy, kidney or liver disease, recent heart attack, heart failure, alcoholism.
500mg 500mg • Take with meals.
500mg 500mg • Increase every 2 weeks if random glucose > 8 and patient is adherent.
1g 500mg • Monitor on step 1 treatment for at least 3 months before moving to step 2.
1g 1g
2 Add Glibenclamide 2.5mg • Continue metformin.
5mg • Take with meals.
5mg 2.5mg • Avoid in pregnancy, severe kidney and liver disease.
5mg 5mg • Increase every 2 weeks if random glucose > 8 and patient is adherent.
7.5mg 5mg
7.5mg 7.5mg
3 Add Basal Insulin (intermediate or 10IU • Continue Metformin and Glibenclamide at the same dose.
long acting) 12IU • Patient to check fasting glucose on wakingdailyto increase the dose of insulin sooner after 48-72hrs then once a week.
If ≥ 7 and patient is adherent, increase dose by 2 units.
14IU • Educate about insulin: injection technique and sites, store insulin in fridge or a cool dark place,
16IU meal frequency, recognition of hypoglycaemia and hyperglycaemia, safe needle disposal.
18IU
20IU
4 Biphasic Insulin 10IU 5IU • Continue with metformin.
14IU 5IU • STOP GLIBENCLAMIDE AND BEDTIME BASAL INSULIN.
14IU 9IU • Patient to check fasting glucose on waking once a week. If ≥ 7 and patient adherent, increase dose by 4 units.
18IU 9IU • Educate about insulin as in step 3 above.
18IU 13IU • Refer if > 30 units per day are needed.

Hypertension: diagnosis
Check blood pressure (BP)
• Seat patient with arm supported at heart level for 5 minutes.
• Use a standard cuff or larger cuff if mid-upper arm circumference is > 33cm.
• Record systolic BP (SBP) and diastolic BP (DBP): SBP is the first appearance of sound. DBP is the disappearance of sound.
• If raised, recheck until a reading is repeated. Use this reading to determine the patient’s BP.
• Do not diagnose hypertension on the basis of one reading alone.
< 180/110 ≥ 180/110

Is there diabetes, ischaemic heart disease, peripheral vascular disease, stroke, heart failure, kidney disease or CVD risk > 30%? Does patient have any of the following:
And or have symptoms (Headache, pahpitations difficulty breathing, chest pain, madness, visual disturbances) headache, difficult breathing, visual
disturbances, chest pain, confusion,
leg swelling?
No Yes No Yes
< 140/90 140/90–179/109 130/80–179/109 < 140/90 • Diagnose Patient needs urgent
hypertension. care
• Review Check BP on 2 further occasions at least 2 days apart. Check BP Repeat BP yearly. • Start routine • Only treat BP if no
in 3 years on 2 further hypertension sign of stroke: sudden
if all occasions at care 79. onset of weakness on
140/90–159/99 160/100– • Start drug 1 or both sides, vision
readings least 2 days
179/109 treatment at problems, dizziness,
normal. apart.
Assess CVD risk 71. step 1 and difficulty speaking or
step 2 anti– swallowing.
BP confirmed hypertensive • Give Nifedipine SR
< 10% 10–20% 20–30% 130/80–179/109 treatment 20mg or Nifedipine
80. XL 30mg stat.
• Review in 2 • Avoid short-acting
• Manage • Manage • Manage CVD risk 69. weeks. nifedipine as it may
CVD risk CVD risk • Recheck BP in 3-6 months.
drop the BP too
72. 69. quickly, causing a
• Review • Review stroke.
< 140/90 ≥ 140/90
CVD risk CVD risk • If dizzy or faint after
and BP and BP treatment, check BP:
every every 6 • Continue • Diagnose hypertension. Do not diagnose if more than 25%
years. months. to manage hypertension on the basis of one reading alone. drop or
CVD risk • Start routine hypertension care 80. < 160/100, lie patient
72. • Refer if patient is < 40 years or pregnant. down with legs
• Review BP raised.
and CVD • Refer same day to
risk 3-6 hospital.
months

CHRONIC DISEASES
OF LIFESTYLE
Hypertension: routine care
Assess the patient with hypertension
Symptoms Every visit Manage symptoms on symptom page. Ask about symptoms of stroke or transient ischaemic attack (TIA).
BP Every visit BP is controlled if < 140/90 (or < 130/80 if diabetes, CVD, heart failure or kidney disease). See below.
BMI BMI at diagnosis, weight at every visit BMI is weight (kg)/[height (m) x height (m)]. If BMI > 25, calculate target weight: 25 x height (m) x height (m).
Waist circumference Every visit Measure on breathing out midway between lowest rib and top of iliac crest. Aim for < 80cm (woman), < 94cm (man).
CVD risk At diagnosis and every 3 years If CVD or diabetes no need to check. It reflects the risk of a heart attack or stroke over the next 10 years 68.
Urine dipstick 6 monthly Refer to doctor if blood or protein on repeat dipstick. If glucose on dipstick, screen for diabetes 76.
Glucose Yearly and if glucose on urine dipstick Check random finger-prick glucose 74 to interpret result. Check every visit if patient diabetic.
Creatinine clearance Yearly CrCl reflects kidney function. Give age and sex on form. If < 60 refer to doctor.
Cholesterol At diagnosis/annual Refer to specialist if total cholesterol ≥ 8.
If patient on treatment, check if BP is controlled: < 140/90 (or < 130/80 if diabetes, CVD, heart failure or kidney disease).
BP not controlled on treatment

BP controlled on treatment
• If ≥ 180/110: check for symptoms needing urgent attention 79.
• Continue current treatment.
• Adherent: Step up treatment (to at least step 3 if ≥ 180/110) and review in 1 month.
• Review 6 monthly.
• Not adherent: Explore reasons for non-adherence and advise patient to take current treatment reliably. Review in 1 month.
Advise the patient with hypertension

• Advise patient to avoid non-steroidal anti-inflammatory drugs, oestrogen-containing oral contraceptives 96.
• Educate the patient on to stop it immediately should angioedema (swelling of tongue, lips, face, difficulty breathing) develop.
Treat the patient with hypertension

• Give simvastatin 20mg daily if patient has CVD or a CVD risk > 20%. Avoid in pregnancy, liver disease.
• Give aspirin 150mg daily if patient has CVD and/or diabetes. Avoid if < 30 years, previous peptic ulcers or dyspepsia or if BP ≥ 180/110.
• Treat hypertension stepwise as in table below. If BP ≥ 180/110 start steps 1 and 2 together. If BP is not controlled after 1 month on treatment and patient is adherent, proceed to the following step:
Step Drugs all once a day Note

1 Start Hydrochlorothiazide (HCTZ) 12.5mg; increase HCTZ to 25mg if BP not controlled in 2-3weeks. Avoid in pregnancy, liver or kidney disease, gout. Use enalapril first instead in diabetes, kidney disease, heart failure.
2 Add Enalapril 10mg Avoid/stop in pregnancy, angioedema, persistent cough on enalapril or renal artery stenosis.
3 Add Nifedipine XL 30mg and increase Enalapril to 20mg. Avoid nifedipine in heart failure if possible.
4 Add Atenolol 50mg; increase HCTZ to 25mg and nifedipine XL to 60mg. Avoid atenolol in pregnancy, asthma, COPD, heart failure 75. Refer for specialist if not controlled on 3
treatment.

Heart failure: routine care
• The patient with heart failure has difficulty breathing especially on lying down/with effort and/or leg swelling. A doctor must confirm the diagnosis.
Recognise the patient with heart failure needing urgent attention:

• Respiratory rate > 30 breaths/minute • Irregular pulse
• Fainting/blackouts • Temperature ≥ 38˚C
• Sit patient up and give 100% oxygen via face mask to deliver 40% oxygen.
• Give Furosemide slowly IV. 1st dose 40mg. If respiratory rate does not improve after 30 minutes, give 80mg IV; if still no better after 20 minutes give another 40mg IV. If IV
furosemide unavailabe, give double oral dose.
• If breathlessness is very distressing, give Morphine IV: dilute 15mg with 14mℓ of water for injection or Sodium Chloride 0.9%. Give 1mℓ/min up to 5mg even if no pain.
• Give sublingual Isosorbide Dinitrite 5mg. Repeat 4 hourly even if there is no pain.
• Refer urgently.
Assess the patient with heart failure

Symptoms Every visit Manage symptom as on symptom page. If cough and difficult breathing 16 and refer to doctor.
Pregnancy status Every visit Discuss family planning needs 96. If pregnant, refer for specialist care.
Substance abuse At diagnosis > 21 drinks/week (man) or >14 drinks/week (woman) and/or > 5 drinks per session or misuse of illicit or prescription drugs 89.
Weight Every visit Assess changes in fluid balance by comparing with weight when patient as asymptomatic as possible.
BP Every visit If BP ≥ 130/80 79. Aim to treat hypertension to < 130/80. Avoid atenolol.
Blood tests At diagnosis. Repeat all except TSH yearly. Check Hb, glucose, CrCl, TSH, HIV if status unknown 60.
Advise the patient with heart failure

• Advise patient to adhere to treatment even if asymptomatic.
• Help the patient to manage his/her CVD risk 71. Advise regular exercise within limits of symptoms.
• Restrict fluid intake to less than 1 litre/day if marked leg or abdominal swelling. restrict salt intake.
• Educate on dry weight and self weight monitoring.
Treat the patient with heart failure

• Give drugs as in table below. If symptoms not resolved after 1 month on treatment and patient is adherent, proceed to the following step:
Step Drug Dose Note
1 Enalapril and either Up to 10mg twice a day • Avoid enalapril in pregnancy, previous angioedema or renal artery stenosis. Stop if persistant cough.
HCTZ or 25–50mg daily • Use HCTZ if mild heart failure symptoms and CrCl ≥ 60. Avoid in gout, liver, kidney disease.
Furosemide 40–80mg daily • Use furosemide if significant heart failure symptoms or CrCl < 60. Monitor CrCl and electrolytes.
2 Add Spironolactone 25mg daily Monitor serum potassium. Avoid with potassium supplements and in kidney failure.
3 Add Digoxin 0.125mg daily Also refer patient for further assessment.

CHRONIC DISEASES
OF LIFESTYLE
Stroke: routine care
Sudden onset of any of the following suggests a stroke (or a transient ischaemic attack (TIA) if symptoms lasted < 24 hours and resolved completely):
• Weakness, numbness or paralysis of the face, arm or leg on one or both sides of the body
• Blurred or decreased vision in one or both eyes or double vision
• Difficulty speaking or understanding
• Dizziness, loss of balance, any unexplained fall or unsteady gait
• Severe new headache
A doctor must confirm the diagnosis of stroke.
Give urgent attention to the patient with stroke/TIA if within 48 hours of onset of symptoms:
Stroke/TIA is a brain attack. Quick treatment within 48 hours of onset of symptoms of a minor stroke or TIA reduces the risk of a major stroke.
• Give face mask oxygen.
• Nil by mouth until swallowing is formally assessed.
• Check blood glucose: if ≤ 3.5 give up to 50mℓ 50% Dextrose Water IV.
• Do not treat raised BP as this may worsen stroke and can be managed at referral hospital.
• Give Aspirin 150mg stat if patient unable to reach hospital within 24 hours of onset of symptoms.
• Refer urgently for thrombolysis if the patient can reach the unit within 4 hours of onset of symptoms.
• Otherwise refer same day to nearest hospital if symptoms of stroke/TIA > 4 hours but < 48 hours.
Assess the patient with stroke/TIA

Symptoms Every visit Ask about symptoms of another stroke/TIA. Also ask about chest pain 83 or leg pain 82.
Depression Every visit Screen for depression if patient has low mood or not coping as well as in the past 88.
Rehabilitation needs Every visit Refer to appropriate therapist: physiotherapy for mobility, physiotherapy/occupational therapy for
self care, speech therapist for swallowing, coughing after drinking/eating, speaking and drooling.
BP Every visit Aim for BP < 130/80. Start treatment only 48 hours after a stroke 82.
Glucose At diagnosis and yearly Check random finger-prick glucose 76 to interpret result.
Fasting cholesterol and triglycerides At diagnosis if not already done Refer to specialist if total cholesterol ≥ 8 or triglycerides ≥ 5.
HIV At diagnosis if status unknown especially if patient < 50 years Test for HIV 60. The HIV patient needs routine HIV care 61.
Advise the patient with stroke/TIA

• Help patient to manage cardiovascular disease risk 71.
• If patient is < 55 years (man) or < 65 years (woman), advise the first degree relatives to have CVD risk assessment 71.
• Avoid oral contraceptives containing oestrogen. Advise other method such as IUCD, injectable, progesterone-only pill 96.
Treat the patient with stroke/TIA

• Give Aspirin 150mg daily for life. Avoid if < 30 years, haemorrhagic stroke, previous peptic ulcers or dyspepsia.
• Consider warfarin instead of aspirin if patient has prosthetic heart valve, valvular heart disease or atrial fibrillation.
• Give Simvastatin 10mg daily for life if patient had an ischaemic stroke. Avoid in pregnancy and liver disease.

Ischaemic heart disease (ihd): diagnosis
• Angina due to IHD is typically central crushing chest (or epigastric) pain that may spread to jaw, left shoulder, down left arm and is suggested by:
--Pain lasts < 10 minutes and
--Pain is usually brought on by exercise, effort or anxiety and
--Pain is usually relieved by rest.
• A doctor must make or confirm the diagnosis of ischaemic heart disease.
Give urgent attention to the patient with possible unstable angina or heart attack and one or more of:
• Chest or epigastric pain at rest or minimal effort.
• Chest pain lasting more than 10 minutes.
• If known IHD: pain worsening, lasting longer than usual, not relieved by sublingual nitrates.
• Patient may be sweating, nauseous, vomiting, breathless.
• If available ECG may show ST segment depression or elevation, but a normal ECG does not exclude diagnosis of angina or heart attack.
• BP < 90/60
Arrange urgent ambulance transfer to hospital and manage as follows:

• Give face mask oxygen if oxygen saturation machine unavailable, or if available saturation is <95%.
• If BP < 90/60 give 200mℓ sodium chloride 0.9% IV.
• Give Aspirin 150mg single dose to chew.
• Isosorbide Dinitrate sublingual 5mg every 5-10 minutes until pain relieved to a maximum of 5 tablets.
• Morphine 15mg diluted with 14mℓ of water for injection or sodium chloride 0.9%. Give 1mℓ/min IV until pain relieved.
For routine care of the patient with IHD 84.

CHRONIC DISEASES
OF LIFESTYLE
Ischaemic heart disease: routine care
Assess the patient with ischaemic heart disease
Symptoms At diagnosis and every visit • Ask about angina and treat as below. Refer if angina persists on full treatment or interferes with daily activities.
• Screen for depression if patient has low mood or not coping as well as in the past 87.
BP At diagnosis and every visit If BP ≥ 130/80 79. Aim to treat hypertension to < 130/80 80.
Glucose At diagnosis and yearly Check random finger-prick glucose 76 to interpret result.
Advise the patient with ischaemic heart disease

• Emphasize the importance of lifelong adherence to medication. Ensure patient knows how to use isosorbide dinitrate as below.
• Patient can resume sexual activity 1 month after heart attack and when symptom free.
• Patient should avoid non steroidal anti-inflammatory drugs like ibuprofen and diclofenac, as they may precipitate angina.
• If patient is < 55 years (man) or < 65 years (woman), advise the first degree relatives to have CVD risk assessment 71.
Treat the patient with ischaemic heart disease

Give the following drugs to prevent a heart attack:
• Aspirin 75-150mg daily for life. Avoid if < 30 years, a history of peptic ulcers or dyspepsia.
• Carvedilol 6.25-25mg bd, even if no angina. Avoid in pregnancy, asthma, COPD, heart failure, peripheral vascular disease.
• Atorvastatin 20-80mg daily for life. No need to monitor cholesterol. Avoid in pregnancy and liver disease.
• If patient has had a heart attack, give Enalapril 2.5mg twice a day and increase slowly to 10mg twice a day. Avoid if pregnancy, angioedema or renal artery stenosis.
Give drugs to treat and prevent angina in a step-wise fashion:

• If angina persists, increase dose to maximum, then add next step.
Step Drug Start dose Maximum dose Note

1 Isosorbide Dinitrate with angina and 5mg sublingual with angina 3 doses of 5mg with 1 episode of angina If angina starts, do not walk through the pain, stop and take 1st sublingual dose. If angina
before exertion and persists, take a further 2 doses 5 minutes apart. If no improvement 5 minutes after 3rd dose, go
to hospital.
Atenolol 50mg daily 100mg daily if systolic BP stays > 95 and Avoid atenolol in pregnancy, asthma, COPD, heart failure, peripheral vascular disease and use
pulse > 55/minute nifedipine instead or if side effects (impotence, fatigue, depression) occur.
2 Nifedipine XL 30mg in the morning 60mg in the morning Avoid in heart failure 81.
3 Isosorbide Mononitrate or 10mg at 8am and 2pm 20mg at 8am and 2pm
Isosorbide Dinitrate 20mg at 8am and 2pm 40mg at 8am and 2pm
Refer if angina persists on full treatment or interferes with daily activities.

Peripheral vascular disease (PVD): diagnosis and routine care
• Peripheral vascular disease is characterised by claudication: muscle pain in legs or buttocks on exercise.
• Refer the patient newly diagnosed with peripheral vascular disease for specialist assessment.
Recognise the patient with peripheral vascular disease needing urgent attention:
Claudication with any one of:
• Pain at rest
• Gangrene
• Ulceration
• Suspected abdominal aortic aneurysm: pulsatile mass in abdomen
Refer same day to hospital.
Assess the patient with peripheral vascular disease

Symptoms At diagnosis and every visit •Document the walking distance before onset of claudication.
•Ask about chest pain 83 and symptoms of stroke/TIA 84.
•Manage symptoms as per symptom pages.
BP At diagnosis and every visit If BP ≥ 130/80 79. Aim to treat hypertension to < 130/80 80.
Femoral pulses At diagnosis and every visit Refer if weak or absent.
Abdomen At diagnosis and every visit If a pulsatile mass felt, refer for assessment for possible aortic aneurysm.
Random glucose At diagnosis and yearly Check random finger-prick glucose 76 to interpret result. Check every visit if patient diabetic.
Advise the patient with peripheral vascular disease

• Walking an hour a day for at least 6 months can increase by 50% the walking distance. Advise patient to pause and rest whenever claudication develops.
• If patient is < 55 years (man) or < 65 years (woman), advise the first degree relatives to have CVD risk assessment 71-72.
Treat the patient with peripheral vascular disease

• Give Atorvastatin 20-80mg daily for life regardless of cholesterol level. Avoid in pregnancy and liver disease.
• Give Aspirin 150-300mg daily for life if no history of peptic ulcers or dyspepsia. Avoid if under 30 years.
Refer if unacceptable symptoms occur despite adherence to advice and drug treatment.

CHRONIC DISEASES
OF LIFESTYLE
Mental Disorders Act
Approach to the mentally ill patient ≥ 16 years in need of hospital admission
• Before sedating the patient (if needed) fully inform patient in his/her own language about reasons for admission and treatment.
• Can patient give informed consent? This means the patient understands that s/he is ill, is needing treatment and can communicate his/her choice to receive treatment.
Yes: Does patient agree to admission? No: Does patient oppose admission?
Yes No Yes No
Admit the patient voluntarily Does patient meet all of the following? Admit as an assisted patient
• Record everything clearly in • Mental illness or severe or profound mental disability and under the Mental Health
patient notes and referral letter. • Refusing treatment and Care Act.
• Patient must complete Mental • Danger of harm to self, others, own reputation, financial interest or property • A health care worker must
Disorders Act form 14. accompany the patient to
hospital.
No Yes • Request police assistance
only if the patient is too
dangerous to be transferred
Manage as an • Applicant1 must complete form1 of the Mental Disorders Act. in a facility vehicle or is
outpatient. • If admission needs to be same day, applicant1 should complete form 6 instead. likely to abscond.
• A doctor must complete Mental Disorders Act form 2.
• The district commisioner issues a reception order (Mental Disorder Act form 4)
after consideration of forms 1 and 2.
• If the application was urgent with form 6, this step can be bypassed.
Admit patient under Mental Disorders Act.
1
The applicant is ≥ 21 years and can be the patient’s spouse, next-of-kin, associate, partner, parent or guardian or health care provider. For a patient < 18 years, the applicant must be a parent or guardian.

Depression and anxiety: diagnosis
Ask the following 2 questions to assess for depression:
1. For at least 2 weeks, has the patient had at least 2 of the core features of depression?
--Depressed mood most of the day, almost every day
--Loss of interest or pleasure in activities that are normally pleasurable
--Decreased energy or increased fatigue
2. For at least 2 weeks, has the patient had any other features of depression?
--Reduced concentration and attention
--Reduced self-esteem and self confidence
--Ideas of guilt and unworthiness
--Bleak and negative view of future
--Ideas or acts of self-harm or suicide
--Disturbed sleep
--Decreased appetite
3. At any point in the past 2 weeks has the patient had ideas or acts of self harm or
suicide? If yes refer patient same day and manage 49
Yes to both questions 1 and 2 Yes to only one question No to both questions
Does the patient have difficulties carrying out ordinary work, domestic or social activities? • The patient is not depressed.
• Is the patient feeling tense/nervous and/or worrying a lot?
Yes No
Diagnose moderate-severe depression. Diagnose mild depression.
Is the patient feeling tense/nervous and/or worrying a lot? Yes No
No Yes
The patient has anxiety. Assess the patient

Does the anxiety have one or more of the following features? on stressed patient
• Induced by a situation page 52.
• Sudden fear, no obvious cause
• Follows a traumatic event
No Yes
• If the patient has depression and anxiety, treat for depression as The patient may have phobia, panic or
treating the depression usually improves the anxiety. post-traumatic stress disorder.
• If there is no depression, treat anxiety as for mild depression.
Refer same week for specialist
Give routine depression and/or anxiety care 88. assessment.

MENTAL HEALTH
Depression and/or anxiety: routine care
Assess the patient with depression and/or anxiety
Symptoms Every visit • Assess for symptoms of depression and/or anxiety 87. Refer if no improvement after 8 weeks of treatment or if patient deteriorates.
• If patient has hallucinations, delusions and abnormal behaviour, consider psychosis 90. If memory problems, screen for dementia 92.
• Assess and treat other symptoms on symptom pages.
• Ask about side effects of antidepressant medication (see below).
Suicide Every visit If patient has suicidal thoughts or plans, refer same day 49.
Mania Every visit Refer if mania (being abnormally happy, energetic, talkative, irritable or reckless) at diagnosis or develops on antidepressant medication.
Stressors Every visit Help identify the domestic, social and work factors contributing to depression and/or anxiety. If patient is being abused 53.
Substance abuse Every visit > 21 drinks/week (man) or > 14 drinks/week (woman) and/or ≥ 5 drinks per session or misuse of illicit or prescription drugs 89.
Family planning Every visit Discuss patient’s contraceptive needs 96. If patient is pregnant refer for specialist care.
Chronic disease Every visit • Ensure other chronic diseases are adequately treated.
• If patient has an incurable illness and you would not be surprised if s/he died within the next year, also give end-of-life care 107.
• Discuss with specialist if patient is on medication that might cause depression like oral steroids, efavirenz and atenolol.
Thyroid function At diagnosis Check TSH if weight change, dry skin, constipation, intolerance to cold or heat, pulse > 80, tremor, or thyroid enlargement. Refer to doctor if result abnormal.
Advise the patient with depression and/or anxiety

• Devise with patient a strategy to cope when thoughts of self harm, suicide or substance misuse occur. Refer patient to available support group.
• Deal with negative thinking: encourage patient to question his/her way of thinking, examine the facts realistically and look for strategies to get help and cope.
• Encourage patient to do activities that used to give pleasure, to engage in regular social activity and to exercise for at least 30 minutes 5 days a week.
• Discuss sleep hygiene 54 and relaxation techniques.
• The best treatment for mild depression and/or anxiety is cognitive behavioural therapy. Antidepressants work best for those with moderate-severe depression.
Treat the patient with depression and/or anxiety

• Refer patient for counselling, ideally cognitive behavioural therapy, with counsellor, social worker or psychologist.
• Treat the patient with moderate-severe depression with an antidepressant. Refer the patient who is pregnant, breastfeeding or bipolar for specialist care.
• Antidepressants can take 4–6 weeks to start working. Review 2 weekly until stable, then monthly. Refer if no response after 8 weeks.
• Emphasise the importance of adherence even if feeling well and to stop antidepressants only with the guidance of a doctor.
Drug Dose Note

Fluoxetine Start 20mg daily (or 10mg if > 65 years). If partial or no response after 4 weeks Use if thoughts of self harm/suicide and if CVD. Avoid in kidney or liver disease. Monitor glucose in diabetes and for fits in
increase to 40mg daily. epilepsy. Side effects: headache, nausea, diarrhoea, sexual dysfunction.
Amitriptyline Start 50mg at night (or 25mg if > 65 years). Increase by 25mg/day every 3-5 days (or Avoid if suicidal thoughts (can be fatal in overdose), heart disease, urinary retention, glaucoma, epilepsy. Side effects: dry mouth,
7–10 days if > 65 years). Maximum dose: 150mg/day (or 75mg if > 65 years). sedation.
• Doctor to consider stopping antidepressant when patient has had no or minimal depressive symptoms and has been able to carry out routine activities for 9–12 months: reduce dose gradually over at least
4 weeks (more gradually if withdrawal symptoms develop: irritability, dizziness, sleep problems, headache, nausea, fatigue).

Substance abuse: diagnosis and routine care
Identify the patient with substance abuse
• The misuse of drugs or alcohol causes serious problems for patient, the family and perhaps even the community and/or
• Abnormal alcoholic drink/day - 1 drink is 1 tot of spirits, or 1 small glass of wine or 1 can of beer or bottle(330ml) 104
• Yes to 2 or more CAGE questions: Ever felt you should Cut down on drinking? Annoyed if criticized about drinking? Ever felt Guilty about drinking? Ever drink to wake up?(eye opener) and/or
• Any use of illicit drugs or misuse of prescription drugs.
• Counselling
Assess the patient with substance abuse

Assess Note
Symptoms Restlessness, confusion, sweating, sleeplessness, hallucinations, agitation, weakness, tremor, headache, nausea - may be withdrawal: refer same day.
Harmful use Alcohol: > 35 drinks/week (man); > 20 drinks/week (woman); > 5 drinks/session and/or any use of illicit or prescription drugs can become harmful. 89, 104.
Dependence Much time and energy spent on getting and using substance and withdrawal symptoms above occur on stopping or cutting down.
Trauma/abuse If patient reports recent trauma or emotional or sexual abuse 53.
Chronic disease Chronic use of alcohol and/or drugs can have a long term impact on physical health. Assess and manage according to symptoms and chronic disease.
Mental illness If low mood or sadness, loss of interest or pleasure, feeling tense or anxious or worrying a lot about things, consider depression/anxiety 87.
Advise the patient with substance abuse

• Educate patient about effects of substance abuse. Explore patient’s willingness to cut down or stop. For communicating effectively 111.
• Alcohol: Advise abstinence or moderate use (≤ 21 drinks/week (man); ≤ 14 drinks/week (woman) and avoid binges). Advise the pregnant woman to abstain.
• Advise patient to stop using illicit or prescription drugs.
Doctor to treat the dependant patient with substance abuse

• Discuss the dependant patient who wishes to stop with psychiatric unit to arrange detoxification and support. Ensure patient is motivated to adhere and has the support of a relative/friend.
• Admit the patient who refuses help under the Mental Disorders Act only if there is an accompanying mental disorder and patient is causing harm to self or others 86.
• For inpatient detoxification if previous withdrawal delirium, fits, psychosis, suicidal, liver disease, failed prior detoxification, no home support, opioid abuse, or if legally committed or detained.
Substance Outpatient detoxification programme

Alcohol • Thiamine 100mg twice a day for 10 days and
• Diazepam orally (if > 60 years or < 60kg start at day 3). Each day drop a dose. The detox should take 6–7 days. If extra diazepam is needed, maximum daily dose 60mg.
Day 1: 10mg with withdrawal symptoms then 5mg at 12h00, 17h00 and 10mg at 21h00.
Day 2: 5mg, 5mg, 5mg, 10mg. Review and adjust doses as needed.
Day 3: 5mg 6 hourly
Cannabis/Mandrax/Cocaine/Tik • Treatment not always needed. Review after 1 day of abstinence.
• Treat anxiety or sleep problems with Diazepam 5mg 1–3 times a day tapering over 3–7 days or promethazine 25–50mg orally 8 hourly.
Benzodiazepines • Avoid suddenly stopping benzodiazepines after long-term use.
• Substitute patient’s benzodiazepine for diazepam eg. lorazepam 0.5mg–1mg = diazepam 5mg (for other benzodiazepines, discuss with specialist).
• Adjust Diazepam according to symptoms, then decrease diazepam by 2.5mg every 2 weeks. On reaching 20% of initial dose taper by 0.5–2mg/week.

MENTAL HEALTH
Psychosis and/or mania: diagnosis and routine care
• Psychosis is likely in the patient who has difficulty carrying out ordinary work, domestic or social activities and any of the following:
--Hallucinations: hearing voices or seeing things that are not there
--Delusions: unusual/bizarre beliefs, not shared by society; beliefs that thoughts are being inserted or broadcast
--Abnormal behaviour: incoherent or irrelevant speech, unusual appearance, self neglect, withdrawal, disturbance of emotions
--Manic symptoms: several days of being abnormally happy, energetic, talkative, irritable or reckless.
• Consider bipolar disorder if patient has manic symptoms on some occasions, and depressed mood and energy on others.
• The patient with psychosis and/or mania must be assessed initially by a doctor.
Give urgent attention to the patient with psychosis and/or mania:

• Suicidal thoughts or attempt 49
• If aggressive or violent 50
• First episode psychosis or mania
• Pregnant or breastfeeding
• Muscle spasms (may be painful) within 48 hours of initiating antipsychotic medication
Management:
• Consider admitting under the Mental Disorders Act if refusing treatment or admission and a danger of harm to self, others, own reputation or financial interest/property 86.
• For muscle spasms, give Biperiden 2mg IM. Repeat every 30 minutes to a maximum of 4 doses in 24 hours.
• Refer patient same day.
Assess the patient with psychosis and/or mania

Symptoms Every visit • Ask about symptoms of psychosis and mania above. If symptomatic despite treatment refer.
• Assess for symptoms of depression and/or anxiety 87. If memory problems, screen for dementia 92. If present refer.
• Assess and treat other symptoms on symptom pages.
Suicide Every visit If patient has suicidal thoughts or plans, refer same day 49.
Stressors Every visit Help identify the psychosocial stressors that may exacerbate symptoms. If patient is being abused 53.
Substance abuse Every visit > 21 drinks/week (man) or > 14 drinks/week (woman) and/or > 5 drinks per session or misuse of illicit or prescription drugs 89, 104.
Family planning Every visit Discuss patient’s contraceptive needs 96. If patient is pregnant or breastfeeding refer for specialist care.
Chronic disease Every visit • Refer the patient with other chronic diseases. Give routine chronic disease care as per chronic diseases pages.
• Discuss with specialist if patient is on medication that might cause psychosis like oral steroids, efavirenz and antidepressants.
Medication Every visit • Ask about side effects of antipsychotic medication 91. Refer if these are present.
• If non adherent re-commence medication. Consider changing from oral to depot medication.
HIV, RPR First visit • If status unknown, test for HIV 60. Give routine HIV care to HIV patient 61-67.
• If RPR positive, refer.

Advise the patient with psychosis
• Educate the patient and carer/family about the condition: the patient with psychosis often lacks insight into the illness and may be hostile towards carers and health care workers. S/he may have difficulty
functioning, especially in high stress environments.
• Emphasize the importance of adherence with medication.
• Encourage patient to resume social, educational and work activities as appropriate. Work with local agencies to find educational or employment opportunities.
• Explore housing/assisted living support if needed and available.
• Refer for support group and cognitive behavioural therapy if available.
• Liaise with available health and social resources to provide support for the family and refer for family therapy if available.
• People with psychosis are often discriminated against. Always consider protection of the patient’s human rights and the need to avoid institutional care.
Treat the patient with psychosis

• Initiation, titration and withdrawal is best done by a psychiatrist.
• Use intramuscular antipsychotic medication if patient is not adherent to oral medication and needs long term treatment.
Drug Starting dose Maintenance dose Note

Haloperidol 1.5–10mg oral as a single dose or in 2 divided doses. If > Usually 2–10mg per day. Minimal anticholinergic side effects.
60 years start at lower dose and increase more gradually.
Chlorpromazine 25mg oral twice daily Usually 75–300mg daily but 1000mg may be needed. Once symptoms One of the most sedating antipsychotics.
are controlled, give as a single bedtime dose.
Fluphenazine Decanoate 12.5mg deep intramuscular injection Usually 25–50mg every 4 weeks but can be halved and given 2 weekly. Full response can take 2 months
Fewer anticholinergic side effects than chlorpromazine.
Flupenthixol Decanoate 20mg deep intramuscular injection Usually 60mg every 4 weeks but can be halved and given 2 weekly. Full response can take 2 months.
Fewer anticholinergic side effects than chlorpromazine.
Discuss with a psychiatrist if any side effects develop on antipsychotic medication

• Anticholinergic side effects: dry mouth, blurred vision, constipation, urinary retention, worsening of closed angle glaucoma
• Extrapyramidal side effects:
--Acute dystonic reactions (often painful muscle spasms) may appear within 24-48 hours of starting medication. Give Biperiden 2mg IM, repeat every 30 minutes to maximum 4 doses in
24 hours.
--Refer patient same day for further management.
--Parkinsonian signs (bradykinesia, tremor, rigidity) may occur after weeks or months on treatment, more commonly in elderly patients. Alternate Diazepam 5mg IV stat
--Akathisia (motor restlessness) may occur after days or weeks of treatment.
--Tardive dyskinesia (persistent involuntary movements) may occur after months (usually more than 6 months) of treatment.

MENTAL HEALTH
Dementia: diagnosis and routine care
• Ensure a doctor confirms the diagnosis of dementia. Consider dementia in the patient who for at least 6 months:
--Has problems with memory. Test by asking patient to repeat 3 common words immediately and then again after 5 minutes.
--Is disoriented for time (unsure what day/season it is) and place (unsure of shop closest to home or where the consultation is taking place).
--Experiences difficulty with speech and language – unable to name parts of the body.
--Struggles with simple tasks, decision making and carrying out daily activities.
--Is less able to cope with social and work function.
--If patient has HIV, has difficulty with coordination.
Assess the patient with dementia

Symptoms At diagnosis, every visit • Check for new symptoms and manage as per symptom pages.
• If recent change in mood, energy/interest levels, sleep or appetite, consider depression and refer. Assess risk for self-harm 49.
• If patient has hallucinations, delusions, agitation, aggression or wandering refer to psychiatrist.Screen for infection,constipation, nuttitional status, routine blood T/
Vision/hearing problems At diagnosis, every visit Manage poor vision or hearing with proper devices.
Nutritional status At diagnosis, every visit Ask about food and fluid intake. Arrange nutritional support if BMI < 18.5. BMI = weight (kg) ÷ height (m) ÷ height (m)
Cardiovascular disease At diagnosis Assess CVD risk 71. Ask about previous stroke/TIA, chest or leg pain.
End-of-life care At diagnosis, every visit If any of: bed-bound, unable to walk and dress alone, incontinence, unable to talk meaningfully or do activities of daily living, s/he also needs end-of-life care 107.
HIV At diagnosis • HIV-associated dementia may improve on ART. If status unknown, test for HIV 60.
• If HIV give routine care 61 and test for coordination problems: with non-dominant hand as quickly as possible (allow patient to practice twice):
--Open and close the first 2 fingers widely.
--On a flat surface, clench a fist, then place palm down, then on the side of the 5th digit.
Syphilis At diagnosis Refer the RPR positive patient with dementia.
Thyroid At diagnosis Refer if result is abnormal.
Advise the patient with dementia and his/her carer

• Discuss what can be done to support the patient, carer/s and family. Identify local resources, social worker, counsellor, NGO.
• Discuss with carer if respite or institutional care is needed. Advise the carer/s to:
--Give regular orientation information (day, date, weather, time, names) --Plan daily activities that assist the person to be independent.
--Try to stimulate memories with newspaper, radio, TV, photos. --Remove clutter in the environment.
--Use simple short sentences. --Regulate fluid intake to deal with incontinence.
--Avoid changes in routine. --Maintain physical activity.
Treat the patient with dementia

• HIV-associated dementia often responds well to ART 61-67.
• Treat aggressive or violent behaviour towards self or others 50.
--Treat agitation, distressing behaviour, psychotic symptoms with Haloperidol 0.5–1mg up to twice daily. Refer to psychiatrist
1
Tardive dyskinesia (persistent involuntary movements) may occur after months (usually more than 6 months) of treatment.

Epilepsy: diagnosis and routine care
• If the patient is fitting 2 to control the fit. If the patient is not known with epilepsy and has had a fit 2 to assess and manage further.
• Epilepsy is a doctor diagnosis in the patient who has had at least 2 definite fits with no identifiable cause or 1 fit following TB meningitis, stroke or head trauma.
Assess the patient with epilepsy

Symptoms Every visit Manage symptoms as on symptom page.
Fit frequency Every visit Review fit diary. Assess if fits prevent patient from leading a normal lifestyle.
Adherence Every visit, if fits occur Assess attendance, pill counts and if still fitting on treatment, drug level (doctor decision).
Side effects Discuss at diagnosis, every visit Side effects often explain poor adherence. Patient may need to weigh side effects with fit control.
Other medication If fits occur Check if patient has started other medication like TB treatment, lopinavir/ritonavir or oral contraceptive. See below.
Substance abuse At diagnosis, if fits occurs or adherence poor • Alcoholic drinks per day or misuse of illicit or prescription drugs 104.
Family planning Every visit • Refer same week if patient is pregnant or planning to be, for epilepsy and antenatal care 93.
• Assess family planning needs: avoid oral contraceptives on carbamazepine or phenytoin 96.
Drug level Only if needed Doctor to check drug level if unsure about adherence or on higher than maximum dose of phenytoin.
Advise the patient with epilepsy

• Educate about epilepsy and stress the importance of adherence to treatment. Advise patient to keep a fits diary to record frequency dates and times of fits.
• Advise avoiding sleep deprivation, alcohol and drug use, dehydration, flashing lights and video games. These may trigger a fit.
• Avoid dangers like heights, fires, swimming alone, cycling on busy roads, operating machinery. Avoid driving until fit free for 1 year.
• Advise patient that there are many drugs that interfere with anti-convulsant treatment (see below) and to discuss with doctor when starting any new medication.
• Councel female patients on implications and consequences of epilepsy on family planning, pregnancy, foetus
Treat the patient with epilepsy

• Initiate with single drug and review every 2 weeks until no seizures. Giving 2 anti-convulsant drugs together is a specialist decision.
• If still fitting and on treatment for 2 weeks on max. dose of 1 drug or side effect are intolerable, or no substance abuse, refer to internist/psychiatrist/family medicine for a 2nd anticonvulsant
• If still fitting after 4 weeks on maximum dose or side effects intolerable, add new drug and increase 2 weekly until fit free. Then taper off old drug over 2-3 month in consultation with a specialist.
Drug Start dose Maximum dose Note

Sodium 300mg twice a day 1g twice a day • Avoid in liver disease. Side effects: nausea, vomiting, diarrhoea, constipation, fatigue, incordination. Drug interactions: aspirin, warfarin, AZT.
valproate
Carbamazepine 100mg twice a day 1200mg daily in 2 or 3 divided doses • Side effects: skin rash, blurred or double vision, ataxia, nausea. Drug interactions: isoniazid, warfarin, fluoxetine, cimetidine, theophylline, amitriptyline,
oral contraceptives, antiretrovirals: if starting ART, refer to change anticonvulsant.
Phenytoin 150mg daily 300mg daily or in 2 divided doses • Avoid in women as it can cause facial hair/coarse facial features. Side effects: skin rash, drowsiness, slurred speech. Drug interactions: isoniazid,
warfarin, cimetidine, furosemide, oral contraceptives.
• If patient is fit free review patient every 1 month for 3months and then after every 6 months. Doctor should review monthly the patient who is fitting until fit frequency improves.
• Refer if still fitting after maximum doses of 2 drugs for 4 weeks each.
• Doctor can consider with patient stopping treatment if no fits for 2 years: gradually withdraw 1 drug at a time over 2–3 months.

EPILEPSY
Chronic arthritis: diagnosis and routine care
• If patient has discrete episodes of joint pain and swelling that completely resolve in between, consider gout 95.
• The most common chronic arthritis (lasting > 8 weeks) is osteoarthritis. Rheumatoid arthritis is the most common form of chronic inflammatory arthritis:
Osteoarthritis Inflammatory arthritis
• Affects joints only. • Can be systemic: weight loss, fatigue, poor appetite, muscle wasting.
• Weight-bearing joints and maybe 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 improves with rest. • Pain and stiffness improve with activity.
Refer the patient with probable inflammatory arthritis or an unclear diagnosis for specialist assessment.
Assess the patient with chronic arthritis

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 problems sleeping 54.
Depression Every visit If low mood or sadness, loss of interest or pleasure, feeling tense, worrying a lot or not coping as well as before, consider depression/anxiety 88.
Joints Every visit Look for warmth and tenderness of joints.
BMI At diagnosis BMI is weight (kg) ÷ height (m) ÷ height (m). > 25 is overweight and puts stress on weight-bearing joints. Assess patient's CVD risk 71.
Blood monitoring If on disease modifying anti-rheumatic drugs Ensure the patient using disease modifying drugs knows to have regular blood monitoring depending on the prescribed drugs from the specialist clinic.
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 patient to manage CVD risk 75.
• Encourage the patient to be as active as possible, but to rest with acute flare-ups.
• Refer patient and carer for education about chronic arthritis. Suggest patient join or start a support group.
Treat the patient with chronic arthritis

• Refer to physiotherapist or occupational therapist if rheumatoid arthritis and/or difficulty with activities of daily living.
• Give Paracetamol 1g 6 hourly. If no response and inflammation is present in the patient with osteoarthritis, give Ibuprofen 200–400mg 8 hourly after meals only as needed.
• Give Amitriptyline 25mg night, 12.5mg if patient > 65 years.
• Rheumatoid arthritis must be treated early with disease modifying anti-rheumatic drugs to control symptoms, preserve function, and minimise further damage.
• If specialist appointment unavailable within 1 month and inflammatory arthritis likely, discuss with specialist.
Review monthly until symptoms controlled, then 3–6 monthly. Refer patient to a specialist if poor response to treatment.

Gout: diagnosis and routine care
• Gout is a metabolic disease where uric acid crystals are deposited in the joints. It occurs most commonly in men over 40 years and post-menopausal women.
• Acute gout tends to affect 1 joint (often big toe, knee or ankle) and to recover completely.
• In chronic gout, many joints may be affected and they may not be very painful, but there is incomplete recovery in between.
Assess the patient with gout

Symptoms Every visit Manage symptoms as per symptom pages.
Substance abuse At diagnosis > 21 drinks/week (man) or >14 drinks/week (woman) and/or > 5 drinks per session or misuse of illicit or prescription drugs 89, 104.
Medication Acute attacks Hydrochlorothiazide, ethambutol, pyrazinamide and aspirin can all induce acute gout attacks. Discuss with doctor.
Joints Every visit • Recognise the acute gout attack: Sudden onset of 1–3 hot, extremely painful, swollen joints with red, shiny overlying skin (often big toe, knee or ankle).
• Tophaceous gout appears as painless yellow hard irregular lumps around the joints (picture).
CVD risk At diagnosis Assess cardiovascular disease risk 68. If BMI < 25 or < 40 years, refer within 1 month to exclude possible cancer cause for gout.
Creatinine clearance At diagnosis If CrCl < 50, refer.
Urate At diagnosis and with allopurinol Normal is ≤ 0.3. The patient needs allopurinol if urate > 0.5. Adjust allopurinol dose until urate < 0.3.
Advise the patient with gout

• Help the patient to manage his/her cardiovascular disease risk 74.
• Give dietary advice:
--Avoid fizzy drinks, alcohol, red meat, liver, kidneys, turkey, crayfish, sardines and anchovy.
--Avoid fasting.
--Drink at least 3ℓ of fluids a day.
• Advise bed rest until the pain subsides.
• Advise patient there are drugs that may induce a gout attack, like aspirin/grand pa and to discuss with doctor when starting any new medication.
Treat the patient with gout

Treat the patient with an acute gout attack
• Give Ibuprofen 800mg after food 8 hourly for 1–2 days. Then Ibuprofen 400mg 8 hourly until pain and swelling are improved.
• If patient has peptic ulcer, asthma, hypertension, heart failure or kidney disease, give Prednisolone 40mg daily for 3–5 days instead of ibuprofen.
• If patient is already using allopurinol, do not stop it during the acute attack.
Treat the patient with chronic gout
• To Doctor refer patient for Allopurinol if: > 2 attacks per year, chronic tophaceous gout (picture), kidney stones, kidney disease or serum urate > 0.5.
• Give Allopurinol 100mg once daily. Do not start allopurinol during or for 3 weeks after an acute attack.
• Increase by 100mg monthly until serum urate < 0.3 or the maximum dose of 400mg.
Refer patient to specialist if no response to treatment or unsure about diagnosis.

MUSCULOSKELETAL
DISORDERS
Contraception
Give emergency contraception if patient had unprotected sex in past 3 days and does not want pregnancy:
• First exclude pregnancy. If pregnant do not give emergency contraception 93.
• Give ideally within 72 hours of unprotected sex: levonorgestrel 0.75mg 2 tablets once or norgestrel/oestradiol 0.5/0.05mg 2 tablets and repeat after 12 hours.
• If patient chooses, insert emergency IUCD instead. Encourage client to continue IUCD as long term cotraception. See below.
Starting contraception
• Help patient and partner to choose contraception based on preference, plan for future pregnancies and contraindications: injection, pills, intrauterine device or sterilisation.
• Advise the patient and partner that condoms alone are not entirely reliable contraception but combined with another method will protect from STIs and HIV.
• In the menopausal patient: if < 50 years, give contraception for 2 years after last period; if ≥ 50 years, for 1 year after last period 100.
Hormonal injection Hormonal pills Intrauterine device Sterilisation

• 3 monthly injection • Patient motivated to take pill daily at the same time. • Effective for 10 years • Permanent
• Fertility returns 6–9 • Fertility returns once pill is stopped. • Fertility returns on removal. contraception
months after last • Avoid if unlikely to take pill reliably, on rifampicin, LPV/r or phenytoin, previous breast • Avoid if patient has multiple • Surgical procedure
injection. cancer, heart or liver disease. partners, heavy periods or had an • For men or women
• Choose progesterone-only pill if patient is breast feeding, smoker > 35 years, BP ≥ 140/90, STI in past 3 months. • Refer for assessment.
has migraine with focal symptoms or DVT or pulmonary embolus.
Method Instructions for use Side effects

Injectable • Can start any time in menstrual cycle, if after day 5 of starting • Amenorrhoea: reassure that this is common.
• Medroxyprogesterone Acetate IM bleeding, need to use condoms for 7 days • Spotting: common in first 3 months, check Pap and for STI. Refer if it continues.
150mg 12 weekly • Heavy or prolonged bleeding: if newly started, give combined oral contraceptive for 2–3 cycles. If no better refer.
• Severe headaches and blurred vision: switch to non-hormonal method.
• Weight gain
• Acne: switch to non-hormonal method.
Combined oral oestrogen and • Must be taken every day at the same time day 1 – 5 of menses. • Nausea, dizziness: reassure that this will resolve.
progesterone pill • Use condoms inaggition for 7 days to insure efficacy of • Tender breasts: exclude pregnancy, then reassure.
• Monophasic low dose: Levonorgestrel/ contraception. • Moodiness: reassure that this should resolve. If patient has low mood or not coping as well as before screen for
Ethinyl Oestradiol 0.15/0.03mg or • Advise patient with diarrhoea/vomiting or on antibiotics to use depression/anxiety 87 and change method.
• Monophasic high dose: condoms during illness and for 7 days thereafter. • Amenorrhoea: exclude pregnancy then reassure.
Norethisterone/Mestranol 1.0/0.05mg • Slight weight gain
• Abnormal bleeding: common in first 3 months: ensure correct use, no diarrhoea, vomiting or antibiotics, check Pap,
pregnancy and STI. If > 3 months, refer.
• Severe headaches: switch to non-hormonal method and 9.
Oral progesterone pill • Must be taken at the same time every day. • Abnormal bleeding: common in first 3 months: ensure correct use, no diarrhoea, vomiting or antibiotics, check Pap,
• Levonorgestrel 0.03mg • Start within 3 days of starting bleeding, use condoms for next 7 days. pregnancy and STI. If > 3 months, refer.
• If breastfeeding, start 6 weeks postpartum. • Mild headaches, nausea, breast tenderness: reassure that these should resolve.
Intrauterine device • Is effective for 10 years. • Periods may be heavier, longer or more painful. Refer if excessive bleeding occurs after insertion. If patient tired
• Copper T device • Insert within 5 days of starting bleeding. If later, exclude pregnancy check Hb, if < 10 refer to doctor.
first. • If uterus enlarged, exclude pregnancy, do not insert device and refer.

Contraception: routine care
Assess the patient using contraception
• Follow up the patient on pill after 3 months, thereafter 6 monthly. Follow up patient with IUCD, 6 weeks after insertion to check strings, thereafter yearly.

Symptoms Every visit • Ask about side effects of contraceptive method 96.
• Check for symptoms of STIs: vaginal discharge, ulcers, lower abdominal pain. If present 23. If sexual problems 30.
• If > 45 years ask about menopausal symptoms: flushing, irregular periods, irritability, tiredness, mood changes 96.
• Manage other symptoms as on symptom pages.
Adherence Every visit • Ask about concerns and satisfaction with method.
• If patient has missed injections or pills, see below to manage.
Medication changes Every visit If started TB treatment, LPV/r or anticonvulsants switch to injectable contraceptive or IUCD.
Vaginal bleeding Every visit • Exclude pregnancy if missed period in patient using IUCD or combined pill.
• IUCD and hormonal methods may cause abnormal bleeding. See method to manage 96.
Breast check Yearly on pill If any lumps found in breasts or axillae 18.
Weight Every visit If BMI > 25 assess CVD risk 71.
BP Every visit on pill If BP ≥ 130/80 73 to interpret result. If BP ≥ 140/90 avoid/change from combined pill.
HIV Every visit If status unknown test for HIV 60. The HIV patient needs routine HIV care 61-67.
Pap smear When needed If HIV negative and 30–49 years: do smear 5 yearly. The HIV patient needs smear at diagnosis then 3 yearly if normal 27.
Advise the patient using contraception

• Advise patient to discuss concerns, problems with contraceptive method and find an alternative, rather than just stopping it and risking an unwanted pregnancy.
• Educate about the availability of emergency contraception 98 to prevent unwanted pregnancy.
• Encourage patient to have 1 partner at a time and to test for HIV between partners. Encourage partner involvement and support with using contraception.
• Condoms alone are not entirely reliable contraception but with another method will protect from STIs and HIV. Demonstrate and give male/female condoms.
• Advise patient on pill to inform clinician if starting TB treatment, LPV/r or anti-convulsants as these may interfere with pill effectiveness.
• Advise patient on pill with diarrhoea/vomiting or on antibiotics to use condoms during illness and for 7 days thereafter.
• Educate patient to use contraception reliably. If patient has missed pills or injections:
Late injection Missed/late Missed combined oral contraceptive pill

• < 2 weeks late: give injection, there is no loss of progesterone only pill • 1 active pill missed: take pill as soon as remembered and take next 1 at usual time.
protection. • Pill missed or > than 3 hours late: • 2 active pills missed: take last missed pill as soon as remembered and next 1 at usual
• ≥ 2 weeks late: exclude pregnancy. If pregnant 96. take pill as soon as possible and time. Use condoms or abstain for next 7 days.
If not pregnant, give injection and use condoms continue pack and use condoms • 2 or more pills missed in last 7 active pills of pack: omit the inactive tablets and
for 7 days. for 48 hours. immediately start first active pill of next pack.
• If unable to exclude pregnancy offer emergency • If ≤ 5 days since unprotected sex, • 2 or more pills missed in first 7 active pills of pack and patient has had sex: give
contraception 96, use condoms for 4 weeks, then give emergency contraception emergency contraception 96, restart active pills 12 hours later and use condoms
give injection if pregnancy test negative. 96. for next 7 days.

WOMEN'S HEALTH
The pregnant patient
Give urgent attention to the pregnant patient with any of:
• Fitting • Swollen red calf
• Diastolic BP ≥ 160 and proteinuria: pre-eclampsia • Vaginal bleeding
• Diastolic BP ≥ 90 and headache, blurred vision, abdominal pain: pre-eclampsia • Decreased/no fetal movements
• Temperature ≥ 38˚C and headache, weakness or back pain • Preterm labour: painful contractions, 3 per 10 minutes < 37 weeks
• Difficulty breathing • Preterm prelabour rupture of membranes < 34 weeks
Management:
• If fitting or having difficulty breathing give face mask oxygen. See below.
• If BP < 90/60 give IV Sodium Chloride 0.9% rapidly until BP > 90/60.
• If client has vaginal bleeding and is > 22 weeks pregnant, insert urethral catheter and check baseline Hb and blood group. Do not do a vaginal examination.
• If temperature ≥ 38˚C give Ceftriaxone 1g IM/IV, if unavailable Amoxicillin 1g orally. If also a vaginal discharge, give Metronidazole 2g orally as well.
• Manage further according to problem and refer same day:
Preterm labour Preterm prelabour Pre-eclampsia Fitting

Determine duration of pregnancy. rupture of membranes
• Give Sodium Chloride 0.9% 1ℓ • Place patient in lateral lying position. Avoid placing anything in the
26–33 weeks < 26 or ≥ 34 • Confirm amniotic slowly IV. mouth.
weeks fluid leak with sterile • Give Magnesium Sulphate 4g • Give facemask oxygen.
speculum, liquor is in 200mℓ ½ Darrows Dextrose • If glucose < 3.5 or unable to measure, give 50mℓ of 50% Glucose IV.
• Dexamethasone alkaline. 5% IV over 20 minutes and 5g • Give Dextrose 5% in Sodium Chloride 0.9% IV (30 drops/minute).
12mg IM, record Allow labour to • Avoid digital vaginal IM in each buttock. • Manage further according to gestation:
time given in continue. examination. • Insert urethral catheter and
referral letter. • Give Dexamethasone record urine output hourly.
• Give Sodium 12mg IM, record time • Stop Magnesium Sulphate ≥ 20 weeks - up to 1 week post partum: < 20
Chloride 0.9% given in referral letter. if urine output < 100mℓ in 4 Patient has eclampsia. weeks
300mℓ IV. • Refer same day. Ensure hours or respiratory rate < 16
• Then give bed rest en route to breaths/minute. • Give Magnesium Sulphate 4g in 200mℓ ½ Darrows 2
Nifedipine 20mg hospital. • Check BP after 15 minutes. If dextrose 5% IV over 20 minutes and 5mg IM in each
oral, then 20mg diastolic BP still ≥ 110, give buttock. Repeat 5g IM 4 hourly in alternate buttocks
after 30 minutes, Hydralazine 12.5mgIm till transferred to hospital.
then 20mg • Repeat BP after 30 minutes. If • Once fit is stopped insert urethral catheter.
4 hourly until diastolic BP still ≥ 110, repeat • Stop magnesium sulphate if urine output < 30mℓ in
transferred. Hydralazine preload with 300ml 1 hour or respiratory rate < 16 breaths/minute.
NS.
Then identify if the pregnant patient not needing urgent attention needs secondary level antenatal care:
• Current medical problems: diabetes, heart/kidney disease, asthma, epilepsy, on TB treatment, substance abuse, diastolic BP > 90 and SBP>140mmHg
• Current pregnancy problems: rhesus negative, multiple pregnancy, currently < 16 or > 36 years, vaginal bleeding or pelvic mass
• Previous problems: stillbirth or neonatal loss, > 3 consecutive spontaneous abortions, birth weight < 2500g or > 4500g, admission for pre-eclampsia, admission for hypertension or reproductive tract surgery
GGive routine antenatal care to the pregnant patient not needing urgent attention or secondary level antenatal care 99-100 .

Routine antenatal care
Assess the pregnant patient not needing urgent attention or secondary level antenatal care at booking visit and 5 follow-up visits at 16–20, 24–28, 32, 34–36, 38–40 weeks.
Symptoms Every visit Manage symptoms as per symptom page.
Estimated date of delivery 1st visit • Plot on antenatal card.
• If ≥ 42 weeks,. Refer immediately to a specialist Oby/Gyn
TB Every visit • If cough ≥ 2 weeks (or any duration if HIV), weight loss, poor weight gain or anaemia, check for TB 55.
• If patient has TB refer for secondary hospital antenatal care.
Mental health Every visit • If 2 or more of: a difficult major life event in last year, unhappy about pregnancy, absent or unsupportive partner, previous depression or anxiety, or experiencing violence at
home, screen for depression/anxiety 81. See also traumatised/abused patient 53.
• If taking ≥ 14 units of alcohol/week or misusing illicit or prescription drugs, screen for substance abuse 83 and refer for secondary hospital antenatal care.
Mid upper arm 1st visit • MUAC < 23cm: exclude TB and HIV, check weight at every visit, refer for nutritional support.
circumference • MUAC > 33cm: continue routine antenatal care but deliver at secondary hospital. Assess and manage CVD risk 68.
Abdominal examination Every visit • If mass other than uterus in abdomen or pelvis, refer for assessment.
• Measure symphysis-fundal distance and plot on antenatal card. Refer for assessment if discrepancy with EDD, <10th or > 90th centiles, or multiple pregnancy likely.
• Look for breech presentation. If present at 32/34 and 38 weeks, refer to high risk clinic.
Vaginal discharge Every visit If abnormal discharge, treat for STI 23. If discharge is runny, suspect premature rupture of membranes 96.
BP Every visit BP is normal if < 140/90. If raised, repeat after 1 hour rest:
• 2nd BP normal: repeat BP after 2 days.
• 2nd BP still raised: check urine dipstick for protein:
--No proteinuria: start Methyldopa 250mg 8 hourly and refer same week to high risk clinic.
--≥ 1+ proteinuria: refer patient same day. If abdominal pain, blurred vision, headache, treat for pre-eclampsia 96.
Urine dipstick: test clean, Every visit • If leucocytes and nitrites in urine treat for urinary tract infection 31.
midstream urine • If protein in urine and BP < 140/90: if dysuria, frequency, treat for urinary tract infection 31. Repeat urine dipstick for protein after 2 days - if still 1+ proteinuria and BP <
140/90, refer to the nearest doctor’s clinic same week. If BP raised see above.
• If glucose in urine, check random blood glucose.
Random blood glucose If glucose in urine • If random blood glucose ≥ 11: refer to high risk clinic same day. If glucose > 15 and ketones in urine, give sodium chloride 0.9% IV 1ℓ 4 hourly and short-acting insulin 10IU IM.
• If random blood glucose 8–11, repeat blood glucose after an 8 hour fast.
--Fasting blood glucose 6–8: assess and manage CVD risk 68. Refer to high risk clinic for next antenatal visit.
--Fasting blood glucose ≥ 8: refer to high risk clinic same day.
Haemoglobin 1st visit and if patient pale • Refer to high risk clinic if < 34 weeks and Hb < 8, or ≥ 34 weeks and Hb < 10.
• Treat if Hb < 10 99-100. Repeat Hb monthly.
HIV 1st visit and at 36 weeks if • If status unknown test for HIV 60. If patient refuses, offer at each visit, even in early labour.
negative • If positive give routine HIV care 61-67 and antiretrovirals 61-67.
CD4, stage, baseline bloods At 1st visit if HIV not on ART Assess stage and baseline bloods 67
Rhesus 1st visit If rhesus negative refer to high risk clinic.
Syphilis 1st visit If positive give Benzathine Penicillin 2.4MU IM weekly for 3 weeks 28.

WOMEN'S HEALTH
The unconscious patient Advise the pregnant patient
E
• Advise to stop smoking and to stop drinking alcohol.
N
• Discuss safe sex. Advise patient to use condoms throughout pregnancy and have only 1 partner at a time.
LI
• Complete antenatal card and give to patient, remind patient to bring it to every visit and when in labour.
• Ensure patient knows the signs of a pregnancy emergency 96 and of early labour.
• Discuss contraception following delivery 96-104.
• Advise HIV negative patient to exclusively breastfeed for 6 months.
D E
UI
• Help HIV patient decide on feeding choice depending on preference, social or family support, availability and affordability of formula, and access to safe, clean water.
Treat the pregnant patient
T G
• Give Ferrous Salt/Folic Acid 60/0.25mg 1 tablet daily. Avoid tea within 2 hours of taking tablet. If Hb < 10 add ferrous salt 60mg tablet daily for 3 months after Hb > 11.
E N
• Prevent tetanus with 5 Tetanus Toxoid injections in a lifetime: TT1 at first visit, TT2 after 4 weeks, TT3 6 months later, TT4 1 year after TT3, then TT5 1 year after TT4.
• Prevent malaria if not on co-trimoxazole in a malaria area: from 14 weeks Proguanil 200mg daily and Chloroquine 300mg weekly. Ensure use of an insecticide-treated bednet.
M
• Treat the HIV patient:
T
--Give Co-Trimoxazole 960mg daily if stage 3 or 4 or CD4 ≤ 200.
EA
--The pregnant HIV client needs antiretrovirals. Manage as below:
T R
Is the client on ART?
On ART
Is client on efavirenz and < 12 weeks?
H I V Not on ART
• If client ≥ 28 weeks pregnant start AZT 300mg 12 hourly same day. Aim to switch to ART within 1 week.
6
• If < 28 weeks pregnant, start ART work-up same day 61. Aim to start within 2 weeks.
01
No Yes
CD4 ≤ 350 and/or stage 3 or 4 CD4 > 350 and stage 1 or 2
2
• Continue ART • Switch efavirenz to
throughout pregnancy nevirapine 200mg 12 hourly Patient needs ART. Patient needs triple antiretroviral prophylaxis (TAP).
E
and labour. if client adherent and viral
H
load in past 3 months < 400. • If < 14 weeks, avoid EFV 60. • Wait till 14 weeks to start TAP 60.
O T • Client must remain on ART for life. • If client is well and still stage 1 or 2, stop TAP 6 weeks after last breastfeed
or if formula feeding 6 weeks following delivery 101.
R T
• When in labour:
F E --Continue ART and

--Give AZT 300mg 3 hourly up to 1500mg or until delivery and
R E --If not on ART or on ART ≤ 4 weeks, also give single dose Nevirapine 200mg in confirmed early labour.
• Give baby born to HIV positive mother:
--Single dose Nevirapine syrup 6mg. If low birthweight or preterm, give 2mg/kg instead.
--4-week course of AZT: 4mg/kg 12 hourly. If low birthweight or preterm, give instead 2mg/kg 12 hourly for 2 weeks then 2mg/kg 8 hourly for 2 weeks.
Give postnatal care to patient and baby 101.

Postnatal care
Assess the mother and her baby 6 hours, 7 days and 6 weeks following delivery
Assess When Note
Symptoms Every visit • Manage mother’s symptoms as on symptom page. Manage baby’s symptoms with IMCI guide.
• If baby has swollen eyelids and pus in eyes, treat below. Refer after 2 days if no better. Treat mother and partner for vaginal discharge 23.
Mental health Every visit • If patient not interacting with baby and/or 2 or more of: a difficult major life event in last year, unhappy about pregnancy, absent or unsupportive partner, previous depression or anxiety,
violence at home, screen for depression/anxiety 86. See also traumatised/abused patient 53.
• If taking ≥ 14 units of alcohol/week or misusing illicit or prescription drugs, screen for substance abuse 89.
Family planning Every visit Assess client’s family planning needs 99-97.
Infant feeding Every visit Monitor baby’s weight as per IMCI guideline. If breastfeeding, check for problems 18. If formula feeding ensure correct mixing.
Uterus Every visit Ask about excessive blood loss. Rehydrate and refer same day. If painful abdomen, smelly vaginal discharge, temperature ≥ 38˚C, give Benzyl Penicillin 5MU IV and refer same day.
BP Every visit If diastolic ≥ 90, recheck after 1 hour rest, if still raised or any of headache, abdominal pain, blurred vision, refer urgently.
BMI Every visit Mother’s BMI is weight (kg) ÷ height (m) ÷ height (m). If < 18.5, arrange nutritional support.
HIV Status unknown • Give routine HIV care 67.
Syphilis If not checked • If mother positive and not already treated, assess, advise and treat 23. Treat baby as below.
• Look for congenital syphilis in baby: ascites, oedema, jaundice, hepatosplenomegaly, runny nose, hoarse cry, skin rash, pseudoparalysis of a limb.
Pap smear 6 week visit • Check pap smear if 30–49 years and not done in past 5 years. If HIV, check pap smear at diagnosis and 3 yearly if normal 27.
Advise the mother

• Encourage mother to become active soon after delivery, rest frequently and eat well. Arrange support for the mother who has little support at home.
• Advise on perineal and wound care following delivery.
• Advise client to return urgently if excessive vaginal bleeding, sepsis, dizziness, severe headache, blurred vision, severe abdominal pain occur or baby is unwell.
• Suggest exclusive formula feeding if mother has HIV and formula is affordable, feasible, accessible, safe and sustainable. Check correct mixing. Discourage mixed feeding.
• If HIV negative or HIV positive on ART and unable to do formula, encourage exclusive breastfeeding for 6 months: baby gets only breast milk (no formula, water, cereal).
• From 6 months, introduce food while continuing with feeding choice. If HIV, consider weaning over 1 month to formula if affordable, feasible, acceptable, safe and sustainable.
Treat the mother

• Continue Ferrous Salt/Folic Acid 60/0.25mg 1 tablet daily for 6 weeks after delivery.
• Ensure Tetanus Toxoid schedule is up to date: 0.5ml subcutaneous/IM, up to 5 in a lifetime: 2nd after 4 weeks, 3rd after 6 months, 4th and 5th each after 1 year.
• If HIV with baseline CD4 > 350 and well, still stage 1 or 2, stop TAP 6 weeks after last breastfeed or 6 weeks after delivery if formula feeding: stop EFV/NVP. Continue 3TC/FTC + AZT/TDF for 1 week, then stop.
• If mother has HIV and on lifelong ART, continue with it 67.
Treat the baby

• Give immunisations as per standard schedule. If mother has HIV manage baby as per 2012 Botswana National HIV&AIDS Treatment Guidelines.
• If swollen eyelids and pus in eyes: give Ceftriaxone 50mg/kg single dose IM and Erythromycin 50mg/kg 6 hourly for 14 days. Treat mother and partner/s for vaginal discharge 23.
• If mother had syphilis or genital ulcer during pregnancy/post delivery and no congenital syphilis, give 1 dose Benzathine Penicillin 50 000 IU/kg IM. If congenital syphilis, refer

WOMEN'S HEALTH
Menopause: diagnosis and routine care
Menopause is the cessation of menstruation for at least 1 year. Most women have menopausal symptoms and irregular periods during the perimenopause.
Assess the menopausal patient

Symptoms Every visit • Ask about menopausal symptoms: flushes, sexual problems 30, sleeping problems 54, headache 9, mood changes.
• If other TB symptoms like weight loss and cough ≥ 2 weeks, exclude TB 55.
• If low mood or sadness, loss of interest or pleasure, feeling tense, worrying a lot or not coping as well as before, consider depression/anxiety 87-88.
• Manage other symptoms as on symptom pages.
Vaginal bleeding Every visit Refer within 2 weeks if bleeding between periods, after sex or after being period-free for 1 year.
CVD risk First visit • Assess CVD risk 68.
BP 3 monthly on HRT • Interpret BP result 79.
Osteoporosis risk First visit If < 60 years with loss of > 3cm in height and fractures of hip, wrist or spine; previous non-traumatic fractures; oral steroid treatment for > 6 months; onset of
menopause < 45 years; BMI < 19; Heavy alcohol user; heavy smoker
Family planning First visit If < 50 years, give contraception for 2 years after last period; if ≥ 50 years, for 1 year after last period 96.
Breast check First visit, yearly on HRT If any lumps found in breasts or axillae, refer same week.
Pap smear When needed If HIV negative and 30–49 years, check 5 yearly. If > 49 years and never had a Pap, do one. If HIV check at diagnosis then 3 yearly if normal 27.
Advise the menopausal patient

• To cope with the flushes, advise patient to dress in layers and to decrease alcohol and caffeine intake.
• Help patient to manage CVD risk if present 72-74.
• If patient is having mood changes and/or not coping as well as in the past, refer to counselor, support group.
• Educate the patient about the risks, contraindications and benefits of HRT and that it can be used to treat menopausal symptoms for up to 5 years. Risk of breast cancer, DVT and cardiovascular disease
increase with increasing age. 6–12 months after discontinuation risk is equivalent to rest of population.
• Advise increase weight bearing exercise such as walking, stop smoking, decrease alcohol and Calcium supplement – 500-1000mg od
• Refer to possible HRT or bisphosphonate therapy.

Health education and counselling on tobacco
Protocols for primary care - Health Education and Counseling ON TOBACCO Classification Of Pure Alcoholic Drink Intake On Average Per Day
Type of Drink Male Female
NO Reinforce message that tobacco Standard drink 10gof pure alcohol per 10gof pure alcohol per
ASK
Do you use increases risk of Heart Disease day(1 drink) day(1 drink)
Tobacco? Hazardous drinking 40-59.9g of pure alcohol 20-39.9g of pure alcohol
per day (4 - < 6 drinks per day (≥2 - < 4 drinks)
Advise to quit in a clear, strong and personalized
manner
Harmful drinking ≥60g of pure alcohol per ≥40 g of pure alcohol per
“Tobacco use increases the risk of developing a heart
day (≥6 drinks) day(≥4 drinks)
ADVISE attack, stroke, lung cancer and respiratory diseases.
YES Quitting tobacco use is theone most important thingyou
can do to protect your heart and
health, you have to quit now.”
ASSESS Are you willing to make a quit attempt now?
YES NO
Assist in preparing a Promote

quitting plan motivation to quit
• Set quit date Provide information
• Inform family and friends on health hazards
ASSIST • Ask for their support of tobacco and give
• Remove cigarettes/tobacco leaflet to the patient
• Remove objects/articles
that prompt you to smoke
Arrange follow up visit*
AT FOLLOW-UP VISIT
ARRANGE Congratulate success and reinforce if patient has relapsed,
consider more intensivefollow-up and support from family
* Ideally second follow-up visit is recommended within the same month and every month thereafter for 4
months and evaluation after 1 year. If not feasible, reinforce counseling whenever the patient is seen for
blood pressure monitoring.

WOMEN'S HEALTH
Cervical screening – PAP smear/VIA
Give urgent attention to the patient who is unconscious and fitting:
• Pap/cervical smears/VIA detect cervical abnormalities which occur before cancer develops. Cervical cancer is caused by some types of human
papilloma virus (HPV), usually transmitted sexually.
• The woman who smokes is more likely to have cervical abnormalities. Advise smokers to stop.
• An asymptomatic HIV-negative woman age 30–49 years should receive a smear 5 yearly.
• An HIV-positive woman should receive a Pap smear/VIA on diagnosis, regardless of her age. If the result is normal, she needs a Pap smear 3 yearly.
• In pregnancy, Pap smears/VIA can be performed safely up to 30 weeks’ of gestation.
• If the patient has an abnormal vaginal discharge, treat the discharge first 25 and then take a Pap smear at a follow-up visit.
• If the patient is menstruating, defer the Pap smear/VIA to another visit.
Manage according to the Pap result
• Unsatisfactory smear: repeat repeat immediately. • Suspicious of cancer: Refer urgent for colposcopy.
• ASC-US: repeat within 6 months. • LSIL: repeat after one year.
• 2 consecutive ASC-US: refer for colposcopy. • 2 consecutive LSIL: refer for colposcopy.
• andASC-H ( ASC-US ?HSIL) or AGUS – refer for • HSIL: refer for forcolposcopy.
colposcopy.n • Normal: arrange repeat Pap date according to HIV status.
Inform patient of symptoms of cervical cancer (abnormal bleeding, vaginal discharge) and instruct her to return should they occur.
ASC-US: Atypical squamous cells of undetermined significance; LSIL: Low-grade squamous intraepithelial lesions; HSIL: High-grade squamous intraepithelial lesions;
ASC-H: Atypical cells - cannot exclude HSIL; AGUS: Atypical glandular cells of undetermined significance

Assessment of suspected cervical cancer
Women who present the following persistent and unexplained signs and symptoms should seek consultation at a PHC:
a) Abnormal vaginal bleeding (i.e. after coitus, between menstrual periods, post menopause)
b) Foul-smelling discharge
c) Pain during vaginal intercourse
d) Any of the above associated with palpable abdominal mass with persistent low back or abdominal pain
Assess likelihood for cervical cancer

• Assess signs and symptoms (i.e. history, intensity, duration, progression)
• Identify relevant risk factors: age (30 years old and above)
• Speculum examination
• Differential diagnosis: abortion in pre-menopausal women, infections (e.g. Chlamydiae, gonococcal, etc.), genital ulcers, cervical inflammation, uterine
polyps, dysfunctional uterus hemorrhage, endometrial or vaginal cancer
Women presenting with a) b) or c) Women presenting with d)
Without clinically With clinical detected

detected cervical cervical growth or
growth or ulceration ulceration
Follow obstetric
and gynecological
guidelines as
appropriate
Refer if condition is not

manageable at PHC,
persists or worsens Refer immediately to next level
Reference: Guidelines for referral of suspected breast and cervical cancer at primary care

WOMEN'S HEALTH
Assessment of suspected breast cancer
Women who present the following persistent and unexplained signs and symptoms should seek consultation at a PHC:
a) Breast lump, or any change in the shape or consistency of the breast
b) Breast lump that enlarges and/or is fixed and hard
c) Other breast problems (i.e. eczematous skin changes, nipple retractation, peaud’orange, ulceration, unilateral nipple discharge – particularly bloody discharge –,
lump in the axilla) with or without palpable lump
Assess likelihood for breast cancer

• Assess signs and symptoms (i.e. history, intensity, duration, progression)
• Identify relevant breast cancer risk factors (such as age, family history, previous history of breast cancer, chest irradiation)
• Clinical examination of both breasts, axillae and neck
• Differential diagnosis: benign breast diseases (e.g. fibroadenoma, fibroadenosis, mastitis, abscess, etc.)
Women < 30 years old Women 30 years old and above
Presenting with a) Presenting with: Presenting with:

a) + relevant risk factors, a) + relevant risk factors,
or b) or c) or b) or c)
Invite for follow-up
visit after menstrual
period
Follow-up visit: if b) or c) Refer immediately to next level
Note: Referral of women with small breast lumps may lead to diagnosis of “early breast cancer”

End of life: routine care
A doctor should confirm the diagnosis that the patient with an incurable illness needs end-of-life care:
• Would you be surprised if the patient died within the next year? If the answer is no then the patient needs end of life care and/or
• Patient with advanced disease chooses end-of-life care only and refuses curative care and/or
• Patient with end-stage heart failure 81, COPD 68, kidney failure, advanced cancer, dementia 92, HIV failed regimen 3 ART 61-67, MDR TB treatment failure 115.
Assess the patient needing end-of-life care

Assess Note
Symptoms • Manage on symptom pages: constipation, nausea/vomiting, difficult swallowing, difficult breathing/cough, sore mouth, weight loss, incontinence, vaginal discharge.
Pain • Does pain limit activity or disturb sleep? Is medication helping? Grading the pain 1–10 may help the client to decide if s/he needs to start or increase pain treatment.
• Infection will cause and worsen pain. If new or sudden pain, temperature > 38˚C, tender swelling, redness or pus, also treat on symptom page. If no better, refer or discuss.
Sleep If client is having difficulty sleeping 54.
Mental health Look for mental health problem and deal with bereavement issues for the client and carer 52.
Side effects Manage side effects on symptom pages: nausea, confusion and sleepiness on morphine usually resolve after a few days. High dose morphine can cause respiratory depression, see below.
TB Exclude TB if cough ≥ 2 weeks 55. Do not stop TB treatment prematurely.
Carer Ask how the carer is coping and what support s/he needs.
Mouth Check oral hygiene and look for dry mouth, ulcers and thrush 14.
Bed sores If patient is bedridden, check common areas for damaged skin (change of colour) and bedsores (see picture). If client has bedsore 46.
Advise the patient needing end-of-life care and his/her carer

• Explain about the condition and prognosis. Explaining what is happening relieves fear and anxiety. For tips on communicating effectively 111.
• Support the patient to give as much self care as possible. Refer patient and carer to available palliative carer, support group, counsellor, spiritual counsellor or pastoral care.
• Prevent contractures/bedsores if bedridden: wash and dry skin daily. Keep linen dry. Move (lift, do not drag) patient every 2–4 hours if unable to shift own weight.
• Prevent mouth disease: brush teeth and tongue regularly and rinse mouth with ½ teaspoon each of salt and bicarbonate of soda 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.
Treat the patient needing end-of-life care

• Aim to have patient pain free and as alert as possible. If patient has any pain, start or increase pain medication stepwise if adherent to current treatment:
Step Drug Start dose Maximum dose Note
First give Paracetamol and 1g 4 hourly 4g daily Advise patient to take 2 tablets of paracetamol and if the pain does not resolve, 4 hours later take paracetamol and
Aspirin or 600mg 4 hourly 3.2g daily ibuprofen or aspirin. Avoid aspirin if history of peptic ulcer or bleeding. Give aspirin or ibuprofen for 5 days maximum as risk
Ibuprofen 400mg 6 hourly of side effects is high. Review after 2 days, earlier if no relief.
If pain persists, add Codeine 30mg 4 hourly 240mg If no diarrhoea, give liquid paraffin to prevent constipation. Review after 2 days.
If pain persists, stop Morphine – oral or rectal 5mg 4 hourly None. If RR < 16, skip 1 • If no diarrhoea, give liquid paraffin to prevent constipation.
codeine and add if unable to swallow dose, then halve dose. • If pain persists after 24 hours, increase dose by 1.5–2. If no better after 2 days, or RR < 16 persists, refer or discuss.

END OF LIFE
Prep room assessment of the patient
Ensure the patient with any of the following gets urgent attention:
• Decreased level of consciousness • Difficulty breathing, breathless while talking
• Fitting • Unable to walk unaided
• Aggressive, confused or agitated • BP ≥ 180/110 or < 90/60 or if pregnant diastolic ≥ 90
• Recent sudden weakness • Headache with vomiting
• Chest pain • Overdose of drugs/medication
Assess the patient not needing urgent attention in the prep room
Has the patient been coughing ≥ 2 weeks?
• Assign the patient with cough to the fast track/coughing queue.
• Collect first sputum for TB 55.
Does the patient know his/her HIV status?
• If no, urge patient to test for HIV.
• If yes and patient negative, encourage patient to test once a year. Record date last tested in patient OPD card.
If the patient is a woman:
• Exclude pregnancy. If late menstrual period do a pregnancy test.
• Check if patient needs a Pap smear: if HIV negative and 30–49 years, do Pap 5 yearly; if HIV positive, Pap smear at diagnosis and then if normal 3 yearly 27.
Do prep room tests according to condition:

Is patient pregnant or known to have diabetes, hypertension, stroke, ischaemic heart disease or peripheral vascular disease?
Patient has hypertension, stroke, ischaemic Patient has diabetes. Patient is pregnant. None of the above
heart disease and/or peripheral vascular
disease.
heck at every visit:
C heck at every visit:
C The patient over 40 years needs a
• BP • Weight cardiovascular disease risk calculated at
Check at every visit: • Finger prick glucose • BP least every 3 years 71:
• BP • Weight • Urine dipstick • Weight
• Weight (kg) • Waist circumference • Height
• Waist circumference (cm) • Urine dipstick only if glucose ≥ 15 Also check at first visit: • BP
• Height (m) – 1st visit only • MUAC • Finger prick glucose
Check once a year: • Hb if pale
Calculate BMI: weight (kg) ÷ height (m) ÷ • Urine dipstick • Rhesus: Rh factor
height (m) • HbA1c • Syphilis: RPR/VDRL
• HIV status
Check once a year:
• Fingerprick glucose
• Urine dipstick

Protect yourself from occupational infection

Adopt measures to diminish your risk of occupational infection
Protect yourself Protect your facility
Adopt hygienic practices Clean the facility
• Wash hands regularly with soap and water. Use alcohol-based hand-cleaner regularly. • Wash all surfaces (including door handles, telephones, keyboards) daily
• Adopt universal precautions in your approach to all patients. with chlorine disinfectant.
• Wear gloves when handling specimens. Ensure adequate ventilation
• Do not recap needles or walk with uncapped needles. Dispose of sharps in the correct manner. • Regularly clean extractor fans.
Get vaccinated • Open windows and use fans to increase air exchange.
• Get vaccinated against hepatitis B. Organise waiting areas
Know your HIV status • Prevent overcrowding in waiting areas.
• If status unknown, test for HIV 60. • Fast track influenza and TB suspects.
• If HIV positive, you are entitled to work in an area of the facility where exposure to Manage sharps safely
TB (especially drug-resistant TB) is limited. • Ensure sharps containers are easily accessible and regularly replaced.
Wear a face mask Manage infection control in the facility
• Wear a N95 respirator when in contact with TB suspects. • Ensure your facility has an infection control plan.
• Wear a surgical facemask when in contact with influenza suspects. • Appoint an infection control officer for the facility to coordinate and monitor infection control
policies.
Approach to possible occupational exposure
TB HIV Influenza
Identify TB suspects promptly • Consider HIV post-exposure prophylaxis (PEP) if you have • Wash hands with soap and water.
• Separate TB suspects from others in the facility. a high risk exposure1. If uncertain, discuss urgently with • Wearing a surgical face mask over the mouth and nose
• Educate TB suspect about cough hygiene. specialist. may be protective when performing procedures on
• Collect sputum outside or in a well-ventilated space only. • Wash exposed area thoroughly. patient suspected of influenza.
• Provide a surgical face mask or tissues to cover mouth • Avoid using antiseptic, bleach or other caustic agents. • Encourage patient who coughs and sneezes to cover
and nose to protect others from infection. • Identify source patient HIV status 60. If unable to mouth/nose with a tissue, to ensure used tissues are
Diagnose TB rapidly ascertain, give PEP. disposed of correctly and to wash hands regularly with
• Complete TB workup in < 4 visits and start treatment as • If health worker status unknown, test for HIV 60. If health soap and water.
soon as diagnosed. worker refuses HIV test, do not give PEP. • Advise patient with symptoms of influenza to stay
Protect yourself from TB • If health worker HIV negative, give PEP ideally within 4 indoors and avoid close contact with others.
• Wear an N95 respirator (not a surgical mask) when in hours and no later than 72 hours of exposure: TDF/FTC/EFV
contact with a patient with untreated or MDR TB. 1 tablet daily for 1 month.
• Check ART bloods as per schedule 61.
• Do not delay PEP for blood tests.
• Repeat HIV test at 6 weeks, 3 and then 6 months.
High risk exposure is the contact of mucous membranes or a break in skin with infectious body fluid/s (blood, genital discharge, breast milk, synovial, cerebro-spinal, amniotic, pleural or pericardial fluid) of a patient with HIV, of unknown HIV status or who tests
1
HIV negative but is possibly in the window period.

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:
• Intoxicated at work – drugs, alcohol
• Aggressive or violent behaviour at work
• Marked inappropriate change in behaviour
• Suicidal thoughts/attempt
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 111.
• Exercise, eat sensibly, minimise alcohol and don’t smoke 103. • Treat colleagues and patients with respect.
• Get screened for chronic conditions as on page 110. • Support each other. Consider setting up a staff support group.
Look after your chronic condition if you have one: • Don’t complain, rather focus on what can be done to effect a solution.
• Adhere to your treatment and your appointments. Cope with stressful events
• Don’t diagnose and treat yourself. • Develop or access policies or procedures to deal with events like complaints,
• If you can, confide in a trusted colleague/manager. harassment/bullying, accidents/mistakes, violence, or staff or patient death.
Manage stress: Look at how to make the job less stressful:
• Delegate; learn to say ‘no’, 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 remedied to make the job easier and frustrations fewer:
• Take time to do a relaxing breathing exercise each day. equipment, drug supply, training, space, décor in work environment
• Find a fun or creative activity to do. • Discuss each team member’s role. Ensure each one has say in how s/he does his/her
• Spend time with supportive family or friends. work.
Have healthy work habits: • Support each other to develop skills to better perform your role.
• Manage your time sensibly. Celebrate:
• Take a breath between patients and observe scheduled breaks. • Acknowledge the achievements of individuals and the team.
• Remind yourself of your purpose as a clinician. • Share patient gratitude with team members.
• Be sure you are clear about your role and responsibilities.
Identify occupational stress in yourself and your colleagues

Possible alcohol or drug problem Change in mood Recent distressing event Poor attendance at work arked decline in work
M
• Drinks > 21 drinks/week (man) or 14 • Indifference • Diagnosis of chronic condition • Frequent absenteeism performance
drinks/week (woman) or > 5 drinks per • Irritability • Bereavement • Frequent lateness • Forgetful
session • Low mood or sadness • Needlestick injury • Often takes sick leave • Inattention to detail/carelessness
• Smells of alcohol • Loss of interest or pleasure • Traumatic event • Fatigue
• Using illicit or misusing prescription drugs • Feeling tense, worrying a lot
The health worker with any of the above may have substance abuse, stress, depression/anxiety or burnout and might benefit from referral for assessment and follow-up.

Communicating effectively
Communicating effectively with your patient during a consultation need not take much time or specialised skills.
Try to use straightforward language and take into account your patient’s culture and belief system.
Integrate these four communication principles into every consultation:
Listen
Listening effectively helps to build an open and trusting relationship with the patient.
DO The patient might feel: DON’T The patient might feel:
• give all your attention • ‘I can trust this person’ • talk too much • ‘I am not being listened to’
• recognise non-verbal behaviour • ‘I feel respected and valued’ • rush the consultation • ‘I feel disempowered’
• be honest, open and warm • ‘I feel hopeful’ • give 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.
• use open ended questions • ‘I choose what I want to deal with’ • force your ideas onto the patient • ‘I am not respected’
• offer information • ‘I can help myself’’ • be a ’fix-it’ specialist • ‘I am unable to make my own decisions’
• encourage patient to find solutions • ‘I feel supported in my choice’ • let the patient take on too many problems at • ‘I am expected to change too fast’
• respect the patient’s right to choose • ‘I can cope with my problems’ once
Empathise
Empathy is the ability to imagine and share the patient’s situation and feelings.
• 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.
• get the patient to summarise • ‘I can make changes in my life’ • direct the decisions • ‘My health worker disapproves of my
• agree on a plan • ‘I have something to work on’ • be abrupt decisions’
• offer to write a list of his/her options • ‘I feel supported’ • force a decision • ‘I feel resentful’
• offer a follow-up appointment • ‘I can come back when I need to’ • ‘I feel misunderstood’

Adult Primary prevention visit
Adult Primary prevention visit :
• The primary prevention visit is intended to provide screening evaluation for males and females aged 40 years or more, who are without known medical diagnosis. These individuals should undergo
this evaluation every 2-3 years.
• The evaluation is intended to diagnose early or facilitate early intervention for conditions that contribute significant morbidity or mortality, including: Hypertension, Overweight/obesity, smoking,
harmful use of alcohol or other substances, early cancer.
• The evaluation is designed to be feasible at the primary care level and with minimal technology – employing history taking, physical exam, and Blood pressure and body measurements only.
Assess Note
Symptoms If any symptoms or known diagnoses, reference the relevant chapter/section in the PHC guidelines
Depression and other psychological symptoms If patient reports low mood or loss of interest in previously pleasurable activities, or feeling tense or anxious or worrying a lot about things, consider depression/anxiety page 81.
Family planning measures Review contraceptive options, if would like to change see page XX (contraceptives)
BP If SBP >= 140 or DBP >= 90, repeat BP the following day and reference page XX (Hypertension)
BMI (weight, height) BMI is weight (kg)/[height (m) x height (m)]. If BMI > 25, calculate target weight: 25 x height (m) x height (m)
Waist circumference Measure on breathing out midway between lowest rib and top of iliac crest. Aim for < 80cm (woman), < 94cm (man)
Tobacco use If smokes, advise patient to stop smoking
Alcohol use If uses illicit substances or alcohol use is > 21 drinks/week (man); > 14 drinks/week (woman); or > 5 drinks/session, see page XX (Substance abuse)
Complete physical exam If any abnormalities, reference the relevant chapter/section in the PHC guidelines
Clinical breast exam If lump detected, see page XX (Breast symptoms)
Pelvic exam with pap smear If services available at given facility, can consider VIA based cervical cancer screening instead
• Provide counseling on healthy diet, weight, physical activity, alcohol use (see figure below); Where relevant provide counseling and refer for supports related to smoking cessation, harmful alcohol use,
substance use, and mental illness
• For patients who screen positive, further evaluation should include cardiovascular risk assessment and any other steps included in the table above. For patients with known diagnoses or
identified symptoms, management should be guided by the relevant sections of the Primary Care guidelines for these diagnoses or symptoms.
• Schedule next visit appropriately:
--If all evaluation is normal, repeat check in 2-3 years;
--If new diagnosis, follow up as per relevant section in the Primary care guidelines;
--All routine referrals for suspected diagnosis should be within 1-2 weeks
111
Annex 1: Diagnostic Algorithm for TB(a)
All people suspected of TB (Presumed -TB)
(adults- Cough of any duration, fever, night sweats or weight loss) Children < 12 years- any 2 of the following-
• History of recent TB contact (past year),Cough >- 2 weeks, Fever >- 2 weeks, Failure to thrive (weight loss or no weight gain in 3 months), Fatigue or reduced playfulness >- 2
weeks, Enlarged lymph nodes (greater than 1x1cm) >- 2 weeks
1. Collect ONE **SPECIMEN for Xpert (spontaneous or induced sputum, gastric lavage, lymph node fine needle aspirate, pleural biopsy or cerebro-spinal fluid)
2. Test for HIV
3. IF under 12 years – do CXR-PA and lateral , TST in addition to genexpert
Xpert results MTB detected MTB detected, MTB detected Rifampicin MTB not detected Invalid, Error or no Result
No Rifampicin (RIF) Rifampicin (RIF) resistance (RIF) resistance detected
Resistance indeterminate
M. tuberculosis detected: Consider the HIV* Xpert test failed

M. tuberculosis detected: TB M. tuberculosiss detected
TB diagnosis status and age of the No interpretable result
Interpretation diagnosis Sensitive to rifampicin Rifampicin resistant
No result available for patient
Presumed MDR-TB
Rifampicin resistance
• 1.Collect another
• *Start retreatment 1. Send another sample sample
Interpretation • TB regimen if history 1. Send another sample for LPA, culture & DST Consider other
for repeat Xpert • 2. Repeat Xpert
of TB treatment 2. Refer to MDR-TB Site diagnoses and refer to
2. *While waiting start for MDR-TB algorithm below
new or retreatment TB treatment initiation
Action • *Start new TB regimen if
no TB treatment history
*If Xpert remains • *If HIV positive initiateCotrim and ART
Send another sample indeterminate send
Monitor for LPA, culture & DST another sample for LPA,
Culture and DST
microscopy at 2/3 microscopy at 3 and
and 5/6 months 7/8 months
• If smear positive, check adherence and send

sputum specimen for culture & DST

Annex 1: Diagnostic Algorithm for TB (b)
Patient with TB symptoms
Xpert MTB Not detected
Age of the patient

• < 12 yrs • ≥ 12 yrs
danger signs (-) ++danger signs (+) follow IMCI guidelines • HIV (+) • HIV (-)
Reassess the patient

REVALUATE FOR TB • Clinically stable Re-assess the patient clinically and consider other
HIV test if not doneTST* 2 sputum samples for 1 genexpert# and 1 culture diagnosis
2 sputum samples for 1 genexpert# and 1 culture If adult cannot produce sputum, collect 2 induced
If child cannot produce sputum, collect 2 gastric REREVALUATE FOR sputum samples for genexpert and smear/culture
aspirates or 2 induced sputum samples for genexpert TBLUATE CXR Treat with appropriate
and culture (If patient is being antibiotics
CXR- PA and Lateral reevaluated and has a
TB contact consider
TB treatment**# if most AFB/genexpert#/ AFB/genexpert/
TST (+) or AFB/ TST (-), AFB/genexpert/ likely diagnosis or refer culture (+) or CXR culture (-) and CXR
• DST/genexpert
genexpert#/ culture (-) and CXR to higher level care for suggests TB doesn’t suggest TB
shows no drug
culture (+) or CXR does not suggest TB further evaluation)
resistance
suggests TB
Treat for TB * Treat with appropriate Re-assess the patient after 2 weeks
antibiotics
Treat for TB* Treat with appropriate No response or

antibiotics and follow up partial response# DST/genexpert DST/genexpert If still symptomatic
shows drug shows drug If well and
in 7-10 days and consider and sick
resistance resistance asymptomatic
other diagnoses Consider other
Advise to return when
symptoms recur* diagnosis or refer for
Good Response *Refer to MDR- reevaluation
Continue TB
TB treatment
treatment
initiation Site
HIV (+) HIV (-)
Discharge HIV care
113
Annex 1: Diagnostic Algorithm for TB (c) among patients > 12 years old
Patient with TB symptoms
Xpert MTB Not detected
HIV positive or < 12 years Age of the patient
Re-assess the patient clinically Consider other diagnosis

Do a chest x-ray
Collect two specimen for one for microscopy&Xpert
and the 2nd culture and DST Treat with appropriate antibiotics
X-ray findings consistent X-ray findings normal Re-assess the patient after one week
with TB
Start new or retreatment Treat with antibiotics If well and asymptomatic If still symptomatic and
TB regimen No follow up is required sick Consider other
Advise to return when diagnosis
DST shows no drug DST shows drug symptoms recur
resistance resistance
Continue TB treatment DST shows drug *If HIV positive initiateCotrim and ART
Start TB treatment if not resistance
on treatment
*Refer to MDR-TB
treatment initiation Site
**If the specimen is pleura fluid, send for culture and DST not for geneXpert
**If the specimen is bloody, please repeat the sample, Xpert cannot be performed on bloody samples.

Annex 2
Recommended Adult Treatment Regimens For TB FIXED - DOSE COMBINATION DRUGS
TB Treatment Regimensa FDCs advantages:

• Clear dose recommendations and easy dose adjustments simplify treatment and reduce
Treatment TB Patients Intensive Phase Continuation prescription errors
Group (daily) PP Phase (daily) • Fewer tablets to swallow which may encourage adherence
• Patients must take all required drugs, reducing the development of drug resistance
New All new adult cases of TB regardless of site, 2HRZEP 4HRE • Improved drug procurement, distribution, dispensing and handling at all levels
smear results or severity of disease FDCs Disadvantages:
Retreatmentc Previously treated cases of TBP: 2HRZES/1HRZEd 5HRE • Prescription errors may still occur, leading to excess dosage and toxicity, or under dosage and the
- Retreatment after relapse development of drug resistance
- Retreatment after default • The ease of treatment may tempt HCW to allow patients to self-administer therapy. FDCs are not a
- Retreatment after treatment failure guarantee of adherence and DOT must still be given.
• FDCs do not remove the need for single drugs. Single-dose formulations must be used in cases of
MDR-TB Patients with confirmed or strongly See Chapter 7 of drug-resistance or adverse events.
suspected the 2012 BNTBP for
MDR-TBP details about MDR-TB
treatment. Formulations Abbreviation
Rifampicin 150mg/ Isoniazid 75mg/Pyrazinamide 400mg/Ethambutol 275mg R 150 H 75Z400 E275
Rifampicin 150mg/Isoniazid 75mg R150H75
Recommended Adult Treatment Regimens For TB Rifampicin 150 mg/Isoniazid 75 mg/ Ethambutol 275 mg R150H75E275
Drug Recommended daily dose in mg/kg body weight (range) Ethambutol 400mg/Isoniazid 150mg E400H150
Isoniazid (H) 5 mg (4-6) Maximum 300mg daily Rifampicin 60mg/Isoniazid 30mg/Pyrazinamide 150 mg (paediatric) R60H30 Z150
Rifampicin (R) 10 mg (8-12) Maximum 600mg daily Rifampicin 60mg/Isoniazid 30mg (paediatric) R60H30
Pyrazinamide (Z) 25 mg (20-30)
Ethambutol (E) 15 mg (15-20)
Streptomycin (S) 5 mg (12-18)
Maximum for < 60 years = 1g
Maximum for ≥ 60 years = 0.75g
a. Direct observation of drug intake is always required

b. streptomyin is an alternative to Ethambutol. Replace Ethamdutol with Streptomycin fo TB meningitis.
c. Collect sputum for culture and DSt from all retreatment patients before starting therapy.
d. The retreatment intensive phase is 3 months. Streptomycin is given for the first 2 months

Treatment for New Cases in Adults
Treatment for New Cases in Adults and Children > 30 kg: 2HRZE/4HRE
Weight Intensive Phase for 2 months Continuation Phase for 4 months

(kg)
150H75Z400 E2751
R
150H75E2752
R
30 – 39 2 tabs 2 tabs
40 – 54 3 tabs 3 tabs
55 – 70 4 tabs 4 tabs
>70 5 tabs 5 tabs
Treatment for New Cases in Children

Treatment for New Cases in Children ≤ 30 kg: 2HRZE/4HR**
Weight Intensive Phase for 2 months Continuation Phase for 4 months

(kg)
R60H30Z1501 Ethambutol R60H302
(400mg tab)
2-2.9 ½ tab ---- ½ tab
3-5.9 1 tab do not use if <4kg 1 tab
6-8.9 1 ½ tab ¼ tab if wt 4-7.5kg 1 ½ tab
½ tab if wt 7.5-11.9 kg
9.0-11.9 2 ½ tab 2 ½ tab
12-14.9 3 tab ¾ tab 3 tab
15-19.9 4 tab 1 tab 4 tab
20-24.9 5 tab 1 tab 5 tab
25-29.9 6 tab 1 1/2 tab 6 tab
1
R150H75Z400 E275 = Adult fixed-dose combination of Rifampicin 150mg, Isoniazid 75mg, Pyrazinamide 400mg and Ethambutol 275mg
2
R150H75E275 = Adult fixed-dose combination of Rifampicin 150mg, Isoniazid 75mg and Ethambutol 275mg.

Annex 3: Treatment of Malaria
a. First line treatment of all types of uncomplicated malaria species b. Treatment of uncomplicated malaria in pregnant women
Artemether-Lumefantrine(AL) Trimester Regimen

1st Quinine 300mg,q8hfor 7dpo. & Clindamycin 10mg/kg body weightx2/d
Body Day1 Day 2 & 3 for 7days (no AL)
Weight Age
2nd AL
(kg)
1st dose After 8hrs Twice a day 3rd AL
<5 Kg <6/12 1 tablet 1 tablet 1 tablet
5-14 6/12- 2 years 1 tablet 1 tablet 1 tablet c. Parenteral (IM, IV)Artesunatein the treatment of severe malaria
15-24 3-8 2 tablets 2 tablets 2 tablets
Timing Children<20kg Children>20kg & Adults
25-34 9-14 3 tablets 3 tablets 3 tablets
During admission 3mg/kg/dose 2.4mg/kg/dose
>34 >14 4 tablets 4 tablets 4 tablets
After 12 hours 3mg/kg/dose 2.4mg/kg/dose
Primaquine 0.25mg/kg stat dose along with the first dose of AL for P.falciparum cases and After 24 hours 3mg/kg/dose 2.4mg/kg/dose
0.25mg/kg once daily for 14 days in P. vivaxrelapse, and P. ovale cases.
Then, Dailyuntil oral antimalarial (AL) is 3mg/kg/dose 2.4mg/kg/dose
tolerated
When oral AL is tolerated Full course of AL for three days + stat dose of Primaquine
with the 1st dose of AL
Body weight (kg) Single dose of Primaquine(mg base)
Pregnant in 1st Trimester Quinine 300mg PO, 8 hourly for 7 days &
10a to < 25 3.75 Clindamycin10mg/kg body weight, twice daily x 7days
25 to < 50 7.5
If Artesunate is not available or contraindicated, use quinine to treat severe malaria.
50-100 15 The Loading dose - 20mg/kg up to 1.2g diluted in 5% dextrose (1-2ml/kg) IV- over four hours; then
after four hours give10mg per kg infused over the next 4 hours and continue the same dose 8hrly. If the
a- children <10 kg is limited by the tablet sizes currently available patient requires IV quinine for more than 48hrs reduce the dose to 5-7 mgs per kg per dose 8hourly

Contributors
Name Institution/Departmment Name Institution/Departmment Name Institution/Departmment
Aderonke Oyewo Kesegofetse Chabaesele Shiang-ju Kung
Adewale Ganiyu Lameck Gabakgorwe Simon Chihanga
Albertine van der Does Lesego Mokganya TaatskeRejkin
Banyana Moatshe Liz Gwyther Tantamika-Kabamba Mudiayi
Benjamin Malaakgosi Luise Parsons Taurayi Tafuma
Billy Tsima Malebogo Motsokono Vincent Appathurai
Blockie O. Modise Malebogo Pusoentsi Vincent Setlhare
Bobie Bosilong Mareko Ramotsababa Vivian Sebako
Bornapate Nkomo Margo Pumar
Brighid Malone Matshwenyego Setshego
Cecilia Ntsime Maxwell Nhlatho
Celda Tiroyakgosi Megan Cox
Culistus Gobotswang Michael Reid
Daniel Kgosiemang Miriam Haverkamp
Deogratias Mbuka Ongona Mmakgomo Raesima
Desmond Johane Montlenyane Madisa
Everton Maisiri Motlalekgomo Samuel
Gagoitsewe Saleshando Motsamai Daniel
Gaone Lekgowe Mpho Thula
Gladness Tlhomelang Olutoyin Topia
Hamilton Mogatusi Patrick Masokwane
Heluf Gessesse Medhin Patrick Zibochwa
Herman Ssemakula Paul Sidandi
Jacquie Firth Peloentle Pheto
Joy Crosbie Penny Makuretsa
Kelebogile Motumise Salome Ntau
Keneilwe Motlhatlhedi Sandra Maripe
Kenosi Nlisi Sharon Munyoro

References

1. Botswana Essential Drugs List (BEDL)
2. Botswana Treatment Guide 2007
3. Botswana National HIV & AIDS treatment guidelines 2012
4. National Tuberculosis Programme Manual 7th edition (2011)
5. National Malaria Control Programme Guidelines for the diagnosis and treatment of Malaria in Botswana (September 2007)
6. Infections – reference manual for health workers June 2005
7. Safe Motherhood Nursing/Midwifery Protocols for Health Posts 2008
8. Guidelines for Antenatal Care and the Management of Obstetric Emergencies and Prevention of Mother to Child Transmission of HIV (2010)
9. Mental Disorders – chapter 63:02 Government printers 2002
10. Botswana Integrated Management for HIV/AIDS and other Illness – palliative care: symptom management and end-of-life care
11. Primary Care 101, Integrated Guideline,Health Department, Republic of South Africa
12. WHO-PEN Package (Prevention and Management of Essential Non-Communicable Disease Interventions) for Primary Heath Care Providers)
13. A novel method for constructing an alternative spacer for patients with asthma H J Zar, C Green, M D Mann, E. G. Weinberg January 1999, Vol. 89, vol. 1 South African Medical Journal
14. Division of Dermatology and ENT Department, Groote Schuur Hospital, Cape Town
15. GINA Guideline 2015
16. WHO/ISH Risk prediction chartsfor 14 WHO epidemiological sub-regions

MINISTRY of HEALTH
REPUBLIC OF BOTSWANA

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Botswana Primary Care Guideline

Shenaaz El- Halabi

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 ii

Dr. Haruna B. Jibril

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 iii

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 iv

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 v

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 vi

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 vii

Pneumonia or meningitis likely Anaphylaxis likely • Stop bleeding. 2.

Write a clear referral letter and refer urgently to hospital.

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 1

Syncope/blackout likely 7.

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 2

First check for TB, HIV and diabetes

Exclude TB Test for HIV Check for diabetes

Ask about symptoms of common cancers:

If food intake inadequate, look for a cause:

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 3

Fever persists within 2 weeks Fever persists after 2 weeks

Consider other cause for fever

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 4

Are nodes equally enlarged < 2cm or 1 or more ≥ 2cm?

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 5

First check patient’s temperature.

Then exclude TB, HIV, pregnancy and stress.

Refer the patient with persistent weakness/tiredness and no obvious cause.

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 6

Systolic BP drops by No change in systolic BP or change < 20mmHg

• Epilepsy care 93.

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 7

Approach to the patient with dizziness not needing urgent attention

Systolic BP drops ≥ 20mmHg No drop or drop in systolic BP < 20mmHg

• Mobilize as soon as possible.

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

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 8

Approach to the patient with headache not needing urgent attention

• Warn patient to avoid overusing analgesics.

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 9

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

Yes No • Wash the eye with

Refer to eye clinic if symptoms do not

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 10

Approach to patient with facial symptoms not needing urgent attention

Face pain Sudden weakness of 1 side of face Swelling of face

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 11

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 12

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 13

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 14

First exclude pain related to heart and lungs.

Refer same week if uncertain of diagnosis.

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 15

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 16

After 1 hour assess if patient still needs urgent attention 16.

No change or worse Better or no symptoms

Discharge plan for the patient who has responded to treatment

Known asthma Known copd

BOTSWANA PRIMARY CARE GUIDELINE FOR ADULTS 2016 17

• Mobilize as soon as possible.

Yes No • Wash the eye with

•M ost vomiting is due to a viral infection and resolves within

• Treat constipation as above. Treat as for Give • Advise good hygiene

Refer same day. • If mother RPR

• Look for STI: if vaginal discharge or lower abdominal pain

Normal • If temperature ≥ 38˚C 4

• Give Paracetamol 1g 6 • Give Paracetamol 1g 6 hourly.

• Rest and elevate joint.