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HEADACHE• Sudden onset of severe headache• New onset, persistent, different to usual headache• Headache that wakes or is worse in the morning• Vomiting• Temperature ≥ 38ºC• Neck stiffness/meningism• BP ≥ 180/110, or if pregnant, diastolic BP ≥ 90.Management:• If temp ≥ 38ºC and neck stiffness, treat for meningitis. Give ceftriaxone 1 2g IM/IV.The patient with headache and one or more of the following needs urgent attention:• If BP ≥ 180/110 and not pregnant, give amlodipine 10mg orally stat. If unavailable, give enalapril 10mg orally stat 2 . If pregnant 93.• Refer same day to hospital• Decreased level of consciousness• Confusion• Vision problems (e.g. double vision, photophobia)• Following a first seizure• Sudden weakness on one or both sides• Speech disturbance• Pupils different in sizeApproach to the patient with headache not needing urgent attentionIs headache recurrent with nausea and/or vomiting and/or visual disturbance that resolves completely?YesNo: Pain or pressure over forehead or cheek/s worse on bending forwards, recent common cold, runny nose?Migraine likely• Give immediately and then as neededparacetamol 1g 6 hourly or ibuprofen 3400mg 8 hourly with food up to 5 daysand metoclopramide 10mg 8 hourly upto 3 doses and refer if no better.• Advise patient to recognise and treatmigraine early, rest in a dark, quietroom, avoid precipitants like loud noise,stress, flashing lights, missing meals,alcohol, chocolate, cheese.• Avoid oestrogen-containingcontraceptives 91.• If ≥ 2 attacks/month, refer/discuss formedication to prevent migraines.• Refer if poor response to treatment.YesSinus infection likely• Give paracetamol 1g 6 hourly.• If nasal discharge for > 6 days,give amoxicillin 500mg 8hourly for 5 days. If penicillinallergic, give erythromycin500mg 6 hourly for 5 days.• Refer if poor response totreatment, meningism, toothinfection, swelling over sinus oraround eye.• If patient has recurrentsinusitis, test for HIV 60.No• Check patient’s medication--ART: Look for meningitis. Refer if headache persists for more than 6 weeks after starting ART.--Overuse of analgesics can cause headaches. Advise to avoid regular use and to cut down onamount used.• If patient not on above medication consider tension headache, temporal arteritis or neck pain:Tightness of scalpTension headache likely• Give paracetamol 1g 6 hourly.• Discuss stress 52.Pain mainlyin neckwith musclestiffness.• Go to neckpain page35.> 50 years, pain over templesTemporal arteritis likely• Check CRP.• Give paracetamol 1g 6 hourly.• Review next day: if CRP > 5, giveprednisone 40mg & refer same day.• Warn patient to avoid overusing analgesics.• Refer if the diagnosis is uncertain or headaches are not responding to treatment.1Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. If giving ceftriaxone IM, divide dose: 1g into 2 different injection sites. 2 Do not give short-acting nifedipine unlesspregnant, as it may drop the blood pressure too quickly, causing a stroke. 3 Avoid ibuprofen if peptic ulcer, asthma, hypertension, heart failure, kidney disease.9
EYE/VISION SYMPTOMSRecognise the patient with eye or vision symptoms needing urgent attention:• 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 76.• 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 1 2g IV/IM statManagement:• If painful red eye associated with coloured haloes around light, dilated oval pupil, headache, nausea and vomiting, acute glaucoma likely. Give acetazolamide oral 500mgimmediately and then 250mg 6 hourly and pilocarpine1% eye drops every 15 minutes for 4 doses.• Refer same day to hospital.Approach to patient with eye/vision symptoms not needing urgent attentionBoth eyes are discharging/wateryIs there prominent itch?Gradual changein visionRed or swolleneyelidsForeign bodyYesAssociated with hayfever, allergic rhinitis?Localised cause(makeup) likely• Wash out eyewith clean water.• Remove thecause.• Treat withoxymetazolineeye drops 6hourly for 3days.Allergicconjunctivitis likely• Treat withoxymetazolineeye drops 1–2drops 6 hourly for7 days.• If symptomspersist > 4 weeks,give cetirizine10mg at night asneeded. Avoidsteroid eye drops.• Refer if no betterafter 2 weeks.NoIs the discharge clear or pus?No Yes Pus ClearBacterialconjunctivitis likely• Givechloramphenicol1% ointment 6hourly for 7 days.• Advise patientto avoid rubbingeyes and to washhands regularly.Viral conjunctivitislikely• Give 0.9% salineeye washes.• Giveoxymetazoline eyedrops 1–2 drops 6hourly for 7 days.Avoid using > 7days as this mayresult in reboundconjunctivitis.Refer to eye OPD if symptoms do notimprove within 2 days.• Exclude diabetes70.• Excludehypertension 73.• If status unknown,test for HIV 60.• Refer fornext availableeye OPDappointment.• Refer HIV patientsame week.• Givechloramphenicol1% ointment 6hourly for 7 days.• Wash crusts onlid margin twicea day with warmwater.Refer to eye OPDif symptoms donot improve withtreatment.• Wash the eyewith clean wateror saline.• Remove foreignbody with cottontippedstick orbud.Refer to eye OPD if:• Damage to eye• Abnormal visionor movement ofeye• No improvementafter 2 days1Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. If giving ceftriaxone IM, divide dose: 1g into 2 different injection sites.TB HIV CHRONIC RESPIRATORYDISEASECHRONIC DISEASESOF LIFESTYLEMENTAL HEALTH EPILEPSY MUSCULOSKELETALDISORDERS10WOMEN'S HEALTH
- Page 4 and 5: CONTENTS: SYMPTOMSAssess and manage
- Page 6 and 7: THE UNCONSCIOUS PatientManage the u
- Page 8 and 9: WEIGHT LOSSRecognise the patient wi
- Page 10 and 11: LYMPHADENOPATHY (enlarged lymph nod
- Page 12 and 13: COLLAPSE• Unconscious 1• Fit 2
- Page 16 and 17: FACE SYMPTOMSRecognize the patient
- Page 18 and 19: NOSE SYMPTOMSRunny or blocked noseA
- Page 20 and 21: CHEST PAINRecognise the patient wit
- Page 22 and 23: WHEEZE/TIGHT CHESTInitial Managemen
- Page 24 and 25: ABDOMINAL PAIN WITH OR WITHOUT SWEL
- Page 26 and 27: DIARRHOEARecognise the ill patient
- Page 28 and 29: GENITAL SYMPTOMSAssess the patient
- Page 30 and 31: VAGINAL DISCHARGE• It is normal f
- Page 32 and 33: OTHER GENITAL SYMPTOMSFirst assess
- Page 34 and 35: ABNORMAL VAGINAL BLEEDING• BP < 9
- Page 36 and 37: URINARY SYMPTOMSRecognise patient w
- Page 38 and 39: JOINT SYMPTOMSRecognise the patient
- Page 40 and 41: NECK PAINRecognise the patient with
- Page 42 and 43: FOOT SYMPTOMS• If the problem is
- Page 44 and 45: BURNSAttend urgently to the patient
- Page 46 and 47: PAINFUL SKINFirm, red lump which so
- Page 48 and 49: GENERALISED ITCHY RASHIf status unk
- Page 50 and 51: GENERALISED NON ITCHY RED RASHIs pa
- Page 52 and 53: CHANGES IN SKIN COLOURYellow skinDa
- Page 54 and 55: SUICIDAL PatientRecognise the patie
- Page 56 and 57: CONFUSED Patient• The confused pa
- Page 58 and 59: TRAUMATISED/ABUSED PatientRecognize
- Page 60 and 61: TB: DIAGNOSISExclude TB in the pati
- Page 62 and 63: TB: ROUTINE CAREAssess the patient
EYE/VISION SYMPTOMSRecognise the patient with eye or vision symptoms needing urgent attention:• 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 76.• 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 1 2g IV/IM statManagement:• If painful red eye associated with coloured haloes around light, dilated oval pupil, headache, nausea and vomiting, acute glaucoma likely. Give acetazolamide oral 500mgimmediately and then 250mg 6 hourly and pilocarpine1% eye drops every 15 minutes for 4 doses.• Refer same day to hospital.Approach to patient with eye/vision symptoms not needing urgent attentionBoth eyes are discharging/wateryIs there prominent itch?Gradual changein visionRed or swolleneyelidsForeign bodyYesAssociated with hayfever, allergic rhinitis?Localised cause(makeup) likely• Wash out eyewith clean water.• Remove thecause.• Treat withoxymetazolineeye drops 6hourly for 3days.Allergicconjunctivitis likely• Treat withoxymetazolineeye drops 1–2drops 6 hourly for7 days.• If symptomspersist > 4 weeks,give cetirizine10mg at night asneeded. Avoidsteroid eye drops.• Refer if no betterafter 2 weeks.NoIs the discharge clear or pus?No Yes Pus ClearBacterialconjunctivitis likely• Givechloramphenicol1% ointment 6hourly for 7 days.• Advise patientto avoid rubbingeyes and to washhands regularly.Viral conjunctivitislikely• Give 0.9% salineeye washes.• Giveoxymetazoline eyedrops 1–2 drops 6hourly for 7 days.Avoid using > 7days as this mayresult in reboundconjunctivitis.Refer to eye OPD if symptoms do notimprove within 2 days.• Exclude diabetes70.• Excludehypertension 73.• If status unknown,test for HIV 60.• Refer fornext availableeye OPDappointment.• Refer HIV patientsame week.• Givechloramphenicol1% ointment 6hourly for 7 days.• Wash crusts onlid margin twicea day with warmwater.Refer to eye OPDif symptoms donot improve withtreatment.• Wash the eyewith clean wateror saline.• Remove foreignbody with cottontippedstick orbud.Refer to eye OPD if:• Damage to eye• Abnormal visionor movement ofeye• No improvementafter 2 days1Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. If giving ceftriaxone IM, divide dose: 1g into 2 different injection sites.TB HIV CHRONIC RESPIRATORYDISEASECHRONIC DISEASESOF LIFESTYLEMENTAL HEALTH EPILEPSY MUSCULOSKELETALDISORDERS10WOMEN'S HEALTH
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