CHEST PAINRecognise the patient with chest pain needing urgent attention:• Respiratory rate ≥ 30 breaths/minute• BP ≥ 180/110 or < 90/60• Pulse irregular, > 100 or < 60• Severe pain• New onset of central chest painManagement:• Pain spreads to the neck, arm or back• Sweating, nausea, vomiting• Pale• At risk of heart attack (diabetes, smoker, hypertension, known CVD risk > 10%)• Known with ischaemic heart disease• If unconscious 1. If conscious, sit patient up.≥ 38ºC• Give 40% face mask oxygen.• If BP < 90/60, give 200ml sodium chloride 0.9% IV.• Manage according to temperature:< 38ºCChest infection likely• Give ceftriaxone 1 1g IV/IM stat.• If BP still < 90/60, give 500ml sodium chloride0.9% IV over 30 minutes.• Repeat if BP persists < 90/60. Stop fluids ifrespiratory rate increases.• Refer patient same day.Do an ECGECG normal or unavailable or uncertainIs chest pain worse on lying down, palpation or breathing deeply?YesHeart attack unlikely: refer urgently.NoHeart attack likely 77ECG abnormalApproach to the patient with chest pain not needing urgent attentionFirst exclude pain related to heart and lungs.Recurrent episodes of central chest pain, brought on by exertion and relieved by rest: angina likely 77. 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• Avoid spicy/acidic food, fizzy drinks, eat small frequent meals and prop up head of bed.• If waist circumference > 88cm (woman), 102cm (man), assess patient’s CVD risk 68.• Give omeprazole 20mg daily for 14 days.• Refer same week if any of: no better after 7 days of omeprazole, new onset and > 45 years, pain on swallowing,vomiting, weight loss, loss of appetite, feeling of early fullness, occult blood positive, abdominal mass.Tender at costochondral junction,no fever or coughMusculoskeletal problem likely• Give ibuprofen 400mg 8 hourlywith food for up to 5 days.• Refer if pain persists > 4 weeks.Burning pain on1 side with orwithout rash for1–2 daysShingles likely41.Refer same week if uncertain of diagnosis.1Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone.15
COUGH AND/OR DIFFICULT BREATHINGRecognise the patient with cough needing urgent attention:The patient with cough and/or difficult breathing and 1 or more of the following signs has respiratory distress:• Breathlessness at rest or while talking• Respiratory rate ≥ 30 breaths/minute• Prominent use of breathing musclesManagement:• Coughing up ≥ 1 tablespoon of fresh blood• Agitation or confusion• BP < 90/60If available, give oxygen (40% face mask or 4L/min nasal prong; if known with COPD, give 24–28% face mask)Temperature ≥ 38°C• Give single dose of ceftriaxone 1 1g IM/IV.• Refer urgently with continuous oxygen.Wheeze and difficult breathing, noleg swelling, if 1st episode ofwheeze, patient < 50 years• Treat wheeze 17Difficult breathing worse on lyingflat especially with leg swelling or 1stepisode of wheeze in patient ≥ 50 years• Heart failure likely 75.Assess the patient with cough and/or difficult breathing not needing urgent attentionCough and/or difficult breathing < 2 weeksCough and/or difficult breathing ≥ 2 weeksSputum, chest pain and feverTreat for chest infection:• Bed rest and regular fluid intake.• Give antibiotic if sputum is new,increased or changed in colour:Is patient at risk of severe infection (HIV,> 65 years, known severe lung, heart,liver disease, diabetes or alcohol abuse)?Yes• Give amoxicillin/clavulanic acid 2875/125mg12 hourly for5 days. Adviseto returnimmediately ifworse or if nobetter after 3days.No• Give benzylpenicillin 22MU IM stat andamoxicillin 2 1g8 hourly for 5 days.• If no betterafter 2 days adderythromycin 500mg6 hourly for 5 days ifnot already on it orrefer same day.Leg swellingor 1st episodeof wheeze inpatient ≥ 50yearsHeart failurelikely 75.Wheezing, noleg swelling, if1st episode ofwheeze, patient< 50 yearsTreat wheeze17.• Doctor to diagnose on historyand X-Ray: give co-trimoxazole320/1600mg 6 hourly for 21 days.• Start workup for ART 61.• Review weekly to assess clinicalresponse and TB culture result:if positive, treat for TB whilecompleting PCP treatment 57.• Refer if X-ray not typical, patientwas adherent to co-trimoxazoleprophylaxis and/or ART, or if noimprovement on treatment.Exclude TB 55.While looking for TB, consider other cause for cough and/or difficult breathing.HIV patient with dry cough,worsening breathlessnesson exertion, CD4 < 200PCP likelyWeight lossConsider lungcancer.SmokerProductivecough mostdays of atleast 3 monthsfor ≥ 2 years,no difficultbreathing orweight lossChronicbronchitisAdvise patient to stop smoking.If TB, lung cancer and chronicbronchitis are excludedLeg swellingor 1stepisode ofwheeze inpatient ≥ 50yearsHeart failurelikely.If heartfailure and TBexcludedIf above conditions excluded, consider asthma or COPD 65.Recent upperrespiratory tractinfection, nodifficultybreathingPost-infectiouscough likely.Advise patientthat the coughshould resolvewithin 8 weeks.Cough persists> 8 weeks, TBexcluded.1Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. 2 If penicillin allergic, give erythromycin 500mg 6 hourly for 5 days.TB HIV CHRONIC RESPIRATORYDISEASECHRONIC DISEASESOF LIFESTYLEMENTAL HEALTH EPILEPSY MUSCULOSKELETALDISORDERS16WOMEN'S HEALTH
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