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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