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WHEEZE/TIGHT CHESTInitial Management• 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 : 1 or 2ml of 0.5% salbutamol solution in 3ml of sodium chloride 0.9% solution every 20 minutes for 1 hour.• Give first dose of oral prednisone 2 40mg if no immediate response, or is currently taking oral prednisone. If prednisone unavailable or patient unable to take it,give hydrocortisone 100mg IV.After 1 hour assess if patient has respiratory distress 16.WorseRefer immediately. While waiting for transport:• Add 2ml ipratropium bromide to salbutamolnebuliser solution.• Continue nebulisation every 20 minutes with oxygenin between. 3No change• Add 2ml ipratropium bromide to salbutamol solution.• Continue nebulisation or large volume spacer every 20minutes with oxygen in between. 3• Refer immediately if no response within 3 hours of arrival.• If improved, follow discharge plan below.Better or no symptoms• If stable after 1 hour, follow discharge plan below.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 65.• If patient received oral prednisone or IV hydrocortisone above, give oral prednisone 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 daysinstead.• 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 see Preface.• 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 65.Known asthma• Start inhaled corticosteroid 66 if 2nd emergency visit for asthma in 6 monthsor previously using inhaled corticosteroid.• If already on inhaled corticosteroid, adjust dose 66.• Give oral prednisone 40mg daily for 7 days if:--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 if: no response to 7 days of oral prednisone in past 4weeks, more than 2 courses of oral prednisone in the last 6 months, or exacerbationoccurs in spite of maximum level of chronic treatment.• Follow up the asthma patient 66.Known copd• Give oral prednisone 40mg daily for 7 days if:--Breathlessness has improved but remains worse than usual.--Patient has been on long-term daily oral prednisone.• Refer same month to doctor if 2 or more exacerbations in6 months.• Follow up the COPD patient 67.Tell patient to return before follow-up appointment if no improvement after completing a short course of oral prednisone.1If an oxygen-driven nebuliser is not available, use an air-driven nebuliser instead and give facemask oxygen between nebulisation. 2 Oral prednisone 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.17
BREAST SYMPTOMSApproach to the patient with a breast symptom who is not breast feedingBreast lump/sOne or both breasts?Breast PainNipple DischargeBreast enlargementBoth breastsThis is likely to becyclical.• Reassure• Changehormonalcontraceptionto nonhormonalmethod 91.NoRe-examinebreast onday 7 ofmenstrualcycle. Refersame week iflump persists.One breastPatient > 35 years or afamily history of breastcancer?YesRefersameweek tobreastclinic.• Reassure patient that breastcancer rarely causes pain.• Advise a well-fitting bra.• If pregnant, reassure andgive antenatal care 94.• Give paracetamol 1g 6hourly as needed.• May be a side effect ofhormonal contraceptive. Ifno better after 3 monthson contraception, changemethod 91.Is the discharge blood stained,on 1 side, in patient > 50years, or in a man?YesRefersameweek tobreastclinic.No• If pregnant,reassure and giveantenatal care94.• If on hormonalcontraceptive,reassure. Changeto non-hormonalmethod ifdistressing 91.One sidedRefer sameweek tobreastclinic.Both breasts• Confirm that this is not obesity.If BMI > 25 assess CVD risk68.• Look for drugs that causebreast enlargement: efavirenz(reassure patient that it oftenresolves by 2 years), cimetidine,nifedipine, amlodipine,fluoxetine. Discuss with doctor.Approach to the patient with a breast symptom who is breast feedingPainful/cracked nipple/sUsually in first few days of breastfeedingdue to poor latching.Painful breast/sIs temperature ≥ 38ºC?Breast lumpIs temperature ≥ 38ºC?NoYesYesNo• Avoid soap on washing nipples.• Help patient to latch properly.• Advise patient to apply breastmilk onto nipplesand areola after feeding and expose to the air.• Advise HIV patient to stop feeding from thebreast, express and heat-treat 1 the milk, andcup-feed baby until cracks have healed.Engorgement likelyAdvise frequentbreastfeeding andcold compresses.Mastitis likely• Give flucloxacillin 500mg 6 hourly for 5 days.• Paracetamol 1g 6 hourly• Advise HIV patient to stop feeding from thebreast, express and heat-treat 1 the milk, andcup-feed baby until mastitis resolves.• Refer if no better after 2 daysBreast abscess likely• Refer same day for incision anddrainage.• Advise HIV patient to stop feedingfrom the breast, express and heattreat1 the milk, and cup-feed babyuntil abscess resolves.Blocked duct likelyAdvise frequentbreastfeeding, warmcompresses and tomassage lump.1Heat-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.TB HIV CHRONIC RESPIRATORYDISEASECHRONIC DISEASESOF LIFESTYLEMENTAL HEALTH EPILEPSY MUSCULOSKELETALDISORDERS18WOMEN'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 14 and 15: HEADACHE• Sudden onset of severe
- 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 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
- Page 64 and 65: Manage the patient with a positive
- Page 66 and 67: HIV: ROUTINE CAREAssess the patient
- Page 68 and 69: Advise the patient with HIV• Supp
- Page 70 and 71: ASTHMA AND COPD: DIAGNOSIS• The p
BREAST SYMPTOMSApproach to the patient with a breast symptom who is not breast feedingBreast lump/sOne or both breasts?Breast PainNipple DischargeBreast enlargementBoth breastsThis is likely to becyclical.• Reassure• Changehormonalcontraceptionto nonhormonalmethod 91.NoRe-examinebreast onday 7 ofmenstrualcycle. Refersame week iflump persists.One breastPatient > 35 years or afamily history of breastcancer?YesRefersameweek tobreastclinic.• Reassure patient that breastcancer rarely causes pain.• Advise a well-fitting bra.• If pregnant, reassure andgive antenatal care 94.• Give paracetamol 1g 6hourly as needed.• May be a side effect ofhormonal contraceptive. Ifno better after 3 monthson contraception, changemethod 91.Is the discharge blood stained,on 1 side, in patient > 50years, or in a man?YesRefersameweek tobreastclinic.No• If pregnant,reassure and giveantenatal care94.• If on hormonalcontraceptive,reassure. Changeto non-hormonalmethod ifdistressing 91.One sidedRefer sameweek tobreastclinic.Both breasts• Confirm that this is not obesity.If BMI > 25 assess CVD risk68.• Look for drugs that causebreast enlargement: efavirenz(reassure patient that it oftenresolves by 2 years), cimetidine,nifedipine, amlodipine,fluoxetine. Discuss with doctor.Approach to the patient with a breast symptom who is breast feedingPainful/cracked nipple/sUsually in first few days of breastfeedingdue to poor latching.Painful breast/sIs temperature ≥ 38ºC?Breast lumpIs temperature ≥ 38ºC?NoYesYesNo• Avoid soap on washing nipples.• Help patient to latch properly.• Advise patient to apply breastmilk onto nipplesand areola after feeding and expose to the air.• Advise HIV patient to stop feeding from thebreast, express and heat-treat 1 the milk, andcup-feed baby until cracks have healed.Engorgement likelyAdvise frequentbreastfeeding andcold compresses.Mastitis likely• Give flucloxacillin 500mg 6 hourly for 5 days.• Paracetamol 1g 6 hourly• Advise HIV patient to stop feeding from thebreast, express and heat-treat 1 the milk, andcup-feed baby until mastitis resolves.• Refer if no better after 2 daysBreast abscess likely• Refer same day for incision anddrainage.• Advise HIV patient to stop feedingfrom the breast, express and heattreat1 the milk, and cup-feed babyuntil abscess resolves.Blocked duct likelyAdvise frequentbreastfeeding, warmcompresses and tomassage lump.1Heat-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.TB HIV CHRONIC RESPIRATORYDISEASECHRONIC DISEASESOF LIFESTYLEMENTAL HEALTH EPILEPSY MUSCULOSKELETALDISORDERS18WOMEN'S HEALTH
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