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ABNORMAL VAGINAL BLEEDING• BP < 90/60• Exclude pregnancy. If pregnant 93.• Following abortion or miscarriageManagement:• Give IV sodium chloride 0.9% and refer same day.Recognise the patient with vaginal bleeding needing urgent attention: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(bleeding > 7 days, passing clots)Any bleeding elsewhere (gums, easy bruising,rash)?Yes• Checkfull bloodcount.• Refer todoctorsameweek.No• If Hb < 11 give ferroussulphate compound BPC170mg 8 hourly after foodfor at least 3 months until Hb> 11.• During period, give ibuprofen400mg 8 hourly with food for2-3 days to decrease pain andblood loss.• If newly started oninjectable contraceptive,give levonorgestrel/ethinyloestradiol 0.15/0.03mg for3 cycles.• Refer the patient if:--Same week if abdominalmass--No better after 3 months--Following IUCD insertionPeriods have irregular pattern(< 24 days or > 35 days between periods)Does patient have hot flushes, moodswings and/or difficulty sleeping?Yes Patient isperimenopausal.98No• If there is weightgain, tiredness,feeling cold allthe time, checkTSH. Referto doctor ifabnormal.• Givelevonorgestrel/ethinyl oestradiol0.15mg/0.03mgfor 6 months91.• Refer togynaecologist ifpatient wantingto be pregnant.Spotting between periods• If STI symptoms: 23.• Do pap smear 27.If on hormonal contraception: manage according to methodOral contraceptive• Ensure correct use.• If diarrhoea and vomiting, advisecondom use until diarrhoea,vomiting and spotting resolve.• If on phenytoin, carbamazepine,rifampicin or lopinavir/ritonavir,change to IUCD or injectable.Bleeding after sex• If STI symptoms: 23.• If assault or abuse 53.Injectable contraceptive• Common in first 3–6months.• Give levonorgestrel/ethinyl oestradiol0.15/0.03mg for 7 days.Give ibuprofen 400mg8 hourly for 3 daysinstead if breast feeding,smoker > 35 years, BP≥140/90, migraine withfocal symptoms, DVT orpulmonary embolus.Refer the patient within 2 weeks if:• Unsure of diagnosis• Menopausal (no periods for at least 1 year)• Bleeding persists: > 1 week after STI treatment, after diarrhoea and vomiting stopor for > 3 months• Abnormal cervix on speculum examination (suspicious of cancer)29
SEXUAL PROBLEMSProblem with erectionsWoman who has pain with sexLoss of libidoWas the onset of the problem gradual or sudden?Gradual onsetPartial or poorly sustainederections• Assess cardiovascular diseaserisk 68.• Screen for substance abuse:if > 21 drinks/week or > 5drinks per session or misusingprescription or illicit drugs 83.• Atenolol, furosemide, HCTZ,fluoxetine, amitriptyline,phenytoin, carabmazepine,cimetidine may cause erectionproblems. Doctor can considerchanging medication but needsto balance disease controlwith possible improvement inerections.• Advise the patient who smokesto stop.• Ask: ‘Are you stressed?’ If yes52.• Refer to urologist if noimprovement once treatmentoptimised and chronic conditionstable.Sudden onsetHas erections in morning,but not during sex• Ask: ‘Are you stressed?’If yes 52.• Ask about sexualassault or abuse 53and anxiety/fear aboutsex and fertility. Referto available counselor.• Assess patient’s familyplanning needs 91.• Discuss condom use.Ensure patient knowshow to use condomscorrectly.Superficial pain• Look for STI: if vaginaldischarge or ulcers23.• Ask about vaginaldryness. If there isvaginal atrophy or hasother menopausalsymptoms like flushes,problems sleeping,mood changes,headaches 98.• Advise use of lubricantwith sex, but to avoidusing Vaseline ® withcondoms.Is the pain superficial or deep?Deep pain• Look for STI: if vaginal dischargeor lower abdominal pain 23.• Ask about irritable bowelsyndrome: recurrent abdominalpain with constipation and/ordiarrhoea and bloating 19.• Severe spasm of vagina duringsex: ask about sexual assault orabuse 53.• Refer to gynaecologist if massin abdomen or periods havebecome heavy and painful.• Ask: ‘Are you stressed?’ If yes52.• Ask about sexual assault or abuse53.• If low mood or sadness, loss ofinterest or pleasure, feeling tenseor worrying a lot or not copingas well as before, considerdepression/anxiety 81.• Screen for substance abuse:if > 21 drinks/week (man) or> 14 drinks/week (woman) or> 5 drinks/session or misusingprescription or illicit drugs 83.• Ask the woman patient aboutpain with sex.• Ask about anxiety/fear about sexand fertility. Refer to availablecounselor.• Assess patient’s family planningneeds 91.Refer if sexual problems do not resolve.30TB HIV CHRONIC RESPIRATORYDISEASECHRONIC DISEASESOF LIFESTYLEMENTAL HEALTH EPILEPSY MUSCULOSKELETALDISORDERSWOMEN'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 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 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
- Page 72 and 73: CHRONIC OBSTRUCTIVE PULMONARY DISEA
- Page 74 and 75: CARDIOVASCULAR DISEASE (CVD) RISK:
- Page 76 and 77: DIABETES: ROUTINE CAREAssess the pa
- Page 78 and 79: HYPERTENSION: DIAGNOSISCheck blood
- Page 80 and 81: HEART FAILURE: ROUTINE CARE• The
- Page 82 and 83: ISCHAEMIC HEART DISEASE (IHD): DIAG
SEXUAL PROBLEMSProblem with erectionsWoman who has pain with sexLoss of libidoWas the onset of the problem gradual or sudden?Gradual onsetPartial or poorly sustainederections• Assess cardiovascular diseaserisk 68.• Screen for substance abuse:if > 21 drinks/week or > 5drinks per session or misusingprescription or illicit drugs 83.• Atenolol, furosemide, HCTZ,fluoxetine, amitriptyline,phenytoin, carabmazepine,cimetidine may cause erectionproblems. Doctor can considerchanging medication but needsto balance disease controlwith possible improvement inerections.• Advise the patient who smokesto stop.• Ask: ‘Are you stressed?’ If yes52.• Refer to urologist if noimprovement once treatmentoptimised and chronic conditionstable.Sudden onsetHas erections in morning,but not during sex• Ask: ‘Are you stressed?’If yes 52.• Ask about sexualassault or abuse 53and anxiety/fear aboutsex and fertility. Referto available counselor.• Assess patient’s familyplanning needs 91.• Discuss condom use.Ensure patient knowshow to use condomscorrectly.Superficial pain• Look for STI: if vaginaldischarge or ulcers23.• Ask about vaginaldryness. If there isvaginal atrophy or hasother menopausalsymptoms like flushes,problems sleeping,mood changes,headaches 98.• Advise use of lubricantwith sex, but to avoidusing Vaseline ® withcondoms.Is the pain superficial or deep?Deep pain• Look for STI: if vaginal dischargeor lower abdominal pain 23.• Ask about irritable bowelsyndrome: recurrent abdominalpain with constipation and/ordiarrhoea and bloating 19.• Severe spasm of vagina duringsex: ask about sexual assault orabuse 53.• Refer to gynaecologist if massin abdomen or periods havebecome heavy and painful.• Ask: ‘Are you stressed?’ If yes52.• Ask about sexual assault or abuse53.• If low mood or sadness, loss ofinterest or pleasure, feeling tenseor worrying a lot or not copingas well as before, considerdepression/anxiety 81.• Screen for substance abuse:if > 21 drinks/week (man) or> 14 drinks/week (woman) or> 5 drinks/session or misusingprescription or illicit drugs 83.• Ask the woman patient aboutpain with sex.• Ask about anxiety/fear about sexand fertility. Refer to availablecounselor.• Assess patient’s family planningneeds 91.Refer if sexual problems do not resolve.30TB HIV CHRONIC RESPIRATORYDISEASECHRONIC DISEASESOF LIFESTYLEMENTAL HEALTH EPILEPSY MUSCULOSKELETALDISORDERSWOMEN'S HEALTH
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