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BACK PAINRecognise the patient with back pain needing urgent attention• Bladder or bowel disturbance• Sudden onset of leg weakness• Recent trauma with severe pain and X-Ray unavailable or abnormal• Temperature ≥ 38ºC and vomiting, pulse rate > 80, respiratory rate > 17, BP < 90/60, diabetes, pregnancy, menopause or male patient: pyelonephritis likely.• Severe stabbing flank pain (one sided) with cramp-like radiation to groin and blood in urine: kidney stone likely.Management:• Pyelonephritis: give IV sodium chloride 0.9% and ceftriaxone 1 1g IM/IV.• Kidney stone: give IV sodium chloride 0.9% and morphine 10–15mg IM single dose.• Refer urgently to hospital.Approach to patient with back pain not needing urgent attention• If patient is a non-pregnant woman of reproductive age with temperature ≥ 38ºC and:--Vaginal discharge with/without lower abdominal pain: pelvic inflammatory disease is likely 23.--Flank pain: uncomplicated pyelonephritis is likely. Give ciprofloxacin oral 500mg 12 hourly for 7 days and paracetamol 1g 6 hourly as needed.• Next, ask about TB symptoms: cough, weight loss, night sweats, feeling unwell.YesExclude TB55 and• Do back X-Ray.• Refer to doctor.YesNo TB symptomsIs there any of: < 20 years, > 55 years, pain progressive or for > 6 weeks, previous cancer or oral steroid use, HIV or deformity?NoWhat is the nature of the back pain?• Sleep not usually disturbed by pain and• No stiffness or stiffness on waking lasts < 30 minutes and• Pain is worse with activity and improves with rest.YesNoUnsureMechanical back pain likely• Measure waist circumference: if > 80cm (woman) or 94cm (man) assess CVD risk 68.• Assess and manage patient's stress 52.• Advise patient to be as active as possible, continue to work and avoid resting in bed.• Give paracetamol 1g 6 hourly.• If poor response after 1 week add ibuprofen 400mg 8 hourly for up to 5 days. Avoid if pepticulcer, asthma, hypertension, heart failure, kidney disease.• If still a poor response add tramadol 50mg 4–6 hourly.• Refer to physiotherapy if pain persists > 2 weeks, or unable to cope with daily activities/work.• Refer to specialist if pain persists > 6 weeks, urgently if bladder disturbance or leg weakness.Inflammatoryback pain likely• Check CRP.• Do back X-Ray.• Refer to specialist.1Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone.TB HIV CHRONIC RESPIRATORYDISEASECHRONIC DISEASESOF LIFESTYLEMENTAL HEALTH EPILEPSY MUSCULOSKELETALDISORDERS34WOMEN'S HEALTH