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NECK PAINRecognise the patient with neck pain needing urgent attention:• Neck stiffness with temperature ≥ 38ºC: give ceftriaxone 1 2g IV/IM stat.• New onset of hand or arm symptoms (weakness or numbness) or gait disturbance (leg weakness, stiffness or loss of balance)• Trauma with neurological symptoms or abnormal X-Ray: immobilise neck with hard collar or sandbags on either side of the neck.Refer same day.Approach to the patient with neck pain not needing urgent attentionIs there any of < 20 years, > 55 years, pain progressive or for > 6 weeks, previous TB, cancer or oral steroid use, feeling unwell or weight loss?YesNoDo X-Ray and refer.Neck pain with arm pain• Give paracetamol 1g 6 hourly. Avoid NSAIDs like ibuprofen.• Do not refer for physiotherapy.Refer if no response after 1 month or hand weakness develops.Neck pain without arm pain• Give paracetamol 1g 6 hourly. Avoid NSAIDs like ibuprofen.• Refer for physiotherapy.Refer if no response after 3 months.ARM SYMPTOMSRecognise the patient with arm symptoms needing urgent attention:• Pain and limitation of movement following injury: refer• Arm, elbow or hand pain with swelling and temperature ≥ 38ºC: refer• Left arm pain with chest pain: exclude ischaemic heart disease 15.• Sudden onset of weakness of arm perhaps with vision problems, dizziness, difficulty speaking or swallowing: consider stroke/T/A 76.Approach to the patient with arm symptoms not needing urgent attentionScreen if problem is in the joint: Place hands behind head; then behind back. Make a fist and open hand. Press palms together with elbows lifted. Walk. Sit and stand up with arms folded.Cannot do screencomfortably.Joint problemlikely33.Painful shoulderReferred pain likelyAsk about chest pain,difficult breathing, cough,abdominal pain, pregnancy.See relevant page.Can do screen comfortably. Check for associated symptoms.Wrist pain worse at night and if armhangs down. May be pins and needles in1st, 2nd and 3rd fingers.Carpal tunnel syndrome likelyReferElbow pain worse on grippingTennis or golfer’s elbow likely• Advise rest.• Give ibuprofen 400mg 3 times a daywith food for 5 days.• Refer if no better.Pain at base of thumb relieved by restDe Quervains tenosinovitis likely• Rest and splint joint.• Give paracetamol 1g 6 hourly.• Refer if no better.1Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. If giving ceftriaxone IM, divide dose: 1g into 2 different injection sites.35