Lesotho Standard Guidelines Essential Medicines

S TA N D A R D T R E A T M E N T G U I D E L I N E S
AND
ESSENTIAL MEDICINES LIST
FOR LESOTHO
2005
M I N I S T RY O F H E A L T H & S O C I A L W E L FA R E
STANDING EXPERT COMMITTEE
1. Mrs T Khetsi Ministry of Health & Social Welfare
2. Mrs M Ntšekhe Ministry of Health & Social Welfare
3. Dr M Moteetee Ministry of Health & Social Welfare
4. Dr
EDITORIAL COMMITTEE
1. Mrs T Khetsi Ministry of Health & Social Welfare
2. Mrs M Ntšekhe Ministry of Health & Social Welfare
3. Dr M Moteetee Ministry of Health & Social Welfare
4. Ms M Tiheli Ministry of Health & Social Welfare
5. Ms N Hoohlo National University of Lesotho
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Acknowledgments
Production of this inaugural edition of the National Standard Treatment Guidelines (STGs) and Essential
Medicines List (EML) for Lesotho is a result of hard and selfless work by a group of individuals. It is not
possible to mention the names of all the people who contributed towards the development and production of
this document.
We wish to express our sincere appreciation to the two consultants who were engaged to develop this
document, Dr NC Moji and Mrs NG Masoga. Without their expertise and hard work, development of these
Standard Treatment Guidelines (STGs) and Essential Medicines List (EML) for Lesotho would still be just a
vision.
Particular acknowledgements and thanks are extended to Consultants at Queen Elizabeth II Hospital and
those at Mohlomi Hospital for their useful and valuable input into various sections of the Standard Treatment
Guidelines.
Finally, it would be remiss not to mention with gratitude the immense contribution of the Standing Expert
and Editorial Committees of the Ministry of Health and Social Welfare, which were engaged in the reviewing
and finalisation of the draft STGs and EML produced by the consultants, and oversaw the process to its
conclusion. To all on the Standing Expert and Editorial Committees, we thank you.
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FOREWORD
The Government of Lesotho through the Ministry of Health and Social Welfare is committed to providing
quality health care services to all Basotho. This can effectively be achieved by developing and implementing
structured systems encompassing, among others, provision of competent health care professionals who will
render basic health care services to the nation, as well as equitable access to these health care services at costs
affordable to the Basotho. Provision of essential medicines is one of the key strategies of this goal.
This concept is enshrined in the National Medicines Policy (NMP) of Lesotho. It is indeed very gratifying to
note that an important milestone towards achieving the objectives of the NMP has been reached. It is thus up
to all the stakeholders in the provision of health to the nation to ensure that the other objectives of the NMP,
closely intertwined with provision of good quality and affordable essential medicines are fulfilled. Of
particular importance here is rational use of the available medicines, which entails rational prescribing and
dispensing.
The STGs and EML have been produced through an extensive consultative process. They therefore represent
a consensus of opinion of experts in the health field. They also take into account the current economic
climate in the country as well as the Lesotho setting, and hence, are appropriately adapted to address our
unique challenges.
Let us all as stakeholders commit to the provision of quality health care to the Basotho through efficient
management of the limited supplies of medicines available to us. I therefore petition all health workers in
Lesotho to use these STGs and EML to rationalize the selection and use of medicines.
May God bless you all.
Dr M Phooko
Hon. Minister of Health and Social Welfare
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TABLE OF CONTENTS
CHAPTER 1: INTRODUCTION
1.1. GENERAL REMARKS ABOUT THE USE OF STANDARD TREATMENT GUIDELINES .............14
1.2. FORMAT UTILISED IN THE DEVELOPMENT OF THE STANDARD TREATMENT ......................
GUIDELINES .........................................................................................................................14
1.2.1. GENERAL REMARKS ..........................................................................................................14
1.2.2. DIAGNOSTIC CRITERIA ......................................................................................................14
1.2.3. TREATMENT GUIDELINES ..................................................................................................15
1.2.5. KEY INVESTIGATIONS .......................................................................................................15
1.2.6. COMMENTS ........................................................................................................................15
CHAPTER 2: NOTIFIABLE DISEASES
2.1. IMMUNISATION SCHEDULE .................................................................................................16

2.2. TETANUS PROPHYLAXIS SCHEDULE ..................................................................................17
CHAPTER 3: TREATMENT GUIDELINES FOR SICK CHILDREN
3.1. MEASLES ..............................................................................................................................18
3.2. DIPHTHERIA .........................................................................................................................19
3.3. PERTUSSIS (WHOOPING COUGH) ........................................................................................20
3.4. TETANUS ..............................................................................................................................21
3.5. RABIES .................................................................................................................................22
3.6. TYPHOID FEVER...................................................................................................................23
3.7. POLIOMYELITIS ...................................................................................................................24
3.8. MUMPS .................................................................................................................................25
3.9. RUBELLA (GERMAN MEASLES) ...........................................................................................26
3.10. CHOLERA .............................................................................................................................26
3.11. PLAGUE ................................................................................................................................27
3.12. VIRAL HAEMORRHAGIC FEVER ..........................................................................................27
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3.13. MALARIA ..............................................................................................................................28
CHAPTER 4: RESPIRATORY CONDITIONS
1. CHEST PAIN ........................................................................................................................29
2. COMMON COLD AND INFLUENZA...............................................................................30
3. BRONCHITIS .......................................................................................................................32
4. ASTHMA ...............................................................................................................................33
5. PNEUMONIA........................................................................................................................35
6. PNEUMONIA IN CHILDREN............................................................................................37
7. PULMONARY TUBERCULOSIS ......................................................................................39
CHAPTER 5: CARDIOVASCULAR CONDITIONS
1. ACUTE BREATHLESSNESS/DYSPNOEA ......................................................................45
2. HEART FAILURE................................................................................................................47
3. HEART FAILURE IN CHILDREN....................................................................................48
4. PULMONARY EMBOLISM ...............................................................................................49
5. RHEUMATIC FEVER.........................................................................................................50
6. INFECTIVE ENDOCARDITIS ..........................................................................................52
7. PERICARDITIS....................................................................................................................53
8. CYANOTIC HEART DISEASE IN THE NEWBORN.....................................................55
9. CONGENITAL HEART DISEASE IN ADULTS..............................................................55
10. CARDIAC ARHYTHMIAS/DYSRHYTHMIAS.............................................................56
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11. HYPERTENSION...............................................................................................................58
12. MALIGNANT HYPERTENSION.....................................................................................61
13. PULMONARY OEDEMA .................................................................................................62
CHAPTER 6: HEAMATOLOGY
1. ANAEMIA .............................................................................................................................65
CHAPTER 7: GASTROINTESTINAL CONDITIONS
1. GASTRO-ENTERITIS: INFECTIVE AND TOXIC.........................................................68
2. HEPATITIS ...........................................................................................................................70
3. NON VIRAL HEPATITIS ...................................................................................................71
4. LIVER CIRRHOSIS.............................................................................................................72
5. PEPTIC ULCER DISEASE .................................................................................................74
6. ACUTE PANCREATITIS....................................................................................................75
7. APPENDICITIS ....................................................................................................................77
8. ACUTE PERITONITIS........................................................................................................77
CHAPTER 8: GENITOURINARY CONDITIONS
1. URINARY TRACT INFECTION .......................................................................................84
2. PYELONEPHRITIS .............................................................................................................80
3. GLOMERULONEPHRITIS................................................................................................81
4. NEPHROTIC SYNDROME ................................................................................................83
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5. ACUTE RENAL FAILURE.................................................................................................84
6. CHRONIC RENAL FAILURE ...........................................................................................86
CHAPTER 9: SEXUA LLY TRAN SMITT E D IN FECTION S AN D HIV/A I DS
1. SEXUALLY TRANSMITTED INFECTIONS ..................................................................88
2. HIV/AIDS ..............................................................................................................................93
3. MANAGEMENT OF OPPORTUNISTIC INFECTIONS ................................................94
3.1. BACTERIAL RESPIRATORY INFECTION ..............................................................................94

3.2. PNEUMOCYSTIS CARINII .....................................................................................................95
3.3. PNEUMOCYSTIS CARINII IN PAEDIATRICS..........................................................................95
3.4. ATYPICAL MYCOBACTERIOSIS ...........................................................................................96
3.5. ORAL CANDIDIASIS ..............................................................................................................97
3.6. VAGINAL CANDIDIASIS .......................................................................................................97
3.7. OESOPHAGEAL CANDIDIASIS .............................................................................................98
3.8. CRYPTOCOCCAL MENINGITIS .............................................................................................98
3.9. TOXOPLASMOSIS .................................................................................................................98
3.10. HERPES SIMPLEX .................................................................................................................98
3.11. HERPES ZOSTER...................................................................................................................99
3.12. CYTOMEGALOVIRUS INFECTION ........................................................................................99
3.13. DERMATOMYCOSIS .............................................................................................................99
CHAPTER 10: CENTRAL NERVOUS SYSTEM DISORDERS
1. HEADACHE ...........................................................................................................................100
2. MIGRAINE.............................................................................................................................102
3. CEREBRO-VASCULAR ACCIDENTS/STROKE.............................................................103
4. PARKINSONISM...................................................................................................................104
5. MOVEMENT DISORDERS-CHOREA, HEMIBALLISMUS, MYOCLONUS ANDDYSTOPIA

105
6. EPILEPSY ..............................................................................................................................106
7. PYOGENIC MENINGITIS...................................................................................................109
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8. ACUTE VIRAL ENCEPHALITIS AND ASCEPTIC MENINGITIS ..............................112
9. SUBACUTE MENINGITIS ..................................................................................................113
10. PERIPHERAL NEUROPATHY ........................................................................................114
11. ACUTE POST-INFECTIOUS NEUROPATHY ..............................................................115
CHAPTER 11: METABOLIC DISORDERS
1. DIABETES MELLITUS ....................................................................................................117
2. DIABETIC KETOACIDOSIS ...........................................................................................119
3. HYPEROSMOLAR NON-KETOTIC COMA.................................................................123
4. HYPOGLYCAEMIA..........................................................................................................124
5. ENDEMIC AND MULTINODULAR GOITRE ..............................................................125
6. HYPOTHYROIDISM.........................................................................................................125
7. THYROTOXIC CRISIS.....................................................................................................126
CHAPTER 12: NUTRITIONAL DISORDERS
1. PROTEIN ENERGY MALNUTRITION (PEM).............................................................128
2. PELLAGRA ........................................................................................................................130
3. OBESITY.............................................................................................................................131
CHAPTER 13: OBSTETRICS & GYNAECOLOGY
1. ANAEMIA IN PREGNANCY ...........................................................................................133
2. ABORTION .........................................................................................................................134
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3. ECTOPIC PREGNANCY ..................................................................................................136
4. ANTE-PARTUM HAEMORRHAGE...............................................................................137
5. POST-PARTUM HAEMORRHAGE ...............................................................................138
6. PERPERAL SEPSIS/PYREXIA........................................................................................141
7. PELVIC INFLAMMATORY DISEASE ..........................................................................144
8. PROBLEMS OF THE NEWBORN ..................................................................................146
9. PREMATURITY ................................................................................................................147
10. NEONATAL JAUNDICE ................................................................................................149
CHAPTER 14: PSYCHIATRIC DISORDERS
1. ACUTE PSYCHOTIC DISORDERS................................................................................150
2. ANXIETY DISORDERS ....................................................................................................151
3. PANIC DISORDER ............................................................................................................152
4. ALCOHOL RELATED MENTAL DISORDERS (ALCOHOLISM)............................153
5. DELERIUM, DEMENTIA AND OTHER COGNITIVE DISORDERS .......................155
6. SCHIZOPHRENIA.............................................................................................................157
CHAPTER 15: EAR, NOSE & THROAT DISORDERS
1. EPISTAXIS..........................................................................................................................161
2. ALLERGIC RHINITIS ......................................................................................................162
3. VESTIBULITIS ..................................................................................................................163
4. EXTERNAL OTITIS..........................................................................................................164
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5. OTITS MEDIA....................................................................................................................165
6. MASTOIDITIS/MENINGITIS..........................................................................................167
7. TONSILITIS........................................................................................................................167
8. PHARYNGITIS ..................................................................................................................195
9. LARYNGITIS .....................................................................................................................171
10. VERTIGO..........................................................................................................................172
CHAPTER 16: DENTAL DISORDERS
1. BACTERIAL INFECTIONS .............................................................................................172
1.1. DENTAL CARIES .................................................................................................................172
2. PERIODONTAL DISEASES.............................................................................................173
2.1. CHRONIC GINGIVITIS ........................................................................................................173

2.2. CHRONIC PERIODONTITIS ................................................................................................173
2.3. ACUTE NECROTISING ULCERATIVE GINGIVITS ...............................................................174
2.4. ACUTE PERIODONTITIS (PERIODONTAL ABSCESS) ..........................................................175
2.5. DENTO-FACIAL INFECTIONS .............................................................................................176
2.6. LUDWING’S ANGINA .......................................................................................................177
3. VIRAL INFECTIONS ........................................................................................................178
3.1. PRIMARY HERPETIC GINGIVOSTOMOTITIS......................................................................179

3.2. HERPES LABIALIS/COLD SORES ........................................................................................179
3.3 HERPES ZOSTER...........................................................................................................180
4. FUNGAL INFECTIONS ....................................................................................................181
4.1. ACUTE CANDIDIASIS ..........................................................................................................181

4.2. ANGULAR CHEILITIS .........................................................................................................181
4.3 RECURRENT APHTHUS STOMATITIS .................................................................................182
5. TRAUMATOLOGY ...........................................................................................................183
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5.1. TOOTH CONCUSSION .....................................................................................................183
5.2. LUXATION ........................................................................................................................183
5.3 SUBLAXATION .................................................................................................................184
5.4 INTRUSION .......................................................................................................................184
5.5 SOFT TISSUE INJURIES ...................................................................................................185
CHAPTER 17: OPHTHALMIC DISORDERS
1. CONJUNCTIVITIS ............................................................................................................188
2. STYE ....................................................................................................................................189
3. EYE INJURIES...................................................................................................................190
4. GLAUCOMA ......................................................................................................................191
5. IRITIS ..................................................................................................................................192
CHAPTER 18: DERMATOLOGICAL CONDITIONS
1. ECZEMA .............................................................................................................................195
2. CONTACT DERMATITIS ................................................................................................196
3. DRUG REACTION ............................................................................................................197
4. ERYTHEMA MULTIFORME/STEVEN’S-JOHNSON SYNDROME ........................198
5. ACNE ...................................................................................................................................199
6. BOILS ..................................................................................................................................200
7. CELLULITIS, ERYSIPELAS AND IMPETIGO............................................................201
8. PSORIASIS..........................................................................................................................202
9. PEDICULOSIS....................................................................................................................203
10. SCABIES............................................................................................................................204
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CHAPTER 19: NEOPLASMS
1. TUMOURS ..........................................................................................................................205
CHAPTER 20: TRAUMA
1. LACERATIONS AND WOUNDS.....................................................................................207
2. MAJOR TRAUMA .............................................................................................................209
3. COLD INJURIES ...............................................................................................................217
4. BURNS .................................................................................................................................218
CHAPTER 21: MEDICAL & SURGICAL EMERGENCIES
1. CARDIAC ARREST...........................................................................................................225
2. ANAPHYLACTIC SHOCK...............................................................................................227
3. SHOCK ................................................................................................................................228
CHAPTER 22: POISONING
1. POISONING........................................................................................................................228
1.1. ORGANOPHOSPHATE POISONING .....................................................................................229

1.2. PARAFFIN POISONING .......................................................................................................229
1.3. PARACETAMOL POISONING ..............................................................................................230
2. SPECIFC POISONS TREATMENT GUIDELINES ......................................................230
2.1. BARBITURATES .................................................................................................................230

2.2. BENZODIAZEPINES ............................................................................................................231
2.3. CARBON MONOXIDE POISONING.......................................................................................231
2.4. NARCOTICS ........................................................................................................................231
2.5. ETHANOL POISONING ........................................................................................................231
2.6. TOBACCO POISONING ........................................................................................................232
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CHAPTER 23: LABORATORY TESTS & INVESTIGATIONS
1. INVESTIGATIONS AND LABORATORY TESTS .......................................................233
1.1. HAEMATOLOGY .................................................................................................................233

1.2. CHEMISTRY........................................................................................................................234
1.3. SEROLOGY .........................................................................................................................235
1.4. VIRAL TITRES ....................................................................................................................235
1.5. ENDOCRINE TESTS .............................................................................................................235
1.6. TUMOURS ..........................................................................................................................235
1.7. MICROBIOLOGY ................................................................................................................236
1.8. OTHER TESTS .....................................................................................................................236
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S T A N DA R D T R E A T M E N T
GUIDELINES 2005
1 INTRODUCTION
1.1 GENERAL REMARKS ABOUT THE USE OF STANDARD TREATMENT GUIDELINES

(STGS)
Medicine is dynamic and therefore the development and adoption for use of standard treatment guidelines is
not the end-all of our desire to improve the quality of care available to Basotho. It is the beginning of an
unending process.
It is therefore important for the users to carry on their obligation to use the Standard Treatment Guidelines
while providing the feedback to the Standing Expert Committee about their limitations or the need to include
emerging conditions.
It is equally important that enabling policies and regulations be continually developed and reviewed to ensure
adherence to the use of STGs by all our public and CHAL facilities.
STGs are a guide to management of the majority of patients. The users, where necessary, should consult
more detailed textbooks and clinical manuals and adapt management of individual cases accordingly.
The rationale for use of certain drugs for various conditions is succinctly outlined in the relevant sections of
the document. Feedback from the users of this document in the form of constructive criticism and/or
proposed improvements that will be necessitated from time-to-time by new developments in the practice of
medicine or by any relevant changes in our environment is highly solicited. This feedback is essential in
ensuring that future editions of this document address the core challenges within the health care sector in an
efficient and cost-effective manner, thus playing a major role in the achievement of the NMP goals. Feedback
on this document can be forwarded to the Standing Expert Committee in the Directorate of Pharmaceuticals
within the Ministry of Health and Social Welfare.
1.2 FORMAT UTILISED IN THE DEVELOPMENT OF THE STANDARD TREATMENT

GUIDELINES
This section presents the structure of the outline followed when developing the Standard Treatment
Guidelines:
1.2.1 General Remarks
This section explains the condition. It discusses the prevalence and impact of the condition
1.2.2 Diagnostic Criteria
This section highlights those important features of the disease that assist in establishing the diagnosis.
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1.2.3 Treatment Guidelines
This section details how the condition should be managed at the various levels in the health care delivery
system. Particular emphasis is placed on key promotion and prevention aspects of the interventions proposed
1.2.4 Key Investigations
This section discusses the various investigations necessary in making the diagnosis as well as in managing the
condition
1.2.5 Comments
Where necessary this section is used to emphasise the important features of the condition that need to be
borne in mind when managing the particular condition
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CHAPTER ONE
Notifiable Diseases and Other Infections
2 NOTIFIABLE DISEASES
These are a number of diseases that are under the WHO surveillance programme. They are grouped into
three (3) categories as follows:
1. Quarantinable Weekly Notifiable Diseases: These include cholera, Plague, Yellow

Fever and Haemorrhagic Fever
2. Non-Quarantinable Weekly Notifiable Diseases: These include Acute Flaccid

Paralysis, Measles, Meningococcal Meningitis, Poliomyelitis, Rabies, Anthrax and Neonatal
Tetanus
3. Monthly Notifiable Diseases: These include Hepatitis A and B, Whooping Cough,

Relapsing Fever, Typhoid and Diphtheria
It is deemed essential that all users of these guidelines and all health care providers be familiar with these
diseases as well as with the Immunisation Schedule defined for the country.
2.1 IMMUNISATION SCHEDULE
Timing Disease Vaccine Name
At Birth ♣ Tuberculosis ♣ BCG

♣ Poliomyelitis ♣ OPV-O
At Six (6) Weeks ♣ Poliomyelitis ♣ OPV-I
♣ Diphtheria ♣ DPT-1
♣ Tetanus ♣ Hepatitis B
♣ Hepatitis B
♣ Pertussis
♣ Tuberculosis (if not already
given at birth)
At Ten (10) Weeks ♣ Poliomyelitis ♣ OPV-II
♣ Diphtheria ♣ DPT-II
♣ Hepatitis B
♣ Pertussis
♣ Tuberculosis (if not already
given at birth)
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Timing Disease Vaccine Name
At Fourteen (14) Weeks ♣ Poliomyelitis ♣ OPV-III

♣ Diphtheria ♣ DPT-III
♣ Hepatitis B
♣ Pertussis
At Nine (9) Months ♣ Measles Vaccine ♣ Measles-I
At Twelve (12) Months ♣ Measles Vaccine ♣ Measles-II
At eighteen ( 18 ) Months ♣ Diptheria ♣ DT Booster

♣ Tetanus
♣ Diptheria ♣ DT Booster
At Five ( 5) Months Years ♣ Tetanus
2.2 TETANUS PROPHYLAXIS SCHEDULE
Toxoid Name/Designation Timing
TT-1 First Antenatal Clinic visit

TT-2 Four (4) weeks after TT-1
TT-3 Six (6) months after TT-2
TT-4 One (1) year after TT-3
TT-5 One (1) year after TT-4
2.3 INTERVENTIONS AT COMMUNITY LEVEL
1. Encourage mothers to immunise their children
2. Educate mothers about the benefits of immunisation
3. Emphasise the need for attending postnatal clinics as scheduled
2.4 INTERVENTIONS AT THE HEALTH CENTRE LEVEL
1. Reinforce the above
2. Emphasise the need to and the importance of immunising children as scheduled
2.5 INTERVENTIONS AT THE HSA HOSPITAL LEVEL
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2. Emphasise the need to and importance of immunising children as scheduled
3 TREATMENT GUIDELINES FOR SICK CHILDREN
3.1 MEASLES
This is a disease condition that continues to affect many children and accounts for a significantly high
proportion of outpatient morbidity and inpatient mortality. It is a viral infection, usually presenting with high
fever, conjunctivitis, cough, diarrhoea and skin rash. One of the most easily identifiable diagnostic features is
the appearance of spots that look like salt grains in the mouth, the so-called Koplik Spots.
3.1.1 Community Level Interventions
1. Isolate the child
2. Continue to feed the child
3. Apply Tepid Sponging where fever is present
4. Refer to a higher level for further care
3.1.2 Health Centre-Level Interventions
1. Encourage home-treatment where possible
2. Ensure that the child is fed well
3. Institute drug therapy where indicated:
♣ For Fever: Paracetamol syrup/tabs 10-15mg/kg orally in 3-4 divided doses per day for 5
days
♣ For Diarrhoea: Oral Rehydration Solution
♣ For Complications such as Otitis Media: Amoxycillin 40mg/kg/24 hourly orally in 3

divided doses
OR
Erythromycin 25 mg – 50 mg/kg orally three times per day for 7 days
♣ For conjunctivitis: Tetracycline eye ointment twice daily
PLUS
Vitamin A 100 000iu – 200 000iu once per day for three days
18
Refer patients with complications
3.1.3 Hospital Level intervention
1. Non-pharmacological management as above
2. Oxygen where indicated
3. Drug Management as appropriate and where indicated:
♣ Vitamin A 100 000iu – 200 000iu daily for two days
♣ Paracetamol 2.5 ml – 10 ml four times per day for 5 days
♣ Benzyl Penicillin iv 100 000 – 300 000 u/kg/24 hours in 4 divided doses for 7days
♣ Gentamycin 5-7.5mg/kg/24 hours in 3 divided doses for 5 days
♣ Where convulsions present: Diazepam 0.25mg – 1.0mg/kg IV or PR
OR
Phenobarbital 10mg/kg Loading Dose STAT, then 5mg/kg/24 hourly nocte
NOT TO EXCEED ADULT DOSE
3.2 DIPHTHERIA
Diphtheria is caused by Bordetella diphtheriae. It is characterised by an inflammatory and exudative reaction

that results in the formation of a greyish pseudo-membrane at the pharynx. Its most severe complications are
myocarditis, neuritis, upper respiratory tract obstruction, nephritis, thrombocytopenia, broncho-pneumonia,
and respiratory failure or even circulatory collapse. A patient with Diphtheria tends to present with a high
fever, sore throat, and hoarse voice with stridor and is often very sick.
1. Isolate the child.
2. Advice parents/care-givers about the seriousness of the condition
3. Refer immediately
3.2.2 Health Centre Level Interventions
1. Same as above
2. Monitor and record vital signs
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3.2.3 Hospital-level Interventions
1. Administer Diphtheria Anti-Toxin
2. Benzyl Penicillin iv 50 000 – 100 000u /kg/24 hourly for 7 days
OR
Pen VK 25mg -50mg/kg orally in 4 divided doses for 7 days
3. For Contacts: Diphtheria Vaccine, Pen VK 50mg/kg/24 hourly in 4 divided doses, OR

Erythromycin 25mg – 50mg/kg/24 hourly orally in three divided doses for 7 days
4. For Carriers: Pen VK 50mg/kg/24 hourly orally in 4 divided doses OR, Erythromycin 25mg –
50mg/kg/24 hourly orally in 3 divided doses for 7 days
3.3 PERTUSSIS (WHOOPING COUGH)
Pertussis is an acute inflammatory communicable respiratory tract infection caused by Bordetella pertussis. It
is characterised by a paroxysmal cough that ends with a loud inspiratory whoop. Crying, eating or drinking
usually precipitates the cough. Cyanosis, sweating, exhaustion and prostration usually accompany the cough.
3.3.1 Community-Level Interventions
1. Supportive treatment.
2. Isolate the patient
3. Encourage mothers/care-givers to have children immunised
4. Refer
1. Immunise all children in the village/area
2. Educate mothers/care-givers about the need to immunise children
3. Attempt home-based management under supervision
4. Refer all cases with cough-related complications
5. Institute Drug therapy where indicated
♣ Erythromycin 50mg/kg/24 hours orally in 4 divided doses for 7 days
♣ Phenobarbital 0.15mg/kg/24 hours orally in 3 divided doses
♣ Salbutamol 0.15mg/kg/24 hours orally in 4 divided doses if bronchospasm is present
♣ Provide prophylaxis for close contacts
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3.3.3 Hospital-Level Interventions
1. Manage as above
2. Administer Oxygen
3. Manage complications accordingly
3.4 TETANUS
Tetanus is an acute illness affecting muscle and is caused by tetanuspasm, a toxin produced by Clostridium
tetani, a gram-positive anaerobic organism. The condition is characterised by stiffness of the neck, back and
abdominal muscles with spontaneous muscle contractions/spasms (the so-called Tonic-Clonic Convulsions)
triggered by even minimal stimuli. There is usually a history of injury or unhygienic care of the umbilical cord
3.4.1 Community-Level Interventions
1. Encourage mothers/care-givers to have children immunised
2. Teach mothers/care-givers, midwives and Traditional Birth Attendants about hygienic

umbilical cord care
3. Treat wounds/lesions effectively
4. Refer all cases
1. Do as above
2. Clean and dress wounds or umbilical cord stump
3. Refer
3.4.3 Hospital Level interventions
1. Do as above
2. Give IV fluids: normal saline or ringers lactate
3. Record and monitor vital signs
4. Administer Oxygen
5. Medication
♣ Tetanus Human Immunoglobulin IM (500iu for Neonates and 2000iu for children)
♣ Benzyl Penicillin 50 000 – 100 000u/kg/24 hourly I.M in 4 divided doses for 7 days
PLUS
♣ Diazepam 0.25mg/kg/24 hourly IM in 3 divided doses
21
OR
♣ Chlorpromazine 2mg/kg/24 hourly IM in 3 divided doses

PLUS
♣ Phenobarbital 5 – 10 mg/kg/24 hourly IM in divided doses
6. Tetanus Prevention
♣ Wound Care
♣ Tetanus Toxoid
PLUS
♣ Tetanus Immunoglobulin 75iu – 250iu IM
♣ Pen VK 125 – 500mg 6 hourly orally for 7 days
♣ Erythromycin 25 – 50mg/kg/24 hours orally in 4 divided doses for 7 days
3.5 RABIES
Rabies is an acute infectious disease of mammals, especially carnivores like dogs. In cases where it is
suspected there is usually a history of a bite by an agitated and vicious dog. It is characterised by CNS
irritability usually followed by paralysis and death if untreated. Therefore urgent medical attention is
mandatory
The condition presents with a short period of mental depression, restlessness, malaise and fever. This may
rapidly progress to uncontrollable excitement with excessive salivation and excruciatingly painful muscle
spasm of the larynx and the pharynx.
3.5.1 Intervention at Community Level
1. Prompt cleansing of the dog bite wound with soap and water
2. Do not suture/close wound
3. Report the dog bite incident to a veterinary authority
4. Refer
3.5.2 Intervention at Health Centre Level
1. Do as above
2. Clean with antiseptic solution
3. Dress with antibiotic ointment
4. Medication
22
♣ Pen VK 125 –500 mg 6 hourly orally for 7 days
5. Refer
3.5.3 Hospital Level Intervention
1. Do as above
2. Secondary suturing of wound if determined to be clean
3. Medications
♣ Ampicillin 500 mg IV 6 hourly for 7 days
♣ Tetanus Toxoid 0.5ml IM
4. Post-exposure Prophylaxis
♣ For Immunised Patients: Rabies Vaccine 1ml IM (repeat on day 3)
♣ For Un-immunised Patients: Human Rabies Immunoglobulin 20iu/kg daily PLUS Rabies
Vaccine 1ml IM
3.6 TYPHOID FEVER
Typhoid is endemic in developing countries. It is a faeco-oral infection spread by ingestion of contaminated

food or water. The causative agent is Salmonellae typhi. Sporadic outbreaks are seen frequently in health
facilities in the country. If untreated this condition may progress to develop fatal complications such as
intestinal perforation, psychosis, peritonitis and/or myocarditis.
The condition usually presents with high fever, constipation or diarrhoea, headache, abdominal pain and
general malaise. Typhoid fever also features in the differential diagnosis of acute confusional state.
1. Safe excreta disposal
2. Assure availability of potable water supply
3. Promote proper personal hygiene
4. Ensure certification of food handlers
5. Refer suspected Cases
1. Non-pharmacological interventions as above
2. Medication
23
♣ Chloramphenicol 100mg/kg orally in 4 divided doses for 7 days DO NOT
EXCEED ADULT DOSE
♣ For drug-resistant cases: Ciprofloxacin 500 mg orally twice daily for 5 days
♣ For Chronic Carriers: Amoxycillin 250-500mg orally 8 hourly for 7 days
3.6.3 Hospital level Interventions
1. Reinforce non-pharmacological intervention above
2. Manage complications accordingly
3. Antibiotic therapy
♣ Chloramphenicol IV 100mg / kg/24hourly in 4 divided doses for 7 days
♣ Chloramphenicol IV 500mg -1gm 8 hourly for 7 days OR
♣ Ciprofloxin 500mg orally twice daily * 5days OR
♣ Ampicillin iv 500mg-1gm 6 hourly for 7 days
3.6.4 Key investigations
-Full blood count; -Widal
-Stool culture; -Blood sugar
3.7 POLIOMYELITIS
Poliomyelitis is a Notifiable and immunisable viral infection that normally presents with muscle weakness
and/or paralysis in children. It is spread through the faeco-oral route consequent to contact with
contaminated water. Three members of the poliomyelitis group of Estero virus cause it.
The patient usually presents with fever, headache, muscle pains or paralysis. The paralysis manifests as an
asymmetrical flaccid weakness evolving rapidly over a few hours or progressing more gradually over a period
of about a week. Respiratory or bulbar paralysis may be the dominant feature
1. Encourage immunisation of children against polio
2. Refer suspected cases
24
3.7.2 Health Centre Level Intervention
1. Do as above
2. Refer suspected cases
3.7.3 Hospital level intervention
2. Confirm the diagnosis
3. Stool specimen
4. Bed rest
5. Supportive care as required
6. Intensive rehabilitation
3.8 CHOLERA, PLAGUE, YELLOW FEVER AND HAEMORRHAGIC FEVER ARE ALL
QUARANTINABLE DISEASES. THOUGH THEY ARE NOT ENDEMIC IN LESOTHO, THEY
ARE IMPORTANT GIVEN THE HIGH VOLUME OF TRAFFIC TO, AND FROM ENDEMIC
AREAS
3.9. MUMPS
Mumps is caused by an RNA Myxovirus and is most common in spring. It most commonly affects children
and teenagers up to the age of 15 years. Characteristic features of mumps are pain and swelling of the parotid
gland (this is typified by an increase in size over a period of about 2-3 days; the sub-mandibular and/or the
sub-maxillary glands may be involved). Additional complications may include aseptic meningitis, encephalitis
and orchitis.
Community Level Interventions
1. Note that there is no specific treatment
2. Ice compression over the gland swelling
3. Pain relief through the use of Paracetamol and/or Aspirin
Health Centre Level Interventions
1. Do as above
2. Refer severe or non responding cases
25
1. Continue as above for health center level interventions
2. Prednisone 40mg daily may reduce very severe and painful swelling
RUBELLA (GERMAN MEASLES)
Rubella remains common in developing countries where effective vaccines programmes are lacking.
Characteristic features of the condition are fever, myalgia and posterior cervical lymphadenopathy; this can be
accompanied by a faint macular erythrema that develops on the face and spreads to the trunk. Arthralgia,
thrombocytopaenic purpura, neuritis and heart block may also occur as complications. When the condition
occurs in pregnancy the most common complications are cardiac and ophthalmologic teratological effects
Community and Health Centre Level Interventions
1. No specific medical treatment
2. Reassure the patient
3. Implement pain-relief with Paracetamol
4. Administer MMR Vaccine for all children in order to reduce incidence
CHOLERA
This is an acute infection caused by the organism Vibrio cholerae. It affects the entire small bowel and is
characterised by profuse watery diarrhoea, vomiting, muscle cramps, dehydration and syncope.
Management
This condition requires hospitalisation. The treatment is as follows:
1. Isolate patient
2. Ensure adequate nutrition
3. Administer Cholera Vaccine
4. Institute fluid replacement: IV Ringers lactate/normal saline
5. Treat with Co-trimoxazole, Tetracycline or Chloramphenicol:
Chloramphenicol 100mg/kg/24 hours orallys in 4 divided doses for 7 days
Tetracycline 250mg four times daily for 7 days
Co-trimoxazole 400/80mg twice daily for 7 days
26
PLAGUE
This is an acute infection caused by the bacillus Yersinia pestis (Pateurella pestis). It presents as a Bubonic or
Pneumonic form. The patient’s pulse may be rapid and thready. Enlarged lymph nodes appear with or shortly
before the fever. The most commonly affected lymph nodes are the femoral and inguinal nodes.
The Pneumonic form of the disease presents with an abrupt onset of high fever, chills, tachycardia, headache
and cough.
1. Refer all suspected cases
Health Centre Level Interventions
2. Refer to hospital
Hospital Level Intervention
1. Confirm diagnosis by isolating the organism from the blood, sputum and the swollen glands
2. Notify the authorities
4. Disinfect patient and his/her clothing
5. Monitor attending staff for fever and treat where indicated
6. Medication
♣ Streptomycin 0.5mg-1gm IM daily for 7 days AND
♣ Tetracycline 500mg orally 4 times daily for 7 days OR
♣ Chloramphenicol 500mg orally 4 times daily for 7 days
VIRAL HAEMORRHAGIC FEVER
This disorder is to be suspected in any person who has travelled to an endemic area and who develops fever
with a bleeding tendency. Other features include pharyngitis, hepatitis and shock. Viruses implicated are
arboviruses, arena-viruses and the Warburg and Ebola viruses
Treatment Guideline
1. Emergency care at hospital
27
3. Notify the relevant authorities
4. Contact specialist centre for further advice
MALARIA
Malaria is to be suspected in any traveller who has come from an endemic area and who develops fever with
rigors, headache, fatigue, lassitude, and sometimes diarrhoea. Tender hepato-splenomegaly may be present.
Jaundice and signs of pulmonary oedema may develop as complications
Treatment should not be attempted at either the community or health centre level. The hospital setting is the
preferred location for treatment.
Treatment Guidelines
1. Advocate for and promote regular anti-malaria prophylaxis when travelling to endemic areas
2. All suspected cases should be hospitalised without delay
3. Malaria parasites are demonstrable in peripheral blood slides (key diagnostic tool/procedure)
4. Supportive care with careful management of fluid balance
5. Specific malaria Treatment
-P. vivax, P. ovale or P. malariae: Chloroquine 600 mg base initial dose,
- Then single dose of 300mg after 6-8 hours and 300mg daily for 3 days OR
-Pramaquine 15mg daily for 4 days
-P. falciparum: MILD: Sulfonamide 500mg plus Pyrimethamine 25mg as a single dose
(adults 3 tablets, children ½ - 2 tablets per kg body weight); OR
Quinine orally 30mg/kg/24 hours in 3 divided doses; SEVERE Quinine orally

10mg/kg/8-hourly for 7 days
6. Malaria prophylaxis as recommended by the CDC
3.14.2 Key investigations
-Full blood count
-Peripheral Blood Slide
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CHAPTER TWO
Respirator y Disorders
1. CHEST PAIN
This is a common problem. When presented with chest pain, the aim is to exclude potentially fatal causes
such as myocardial infarction, unstable angina, pulmonary embolism, aortic dissection or oesophageal
rupture. Therefore any chest pain has to be treated seriously. If one cannot make a confident diagnosis of a
minor self-limiting disorder one has to exclude other causes of chest pain.
1.1 DIAGNOSTIC CRITERIA
The diagnostic criteria below is for potentially fatal causes only. The numerous other causes of chest pain are
not described.
1.1.1 Angina Pectoris
This is recurrent central chest pain often induced by exertion. It typically lasts for just a few minutes and is
relieved by rest
1.1.2 Myocardial Infarction
Characterised by a sensation of tightness and heaviness in the chest and a constrictive chest pain that persists
for more than 30 minutes. This is a pain that is NOT relieved by rest. It may radiate to the left arm, neck or
jaw. In addition the patient may be restless and apprehensive.
1.1.3 Unstable Angina
With this condition pain is felt at rest or even with just minimal exertion
1.1.4 Pulmonary Embolism
This is characterised by pleuritic chest pains associated with breathlessness in a patient with attendant risks
for deep vein thrombosis (DVT)
1.1.5 Aortic Dissection
This condition is characterised by severe chest pains of sudden onset accompanied by asymmetric peripheral
pulses or even aortic regurgitation (detectable on auscultation)
1.1.6 Oesophageal Rupture
In this condition chest pain follows vomiting. The chest pain is when the patient swallows. Other chest signs
such as pleural effusion may accompany it
29
1.1.7 Pericarditis
With this disorder the severity of the chest pain is worsened by inspiration or by lying supine. The pain
lessens when the patient sits upright
1.2 CLINICAL GUIDELINES
1. Educate patients about the seriousness of chest pain
2. Encourage the adoption of “healthy lifestyles”(Refer to VHW manual)
3. Avoid known risk factors for Ischemic Heart Disease (IHD)(Refer to VHW manual)
4. Discourage self-induced vomiting (as in “purging” as part of traditional remedies)
5. Medications
♣ For minor chest pain administer analgesics: Paracetamol 500mg or 1gm three times per
day for 5 days
1. Take measures as above
2. Monitor and record Vital Signs
3. Refer if a confident diagnosis of a minor ailment cannot be made
1.2.3 Hospital level Intervention
1. Reinforce non-pharmacological measures as described above
2. Investigate fully in order to better make an appropriate diagnosis
3. Manage according to the diagnosis made
2 COMMON COLD AND INFLUENZA
Influenza and colds are seen commonly in winter and are characterised by fever and cough with or without
white sputum, and a runny nose. These two conditions account for a significant proportion of outpatient
morbidity.
Colds and influenza are self-limiting viral infections. A patient usually presents with a fever of sudden onset.
The fever may be accompanied by a cough, runny nose, general malaise and arthralgia. The danger lies with
30
the potential for progression to complications such pneumonia, sinusitis, pharyngitis and otitis media in
children.
1. Bed Rest
2. Steam Inhalation
3. Tepid sponging for fever
4. Village health worker follow up of children after 2 days.
5. Medications
♣ Paracetamol syrup125mg-250mg 3 times daily for 5 days(Children)
♣ Paracetamol 500mg-l gm 3 times daily for 5days (Adults)
6. Refer in the event of complications or HIV status
2.2.2 Health centre Intervention
1. Non-pharmacological intervention as above
2. Paracetamol 125 mg -250mg 3 times daily for 5 days (Children)
Paracetamol 500-1gm 3 times daily for 5 days (Adults)
ASA 300mg-600mg 3 times daily for 5days (Adults)
3. If secondary infection is suspected give
Pen VK 125mg-250mg 4 times daily for 7 days (Children)
Pen VK 500mg-1gm 4 times daily for 7days (Adults) OR
Erythromycin 125mg - 250mg 4 times daily for 7 days (Children)
Erythromycin 500mg - 1gm 4 times daily for 7 days (Adults)
Refer if HIV suspected or major complication present
2.2.3 Hospital Intervention
1 Non-pharmacological intervention as above
2 Manage as per complications
31
2.3 Key Investigations
N.B Usually none unless complication are suspected
-Full Blood Count
-X-ray
3. BRONCHITIS
Acute bronchitis is a viral or bacterial infection of the bronchi that often arises as a complication of colds
and/or influenza
Bronchitis usually presents as a cough that may or may not be accompanied by wheezing. At onset the cough
is usually not productive but may progress to being productive of yellowish or greenish sputum.
1. Management is essentially similar to that for colds and influenza
2. Symptomatic relief with the following:
♣ Cough Syrup 2.5 – 5ml 3 times daily (children); sedative
♣ Cough syrup 10ml 3 times daily in adults
N.B if productive give expectorant cough syrup
♣ Paracetamol Syrup 125mg-250mg 3 times daily in children and
♣ Paracetamol tabs 500mg- 1gm 3 times daily in adults
3. Refer if no improvement or cough of more than a mouth
1. Manage conservatively as above
2. Antibiotics may be given if there is evidence of secondary bacterial infection or cardiac disease,
previous pneumonia, in cases of bronchiectasis, in immunocompromised patients or in chronic
overactive disease
3. Antibiotic Treatment: all given for 7 days
32
♣ Amoxycillin 62.6 – 250mg 3 times daily (children)
♣ Amoxycillin 500mg 3 times daily (adults) OR
♣ Erythromycin 62.5 – 250 mg 3-4 times daily (children)
Erythromycin 500mg 3 times daily (adults)
4. Refer if there is evidence of cardiac disease etc
3.2.3 Hospital Intervention
a. Reinforce non-pharmacological intervention as in common cold
b. Treat as per complications
3.3 Key Investigation
-Full Blood count; - Blood sugar
- X-ray; - Sputum
4 ASTHMA
Bronchial Asthma is a condition characterised by episodic and chronic airways obstruction due to
bronchospasm and inflammatory oedema. It is a condition that accounts for a significant proportion of both
inpatient and outpatient morbidity. It is a dangerous disease.
Asthma usually presents with acute or chronic symptoms of breathlessness, chest tightness, cough and an
expiratory wheeze
1. Immediate referral of acute asthma
2. Educate sufferers and the community about the condition
3. Promote avoidance of exposure to factors that trigger asthma attacks
4. Encourage smokers to quit smoking
5. Train patients on the proper use of inhalers used for asthma
6. Allay anxieties that accompany the disease
33
1. Reinforce above messages
2. For Acute Attacks:-
♣ Nebulise with 0.5% Salbutamol solution PLUS
♣ IV Hydrocortisone 1-2mg/kg (children),
♣ Hydrocortisone 100 – 200mg IV Stat (adults) OR,
♣ Prednisone 20 – 40mg po daily for 7 days
3. Observe and refer if no improvement
4.2.3 Hospital Level intervention
1. Reinforce above messages
2. Hospitalise
3. For Acute Attacks:
♣ Oxygen,6L/per mm Nebulise with Salbutamol, as above
♣ IV Hydrocortisone 1-2mg/kg (children),
♣ IV Hydrocortisone 100 – 200mg (adults)
♣ IV Aminophylline 5 – 6mg/kg in 1 000ml of 5% Dextrose Solution
4. Antibiotics may be given for 7 days if there is an indication of a secondary infection:
♣ Amoxycillin 500mg 3 times daily OR,
♣ Tetracycline 500mg 4 times daily, OR
♣ Cotrimoxazole 400/80mg 2 times daily.
5. Refer drug-resistant cases for specialist care
6. For Chronic Cases that have been stabilized:
♣ Salbutamol Inhaler,
♣ Theophylline 200 – 400mg 2 times daily OR
♣ Salbutamol 4mg 3 times daily.
34
4.3 KEY INVESTIGATIONS
-Full Blood count; -Peak flow measurement
-Blood gases and oxymeter; -Blood sugar
-Urea and Electrolytes; - X-ray
5. PNEUMONIA
Lower Respiratory Tract Infections constitute a major global health problem. This is in spite of the
widespread availability of potent anti-microbial drugs. Pneumonia accounts for about 6% of deaths that occur
in institutions as well as for a significant proportion of outpatient morbidity.
Characteristic presentation is that of a fever of sudden onset, usually accompanied by a cold and/or
productive cough. There are pleuritic stabbing chest pains and an accompanying shortness of breath
2. Tepid sponging where fever present
3. Paracetamol 125mg-250mg stat (children)
Paracetamol 500mg-1gm stat (adults)
1. Manage conservatively as above
2. Use analgesics for pain relief
♣ Paracetamol 125mg-250mg 3 times daily (children ) for 5 days
♣ Paracetamol 500mg-1gm 3 times daily (adults) for 5 days
♣ ASA 300mg-600mg 3 times daily (adults) for 7 days
♣ Oxygen 6L/min
35
3. Administer Oxygen if indicated
4. Give antibiotics:
♣ Pen VK 125mg-250mg 4 times daily (children) for 7 days
♣ Pen VK 500mg-1gm 4 times daily (adults) for 7 days or
♣ Erythromycin 125mg-250mg 4 times daily (children) for 7 days
♣ Erythromycin 500mg-1gm 4 times daily (adults) for 7 days
5. Refer to Hospital if no improvement after 3-4 days
1. Conservative management as above
2. For uncomplicated Pneumonia then give:
♣ Amoxycillin 500mg 8-hourly, orally for 7 days OR
♣ Erythromycin 500mg 6-hourly, orally (if the patient is sensitive to Penicillin and/or features
of Atypical Pneumonia or Influenzae are present)
3. For complicated Pneumonia
♣ Amoxycillin 500mg IV 8-hourly for 7 days PLUS
♣ Erythromycin 500mg IV 6-hourly for 7 days
Nosocomial:
♣ Ampicillin 1gm IV 6-hourly for 7 days PLUS
♣ Gentamycin 160mg loading dose STAT; then
♣ Gentamycin 80mg 8-hourly for 7 days OR
Inhalation Pneumonia:
♣ Metronidazole 500mg IV 8-hourly, PLUS
♣ Ampicillin 1gm IV 6-hourly for 7 days OR
♣ Claforan 1gram IV 12-hourly for 7 days
36
-Full blood count; -X-ray
-Blood sugar; -Sputum culture and sensitivity
6. PNEUMONIA IN CHILDREN
Pneumonia is a common inflammatory process affecting the lung parenchyma and is caused by various
infectious agents. The organisms most commonly implicated are S. pneumoniae, H. influenzae, S. aureus, M.
tubercolisis, Mycoplasma pneumoniae and Pneumocystis Carinii (constitutes a common complication in
immuno-compromised children)
The onset is often acute with high fever, flaring of nostrils, cough, tachypnoea, dyspnoea, intercostal
recession and intercostal retraction. The examination may reveal dullness on lung percussion, and bronchial
breathing, crepitations and/or decreased breath sounds on auscultation.
6.2 TREATMENT GUIDELINES
1. Encourage early seeking of medical help
2. Tepid sponging if fever present
3. Maintain child’s nutritional status adequately
4. Refer all cases as soon as possible
1. Manage as above
2. Encourage frequent small feeds
4. Refer all neonates and other patients with respiratory difficulties
5. Medications:
♣ Penicillin Syrup 125 – 250mg orally 4 times daily for 7 days OR
♣ Amoxycillin Syrup 62.5 – 250mg orally 3 times daily for 7 days PLUS
♣ Paracetamol Syrup 2.5ml – 5ml 3 times daily for 5 days.
In cases of Penicillin Sensitivity Erythromycin 62.5 – 250mg 4 times daily for 7 days BEFORE meals, can be
used
37
6.2.3 Hospital Level Interventions
1. Continue non-pharmacological interventions as above
2. Medications for children:
♣ Amoxycillin 50mg/kg/24 hours in 3 divided doses (if<20kg body weight) for 7 days OR
♣ Amoxycillin 250 – 500mg 6-hourly (if >20kg body weight) for 7 days
3. Medications for Neonates:
♣ Ampicillin 50 – 100mg/kg IV 6 hourly PLUS,
♣ Gentamycin 7.5mg/kg IV 24-hourly in 3 divided doses for 7 days
Specific Treatment Where the Organism is known
1. S. pneumoniae:
♣ Amoxycillin 100mg/1kg/24hrs in 3 divided doses for 7 days OR
♣ Flucloxacillin 62.5 – 125mg 6-hourly for 7 days
2. Anaerobic Infection:
♣ Metronidazole 7.5mg/kg 8-hourly for 7 days ( N.B never exceed adult doses)
3. Lobar Pneumonia:
♣ Benzylpenicillin IV 50,000u/kg/24hrs in 4 divided doses for 7 days.
4. Mycoplasma and Chlamydial Infection:
♣ Erythromycin 40 – 50mg/kg 6 hourly for 7 days
-Urea and electrolytes; -Blood sugar
38
7. PULMONARY TUBERCULOSIS
Pulmonary Tuberculosis is caused by Mycobacterium tuberculosis and is a common lung infection that
accounts for a significant proportion of all mortality in the country. It is characterised as a chronic
granulomatous infection of the lung. It has now become a common complication found in malnourished and
immune-compromised children
It presents with a chronic, productive cough that is almost always accompanied by night sweats and a
pronounced loss of weight. There may be a history of contact with an infected person (or persons). Most
children are initially asymptomatic and may only have a positive Mantoux Skin Test.
1. Refer all patients with a chronic cough for screening
2. Avoid sustained overcrowding
4. Supervise known TB patients to take their medications regularly and to complete the prescribed
treatment (DOTS)
5. Refer all cases
2. Reassure the patient that TB is curable if medication is taken as prescribed
4. Refer the patient
1. Non-pharmacological measures as above
3. Confirm diagnosis by doing sputum examination
4. Treat pulmonary tuberculosis as extra-pulmonary TB as recommended below
39
(i) Treatment (in children)
1st Phase (2 months) 2nd Phase (4 months)
Isoniazid/Rifampicin (100mg/150mg)
PYRIFIN
5-10 kg ½ Tab: 50mg/75mg
♣ RIF 120mg
♣ INH 80mg 11-20 kg 1 Tab: 100mg/150mg
♣ PZA 250mg)
21-30 kg 2 Tabs: 200mg/300mg
The duration of the 2nd Phase TB Treatment is 10 months for TB Meningitis, TB Spine and Tuberculoma
(ii) Treatment (in Adults)
♣ The first phase for sputum positive cases is to be under the DOTS approach.
A] Adult New Cases (i.e. new smear positive and other pulmonary and extra-pulmonary tuberculosis)
1. Initial phase (2 months duration)
MEDICINES <50KG >50KG
Isoniazid/Rifampicin
150mg/300mg
2 Tablets 2 Tablets
Pyrazinamide 500mg 3 Tablets 4 Tablets
Ethambutol 200mg 2 Tablets 3 Tablets
2. Continuation phase (4 months duration)
40
MEDICINE <50KG >50KG
150mg/300mg
2 Tablets 2 Tablets
B] Adult Retreatment Cases i.e. smear positive retreatment cases
e.g.
-Relapse
-Treatment failure
-Treatment after interruption.
1. Initial phase (2 months duration)
150mg/300mg
2 Tablets 2 Tablets
Pyrazinamide 500mg 3 Tablets 4 Tablets
Ethambutol 200mg 2 Tablets 3 Tablets
Streptomycin IM 0.75mg-1gm 750mg 1gm
2. Continuation phase (5 to 6 months duration)
Tablets
150mg/300mg 2 Tablets
41
C] Adult multi-drug resistant
This should be managed as per culture and sensitivity
♣ Sputum Negative Cases: Treat with conventional antibiotic (as for pneumonia) for 2
weeks. Only if there is no improvement should a course of anti-TB medication be
initiated
EXTRA PULMONARY TUBERCULOUSIS
Extra pulmonary TB is tuberculosis in which the disease process occurs outside the lungs. The majority
originate from lymphatic or haematogenic spread of mycobacteria from primary focus in the lung. The most
common types of extra pulmonary tuberculosis are :
♣ TB Lymphadenitis
♣ Milliary Tuberculosis
♣ Pleural effusion
♣ TB meningitis
♣ TB pericardial effusion
♣ TB Peritonitis
♣ TB of bones and other organs
Extra pulmonary tuberculosis is often difficult to diagnose and the diagnosis may be presumptive after
excluding other conditions
( i ) Tuberculous lymphadenitis
This has to be differentiated from persistent generalized lymphadenopathy (PGL) related to HIV. It should
be suspected if lymph nodes are tender, painful, non symmetrical, matted, flactuent, rapidly growing or
associated with fever, night sweats or weight loss.
Diagnosis: The diagnosis is made by 18g or 19g needle aspiration or biopsy of lymph node; Mediastinal and
or intra-abdominal lymphadenopathy may be detected by X-ray, ultrasound or CT Scan.
Treatment: Treat as for PTB
( ii ) Miliary Tuberculosis
42
Miliary tuberculosis is caused by the widespread blood bone dissemination of TB bacilli. Patient present with
fever, night sweats and weight loss and may have enlarged liver and spleen.
N.B. Miliary tuberculosis is under diagnosed as the end stage AIDS.
Diagnosis: Chest X-ray shows small miliary nodules uniformly distributed.
Treatment: Treat as for PIB
( iii ) Tuberculous Pleural Effusion
Tuberculous pleural effusion presents with chest pain, breathlssness, tracheal and mediastinal shift away from
the side of the effusion and decreased chest movement
Diagnosis: Chest x-ray shows unilateral uniform white opacity, often with a concave upper border.
Treatment: Treat as for PTB
(iv ) Tuberculosis Meningitis
Tuberculosis meningitis is a life-threatening condition with serious complications. Patients present with
gradual onset of headache and decreased consciousness. There is neck stiffness and positive kerning’s and
Babinski signs
Diagnosis: Lumbar puncture shows elevated white cells with predominant lymphocytes, increased protein
and decreased sugar in cerebrospinal fluid ( CSF)
Treatment: Treat as per PTB
(v) Tuberculous Pericardial Effusions
Tuberculous pericardial effusions present with chest pain, shortness of breath, cough, dizziness and weakness
due to low cardiac output. There may be signs and symptoms of heart failure.
Diagnosis: Chest X-ray shows a large globular heart with clear lung fields.
-ECG shows low voltage with tachycardia flattening or ST waves changes.
-Echocardiogram shows increased effusion in the pericardial sac with normal heart usually.
( vi ) Tuberculous Peritonitis
TB peritonitis presents with ascites .There may be palpable abdominal masses, bowel obstruction and fistula
Diagnosis: Ascitic Tap- Exudate with increased white cell and predominant lymphocytes.
43
-Sputum for AFB (X3); -X-ray; -Lymph node aspiration/biopsy;
-Pleural tap; -Ascitic tap; -Lumbar puncture
-Echocardiogram; -Full blood count; -Blood sugar
-HIV testing
TB Associated with HIV/AIDS:
First give (and complete) 1st Phase anti-TB treatment and only then start Anti-retrovirals
44
CHAPTER 3
Cardiovascular Diseases
1. ACUTE BREATHLESSNESS/DY SPNOEA
Onset of breathlessness (dyspnoea) may be sudden or gradual with or without a productive cough. The aim in
acute breathlessness is to rule out lethal causes such as pneumothorax, pulmonary embolism, pulmonary
oedema, and foreign body aspiration or Adult Respiratory Distress Syndrome. Causes range in nature from
“local” (i.e., localised in the respiratory tract) to general (e.g. cardiac disease, respiratory disease, disease of the
rib cage and metabolic disorders such as diabetic ketoacidosis and anaemia).
Presentation depends largely on the underlying cause:
1.1.1. Pulmonary Oedema:
Should be suspected in patients with cardiac disease who develop sudden onset of breathlessness
accompanied by wheezing and a productive cough
1.1.2. Asthmatic Attack
Symptoms may be provoked by psychosomatic factors. This condition is characterised by a wheeze in the
presence of a reduced peak flow rate. Diurnal or seasonal variations may be reported (Refer to page 48 on
asthma)
1.1.3. Pneumonia
This condition is characterised by a fever accompanied by cough (may or may not be productive) and
pleuritic chest pains. Chest X-ray findings are supportive of the diagnosis (Refer to chapter 2 Pneumonia)
1.1.4. Pulmonary Embolism
Suspect in the presence of risk factors for DVT where there is associated pleuritic chest pains and
haemoptysis
1.1.5. Cardiac Tamponade
There is usually a markedly raised jugular-venous pressure with a paradoxic pulse, cardiomegaly and
reduced/muffled heart sounds
1.1.6. Large Pleural Effusion
Dull percussion over thoracic cavity with reduced air entry into the side affected. Chest X-ray typically shows
a tracheal shift away form the side with the effusion
45
1.2. TREATMENT GUIDELINES
1.2.1. Community Level interventions should consist only of IMMEDIATE referral
1.2.2. Health Centre Level Intervention
1. Pulmonary Oedema:
♣ Frusemide 40 – 80mg STAT
2. Record and Monitor Vital Signs
3. Reassure patient and family
4. Refer
1.2.3. Hospital Level Intervention
1. Bed rest
3. Confirm cause of dyspnoea
4. Manage as per cause
5. Severe Pulmonary Oedema:
♣ Administer Oxygen 6L/min;
♣ Diamorphine 10-15mg IV Slowly PLUS,
♣ Frusemide 40 – 240mg IV bolus PLUS,
♣ Glyceryltrinitrate spray 2 puffs,
-Full blood count; - X-ray
-Blood sugar; -Urea and electrolytes
-Peak flow measurement; -ECG
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2. HEART FAILURE
Heart failure, in all its forms (i.e., mild, moderate and severe) is a common occurrence in the Lesotho setting.
It accounts for approximately 5.3% of the institutional deaths that take place in Lesotho. It is a “clinical
syndrome” that is characterised by the inability of the heart to maintain an adequate cardiac output.
2.1. DIAGNOSTIC CRITERIA
2.1.1. Right Ventricular Failure:
Characterised by elevated venous pressure, palpable liver (hepatomegaly), dependant oedema
2.1.2. Left Ventricular Failure
Characterised by dyspnoea on exertion, cough, fatigue, orthopnoea, paroxysmal nocturnal dyspnoea and
“crackles” in the chest
2.1.3. Bi-Ventricular Failure
Presents with signs and symptoms characteristic of both of the above
2.2.1. Community Level Interventions
1. Education to facilitate early detection
2. Reduce physical activity/exertion
3. Restrict salt intake
4. Refer all cases.
1. Reinforce non-pharmacological interventions described above
2. Administer a diuretic, e.g. Frusemide 40mg daily or Hydrochlorothiazide (HCTZ)

25mg – 100mg daily with potassium replacement (Slow K 600mg orally, daily)
3. If there is no response after two (2) weeks or if the patient’s condition worsens, then
refer patient to nearest Hospital
1. Reinforce non-pharmacological interventions described above
2. Determine and confirm the cause of the heart failure
3. Avoid medications that may cause further stress to the heart, e.g. Beta Blockers
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4. Medications:
♣ Frusemide 40 – 80mg either orally or IV depending on the severity OR
♣ Hydrochlorothiazide 25mg – 100mg orally, daily with potassium supplementation

(Slow K 600mg daily),
5. Medications (Other): Other drugs can be administered depending on the response to

the initial medication and the presence of complications:
♣ ACE Inhibitor (e.g. Captopril) 12.5 – 25mg three times daily;
♣ Digoxin 0.125 – 0.25mg daily if patient has atrial fibrillation or gross cardiomegaly
6. If unable to find a plausible cause, then refer to a specialist facility
- Chest X-ray; -ECG; -Urea and Electrolytes
-Urine; -Echocardiogram; -Blood sugar
-Lipogram
3. HEART FAILURE IN CHILDREN
Heart failure is defined as the “inability of the myocardium to meet the metabolic requirements of the body”.
In children the causes may be congenital or acquired. Commonly implicated congenital abnormalities include
transposition of the great arteries, tetralogy of Fallot, coarctation of the Aorta, Ventricular septal defect,
Patent Ductus Arteriosus and others. The acquired lesions may be rheumatic fever, rheumatic heart disease,
myocarditis, cardiomyopathy, severe anaemia, hypertension and others
The condition is characterised by the presence of all or some of the following:
-Pulmonary venous congestion and/or oedema,
-Hepatomegaly,
-Peripheral oedema,
-Failure to thrive,
-Poor feeding.
These occur in the presence of the signs and symptoms of the underlying cause of the heart failure
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3.2.1. Community and Health Centre Level Interventions
1. Refer for stabilisation
3.2.2. Hospital Level Interventions
1. Admit
2. Institute bed rest
3. Administer Oxygen if cyanosed
4. Determine underlying cause of the heart failure
5. Medication
♣ Digoxin 0.005mg – 0.01mg/kg 24-hourly in 2 divided doses PLUS
♣ Spironolactone 1mg –3 mg/kg 24-hourly b.d or t.d.s
♣ Captopril 0.1 mg– 2mg/kg 24-hourly b.d or t.d.s
♣ Frusemide 1mg – 2mg/kg 24-hourly 1-4 times per day
-X-ray; -Full blood count; -Blood sugar
-Lipogram; -ECG; -Echocardiagram
-Urea and Electrolyetes; - Urine
♣ NB: It is essential that any underlying cause (e.g. cardiac tamponade, infections,
and hypertension) be treated.
♣ Digoxin is contraindicated in bradycardia, hypertrophic cardiomyopathy, heart

block and cardiac tamponade
4. PULMONARY EMBOLISM
This condition should be suspected in any patient with a history of pelvic surgery, obesity, previous cardiac
disease or previous and/or current use of oral contraceptives and who presents with a history of sudden
onset breathlessness, severe oppressive chest pains and haemoptysis.
49
1. Bed Rest
2. Oxygen 6L/min
3. Heparin 5 000 i.u. IV bolus followed by 1 000 – 2 000 i,u IV hourly. Dose should then be
adjusted based on APPT, which itself is expected to be 1.5 – 2 times the normal value
-X-ray; -Full blood count; -Electrolyetes
-Echocardiogram; -Blood sugar; -Urea + electrolyetes
-Blood gases
5. RHEUMATIC FEVER
This is a febrile illness in which the body develops antibodies against its own tissues secondary to an
inadequately treated Group A Streptoccocal infection of the throat.
The condition presents with a combination of signs and symptoms such as persistent fever, arthralgia and
fleeting joint pains, heart murmurs and/or heart failure, rheumatic nodules, erythema marginatum and chorea.
1. Refer cases
2. Analgesics may be given e.g. Paracetamol syrup or Aspirin
1. Refer to Hospital
2. Medication:
♣ Analgesics as above
♣ Pen VK 500mg 4 times daily for 7 days
♣ Pen VK Syrup 125 mg 4 times daily for 7 days (children)
1. Bed Rest
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2. Medication (Adults):
♣ Pen VK 500mg 4 times per day for 10 days or for 7day
♣ Erythromycin 500mg 4 times per day for 7 days if patient is allergic to Penicillin
3. Medication (Children):
♣ 1-5 yrs: Pen VK Syrup 125mg 4 times daily for 7 days
♣ 6-12 yrs: Pen VK Syrup 250mg 4 times daily for 7 days
If Penicillin sensitive:
♣ 1-5 yrs: Erythromycin 125mg 4 times daily for 7 days;
♣ 6-12 yrs: Erythromycin 250mg 4 times daily for 7 days
♣ Aspirin 100mg/kg 24-hourly in 4-6 doses daily for 2 weeks then reduce to 75mg/kg
24hrly daily for an additional 4-6 weeks (DO NOT EXCEED 2g ASPIRIN IN A 24-
hour PERIOD)
♣ If patient has carditis with either heart failure or an enlarged heart (X-ray) then give
Prednisone 2mg/kg daily, orally for 2 weeks
♣ In cases where heart failure is present administer Digoxin and diuretics as described in the
section on Heart Failure
4. For Secondary Prevention (prophylaxis until age 21)
♣ <30 kg: Benzathine Penicillin 600 000 units IM monthly
♣ >30 kg: Benzathine Penicillin 1.2 million units IM monthly
♣ In cases of penicillin sensitivity: Ertythromycin 500mg 2 times daily
-Full Blood Count and ESR; -Chest X-ray; -Anti-streptolysin -O titre
-ECG; -Throat Swab
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6. INFECTIVE ENDOCARDITIS
This is a microbial infection of the endocardium. It is characterised by fever, heart murmurs, petechiae, and
anaemia, embolic phenomena, endocardial vegetations that may be seen by ECG. The vegetations may lead
to valvular incompetence or obstruction, myocardial abscess or mycortic aneurysm
Known or unknown rheumatic heart disease that presents with signs and symptoms as described above. This
diagnosis should be considered in patients with prosthetic heart valves who present with signs and symptoms
suggestive of endocarditis
1. Advice all known cardiac patients to consult with a doctor if they have ANY infection
2. Refer all cases
6.2.2. Health Centre Level Interventions
1. Do as above
2. Medication:
♣ Paracetamol 500 – 1 000mg 3 times daily for 5 days
♣ Aspirin 300 – 600mg 3 times daily for 5 days
If Anaemic:
♣ Iron Sulphate (FeSO4) 200mg 3 times daily PLUS
♣ Folic Acid 5mg Daily
♣ Refer all cases
1. Manage as above
2. Blood Culture x 3
3. Medications (Adults):
♣ Gentamycin 80mg 8-hourly IV for 5 days PLUS
♣ Benzyl Penicillin 4 – 6 million units 4-hourly IV for 7 days
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♣ Refer to Specialist if progress not satisfactory
4. Medications (Children): Treat for 4-6 weeks
♣ Gentamycin 5-7.5mg/kg 24hrly in the divided doses
♣ Benzyl Penicillin 200 000- 300 000 units/kg 24-hourly
♣ Refer to specialist if not satisfactory
-Chest X-ray; -Full Blood Count and ESR
-ECG; -Echocardiogram
7. PERICARDITIS
This condition is an inflammation of the pericardium. In some cases the cause maybe unknown (idiopathic);
the majority of cases are due to infectious disease (viral, tuberculous, fungal and bacterial), acute myocardial
infarction (MI), drugs (hydralazine, procainamide etc.,), uraemia, collagen diseases, rheumatic fever,
neoplasms, myxoedema and injury to the heart (post-cardiac surgery, trauma, or irradiation)
It presents with severe chest pain which is made worse by inspiration or by delaying to expire. The pain
lessens when the patient sits upright. There may be a history of influenza a few days before onset of chest
pain.
1. Bed rest
2. Manage as per “Chest Pain”
3. Refer for further management
1. Bed rest
2. Pain Relief:
♣ Paracetamol 500mg-1000mg 3 or 4 times daily for 7 days OR
♣ ASA 300mg-600mg 3 or 4 times daily for 7 days
53
1. Bed rest
2. Confirm the diagnosis
3. Establish the underlying cause
4. Manage the underlying cause
5. Medications (Pain Relief):
♣ Paracetamol 500-1 000mg 3-4 times per day for 7 days OR
♣ Aspirin 300-600mg 3-4 times per day for 7 days
6. Medications (Bacterial Pericarditis):
♣ Gentamycin 80mg IV 8-hourly for 5 days PLUS
♣ Flucloxacillin 500mg-1gram 6-hourly for 7 days OR
♣ Ampicillin 500mg-1gram I.V 6-hourly for 7 days
7. Medications (Recurrent Pericarditis/Underlying Collagen Diseases)
♣ Prednisone 40 mg orally daily (Adults) for 7 days then taper
♣ Prednisone 2mg/kg/day (children) for 7 days then taper
8. Tuberculous Pericarditis/Effusion
♣ T.B. treatment as described in the section on TB
♣ Prednisone 40mg orally/day (adults) for 7 days then taper
♣ Prednisone 2mg/kg/day (children) for 7 days then taper
7.3. Key Investigations
-Blood x 3 for Culture and Sensitivity; -Chest X-ray
-Full Blood Count and ESR; -Urea and Electrolytes; -ECG
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8. CYANOTIC HEART DISEASE IN THE NEWBORN
Cyanotic heart disease constitutes a group of diseases that present with blue discolouration of the skin and
tongue. This is due to the inadequate oxygenation of the blood that typifies this group of diseases. This may
be due to blood by-passing the lungs, intra-cardiac mixing of blood or reduced lung perfusion (for whatever
reason). In the newborn it is vital to exclude respiratory disorder or central nervous system disorder as a
cause.
The newborn exhibits little or even no improvement with administration of oxygen. There is tachypnoea with
or without a heart murmur. Cardiac lesions are confirmed by the presence of cardiomegaly, with an abnormal
cardiac shape and reduced pulmonary blood flow.
1. Refer without delay
1. Administer oxygen if it is available
2. Refer without further delay
1. Administer 100% oxygen
2. Take blood for Blood Gases if possible
3. Chest X-ray
4. If there is no improvement and cardiac silhouette is suspicious then refer patient for specialist
care
9. CONGENITAL HEART DISEASE IN ADULTS
These are conditions wherein the cardiac lesion has not prevented a patient from surviving to adulthood. The
commonest such lesions include patent ductus arteriosus (PDA), ventricula-septal defect (VSD) and, less
commonly, atrio-septal defect (ASD).
The patients are acyanotic and the lesions may be found on routine medical screening for school or
employment. The symptoms depend on the type of the defect and the severity of the complication
The main objective is to detect congenital heart diseases early.
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9.2.1 Community Level Intervention
Unlikely to be diagnosed at this level
Refer if suspected
1. Full investigation including key investigations below
2. Refer for definitive treatment where indicated
9.3 Key investigation
- Chest X-ray
- ECG
- Echocardiogram
10 CARDIAC ARHYTHMIAS/DY SRHYTHMIAS
These are disorders of cardiac rate, rhythm and conduction. They are commonly seen and present as
palpitations. Palpitations, by definition, are an awareness of the heart beating either rapidly, missing beats, or
“thumping” in the chest. It should be noted that the distinction between palpitations that occur normally and
those that reflect heart disease is not an easy one to make.
Cardiac arrhythmias may present with palpitations, dizziness, syncope attacks or sudden death. There may be
associated chest discomfort, dyspnoea and headache. The pulse rate and regularity is an important feature.
Commonly occurring arrhythmias are of four (4) types:
10.1.1 Atrial Fibrillation
This is an ineffective, irregular and rapid (120-160 beats/min) atrial rhythm. The incidence is higher in the
elderly and the condition is often asymptomatic. The chief risk in this condition is embolic stroke
10.1.2 Ventricular Extrasystoles (premature Ventricular contractions)
Constitutes the most common form of arrhythmia that occurs after an MI. This condition is characterised by
a regular pulse that has intermittent “missed beats” that may occur at regular or random intervals
10.1.3 Complete Heart Block
In this condition, the patient presents with a very slow pulse of between 30-40 beats per minute. Patients may
be asymptomatic or present with attacks or complain of weakness or dyspnoea.
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10.1.4 Paroxysmal Supraventricular Tachycardia
Pulse is regular but very fast 150-200 beats/minute. Palpitations is the common manifestation of the
condition. The attacks begin and end abruptly and may last for a few seconds to several hours. Patients may
be asymptomatic except for awareness of rapid heart action or may experience mild chest pain or shortness of
breath if episodes are prolonged.
10.2.1.1 Community Level Interventions
1. Avoid precipitating factors such as smoking, alcohol, and tea/coffee
2. Reassure the patient since anxiety is a common symptom and most patients tend to be
frightened
3. Refer
1. Manage as above
2. Refer if rheumatic heart disease, myocardial infarction, uncontrolled hypertension,

thyrotoxocosis, cardiomyopathy or digitalis poisoning cannot be ruled out
3. Medication:
♣ Diazepam 2-5mg orally 2 times daily PLUS
♣ Imipramine 10-20mg orally 2 times daily
♣ Chlordiazepoxide
2. Treat underlying cause
3. For Atrial Fibrillation/Flutter
♣ Digoxin 0.25mg orally 2-3 times daily, then maintenance of 0.25mg once daily OR,
♣ Verapamil 40mg orally 3 times daily OR,
♣ Atenolol 50-100mg 3 times daily PLUS,
♣ Aspirin 75-150mg daily
♣ Treat underlying cause
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4. For Supraventricular Tachycardias
♣ Non pharmacological measures as above
♣ Propranolol 10-40mg orally 4 times daily OR,
♣ Atenolol 50-100mg daily OR,
♣ Verapamil 40-120mg 3 times daily OR,
♣ Digoxin 0.25 –0.5mg daily
♣ Warfarin 2.5-5mg adjusted per INR
5. For Ventricular Tachycardias
♣ Cardioversion
♣ Lignocaine 50-100mg IV or infusion and follow with
♣ Amiadaron 200mg orally daily
6. Heart Block
♣ Atropine 0.6-1.2mg IV as a bolus dose OR,
♣ Adrenaline 5ml IV of 1:10 000 solution OR,
♣ Isoprenaline 0.5-5 micrograms per minute
♣ Refer for pacemaker
-ECG; -Urea/electrolytes; -Thyroid function test
-Digoxin level; -Lipid Profile; -Blood sugar
-ASOT-titre
11 HYPERTENSION
Hypertension is a major risk factor for stroke and myocardial infarction. It is usually asymptomatic, so
screening is a vital component of management. Blood pressure has a skewed normal distribution within the
general population. It is therefore impossible to define “hypertension”. The convention is to select a value
above which risk is significantly increased, and the benefit of treatment is clear-cut. A figure of
160/100mmhg is usually quoted. For many years diastolic pressure was considered to be more important than
58
systolic pressure. However recent evidence indicates that systolic pressure is the most important determinant
of cardiovascular risk. 1
In the vast majority of cases (up to 95%) the cause is unknown. This is the so-called “essential hypertension”.
In the remaining 5% of cases where a cause can be determined there are usually three categories of causes:
renal disease, endocrine disease and “others”
A diagnosis of Hypertension is made if the blood pressure is elevated above normal on three (3) separate
occasions. In adults, a systolic pressure greater than 140mmHg or a diastolic pressure greater than 90mmHg
fulfill the criteria. As stated above, hypertension is usually asymptomatic, except in cases of “malignant”
hypertension. It is therefore always necessary to undertake a full examination of the cardiovascular
system and to check for retinopathy. In the same vein, it is also necessary to assess the patient for features
of a secondary cause, and to also check for end-organ damage (proteinuria and/or retinopathy), which can
provide clues about the severity and duration of hypertension as well as the prognosis thereof.
1. Promote early detection and encourage the adoption of “healthy lifestyles”( Stop smoking, lose
weight, do regular physical exercise, avoid excessive alcohol intake)
3. Stress the importance of taking medications as prescribed
4. Refer suspected cases/defaulters
1. Reinforce non-pharmaceutical interventions as outlined above
2. Medication (for mild hypertension)
♣ Hydrochlorothiazide (HCTZ) 12.5mg orally, daily
♣ If control not satisfactory after one (1) month, increase dose of HCTZ to 25mg daily
♣ If control still not satisfactory after three (3) months, then refer to hospital
♣ Refer all cases with a systolic pressure >160mmHg or
Diastolic >100mmHg
1. Reinforce non-pharmacological management as described above
1 See Oxford Handbook of Clinical Medicine, 4th Edition, and Page 300.
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2. Medications 2:
♣ Propranolol 40-80mg daily OR,
♣ Captopril 12.5-25mg daily OR,
♣ Hydralazine 25-50mg daily
♣ If control is not achieved with a combination of two drugs, it may be necessary to add a
third drug such as Nifedipine 5-10mg 3 times daily
♣ In severe cases IV therapy may be instituted with Dihydralazine 10mg IV or Frusemide

40-80mg.
11.3. Key Investigations
-Chest X-ray; -ECG; -Urea and Electrolytes
-Urine Microscopy; -Echocardiogram; -Full Blood Count and ESR
-Blood sugar; -Lipid profile; -Fundoscopy
11.4. Treatment of Hypertension Occurring in the Presence of Other Medical Conditions

N.B Therapy normally will be initiated at the hospital level
1. Diabetes Mellitus
♣ HCTZ 12.5mg daily OR,
♣ Indapamide 2.5mg daily OR,
♣ ACE-inhibitor (captopril) 12.5mg once daily OR,
♣ Nifedipine 10-20mg once daily
2. Heart Failure
♣ Frusemide 20-40mg daily PLUS,
♣ Captopril 12.5 –25mg once daily
3. Renal Failure
2 The convention is to start with drugs of proven benefit i.e., thiazides or β-blockers. Calcium-channel blockers and ACE-
inhibitors can be considered next
60
♣ Frusemide 20-40mg once daily and/or
♣ Captopril 12.5-25mg once daily and/or,
♣ Verapamil 40-70mg once daily
4. Coronary Artery Disease (CAD)
♣ Captopril 12.5-25mg once daily OR,
♣ Verapamil 40-80mg once daily
5. Pregnancy induced hypertension
♣ Refer to chapter II on obstetrics and gynaecology.
12. MALIGNANT HYPERTENSION
This refers to severe hypertension (e.g. systolic pressure >200mmHg, diastolic pressure >(120)130mmHg) in
conjunction with bilateral retinal haemorrhages and exudates; papilloedema may or may not be present.
Common symptoms are headache and visual disturbances. The danger with this condition is that it may
precipitate acute renal failure, heart failure, or encephalopathy all of which constitute hypertensive
emergencies and require urgent treatment.
Most patients can be managed with oral therapy, except for those with encephalopathy. The main aim with
treatment in this condition is to achieve a controlled reduction in blood pressure over days, not hours. It is
critical to avoid sudden drops in blood pressure, as cerebral auto-regulation is poor, with a resultant rise in the
risk for stroke.
12.2.1. Community level intervention
Refer immediately
12.2.2 Health centre level intervention
Refer without delay
All patients suspected of having this condition are to be admitted to hospital for management thereof.
1. Bed rest
61
2. Medications
♣ Frusemide 40-80mg twice daily, orally
♣ Nifedipine 10-20mg 8-hourly
♣ Hydralazine 25-50mg 8-hourly
♣ Atenolol 50-100mg twice daily, orally
3. For Encephalopathy
♣ The main aim should be to reduce blood pressure to approx. 110mmHg over a period of
4 hours
♣ Dihadralazine 10mg IV every 10-15 minutes PLUS,
♣ Frusemide 40-80mg IV 8-hourly
12.3. Key investigations
-ECG; -Echocardiogram; -Lipid profile
-Blood sugar; -Urea and electrolytes; -Fundoscopy
13 PULMONARY OEDEMA
Left Ventricular Failure (occurring either post-MI or secondary to Ischaemic Heart Disease) is the most
common cause. Other cardiac causes include mitral stenosis, arrhythmias, and malignant hypertension. Non-
cardiac causes, though rare, still occur. These include allergic reactions (e.g. IV contrast agents), fluid overload
(usually iatrogenic secondary to excessive IV fluid infusion), smoke inhalation, acute respiratory distress
syndrome (trauma, sepsis, post-op), infection, carbon monoxide poisoning, amniotic fluid embolus, SLE, and
drug overdose (Aspirin, Glue).
The main symptoms associated with this condition are dyspnoea, paroxysmal orthopnoea, and pink frothy
sputum. The patient usually presents in distress, pale, sweaty and with a rapid pulse and respiratory rate. JVP
is usually raised and there is an accompanying wheeze (the so-called cardiac asthma) and “fine lung crackles”.
N.B This is a medical emergency diagnosed and managed at hospital level.
1. Treatment should be begun BEFORE investigations are initiated.
2. Sit the patient up
62
3. Give Oxygen by face mask: 100% if there is no pre-existing lung condition
4. Monitor ECG and treat any arrhythmias
5. Restrict fluids
6. Measure urine output
7. Frequent check of BP, Pulse, and Heart Sounds
8. U&E and ECG Daily
9. Medications:
♣ Frusemide 40-160mg IV slowly
♣ Diamorphine 10,-15mg IV slowly (ensure there is no liver failure or COPD)
13.3 Key Investigations:
-ECG and Echocardiogram; -Chest X-ray -FBC
-Arterial Blood Gases; -U&E
14. MYOCADIAL INFARCTION
Characterrised by a sensation of tightness and heaviness in the chest and a constrictive chest pain that persists
for more than 30 minutes. This is a pain that is NOT relieved by rest. It may radiate to the left arm, neck or
jaw. In addition the patient may be restless and apprehensive
1. Bed Rest
2. Reassurance given that patient is likely apprehensive
3. Oxygen 6l/min
4. Medication:
♣ Aspirin 75mg-150mg daily PLUS
♣ Glyceryl Trinitrate 0.5mg sublingually (may be repeated every 5-10 minutes);
♣ Morphine or Diamorphine 10-15mgPLUS
♣ Atenolol 50mg daily PLUS
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♣ Heparin IV bolus dose of 5 000iu followed by 1 000 – 2 000iu 4-hourly as per APPT;
♣ If sever and symptomatic bradycardia is present administer Atropine IV 0.6 – 1.2mg
♣ Where appropriate supportive and diagnostic measures are available consider using
thrombolytic agents such as Streptokinase
2. Unstable Angina
♣ Bed Rest
♣ Oxygen if hypoxic
♣ Reassurance if patient is apprehensive
♣ Medications (as with MI)
3. Chronic Stable Angina
♣ Non-pharmacological measures aimed at modifying the risk factors
♣ Patient education with regard to the condition
♣ Medication:
- Isosorbide Dinitrate 5mg-40mg as indicated PLUS
- Atenolol 50mg-100mg daily PLUS
- Aspirin 75mg-150mg daily
-Full Blood Count; -Chest X-ray; -ECG
-Echocardiogram; -Cardiac Enzymes; -Urea and Electrolytes
-CT Scan
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CHAPTER 4
Haematolog y
1. ANAEMIA
Anaemia is a decrease in red blood cells or haemoglobin content due to blood loss, impaired production of
red blood cells or increased destruction of red blood cells (i.e., common feature is low red cell mass).
Anaemia is a symptom and not a diagnosis by itself. 3
1.1 IRON DEFICIENCY ANAEMIA
Iron deficiency is one of the commonest causes of anaemia. It results in what is referred to as microcytic,
hypochromic anaemia. This loss of iron may be due to excessive blood loss or to the consumption of a diet
low in iron. Other causes may be an increased iron requirement by the body or impaired iron absorption.
1.1.1 Diagnostic Criteria
This type of anaemia presents with symptoms such as lethargy, fatigue, dizziness, dyspnoea and palpitations,
all of which are suggestive of an impaired oxygen carrying capacity. There is pallor of the mucous membranes
of the eyes, mouth, fingernail bed, and the palms of the hands. There may be muco-cutaneous lesions such as
angular stomatitis, glossitis, koilonychias and brittle hair and nails
1. Community Level Interventions
♣ Health education about a balanced dietary intake
♣ Encourage consumption of dark, leafy green vegetables, meat, eggs, beans and peas
♣ Supply prophylactic treatment
-ferrous sulphate/fumarate 200mg daily
-Ascorbic acid 250 mg daily
-Folic acid 5mg daily
3If the low Haemoglobin is due to dilution from an increased plasma volume (as in pregnancy) the anaemia is called
“physiological”
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.
2. Health Centre Level Interventions
♣ Reinforce the above non-pharmacological interventions
♣ Supply
-Ferrous Sulphate or Fumerate tablets 200mg 3-times daily (for children give 1 teaspoon
Ferrous Sulphate Solution 3-times per day)
♣ Refer if condition deemed severe or if there are signs suggestive of heart failure
3. Hospital Level Interventions
♣ Reinforce non-pharmacological measures as above
♣ Determine cause of iron deficiency
♣ Manage the underlying cause of the anaemia
♣ Treat the complications
♣ Manage other causes of microcytic anaemia
1.2 MACROCYTIC ANAEMIA
This is anaemia characterised by marked macrocytosis. The usual cause is either a Vitamin B-12 or Folic Acid
deficiency. Liver diseases, particularly in conjunction with chronic alcohol abuse, may also present with
macrocytic anaemia.
Vitamin B-12 deficiency occurs most often as a consequence of either dietary insufficiency (as in a vegan diet)
or as a result of intestinal malabsorption. For folic acid deficiency, the causes are commonly nutritional
deficiency (as occurs in chronic alcoholism, old age and/or psychiatric disorders), malabsorption, increased
(but unmet) requirement for folate by the body, and the use of folate-antagonist drugs.
1. Community Level Interventions
♣ Health education regarding the importance of a balanced diet
♣ Prophylactic folic acid supplements during pregnancy (see Community Health Worker
package)
2. Health Centre Level Interventions
♣ Manage as above
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♣ Refer
3. Hospital Level Interventions
♣ Reinforce non-pharmacological measures as described above
♣ Establish the diagnosis
♣ Replacement therapy as per laboratory result for 3 months
-Folic acid 5-10mg daily, orally;
-Vit B12, 1 000 units daily for 1 week, then maintain on 1 000 units weekly
thereafter
-Ferrous sulphate/Fumerate
-Full blood count; -Vitamin B12; - Folate Level
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CHAPTER 5
Gastrointestinal Disorders
1. GASTRO-ENTERITIS: INFECTIVE AND TOXIC
This is a group of syndromes whose presentation manifests primarily in the form of Upper Gastrointestinal
Tract symptoms (nausea and vomiting), diarrhoea and abdominal discomfort. Viruses, bacteria, parasites and
certain toxins or GIT-irritating substances may cause it. The loss of electrolytes and fluids that occurs in the
presence of this condition is of grave significance, particularly in the old, the young, and those with pre-
existing disease.
1.1.1 Gastroenteritis with Mild Dehydration
This condition is characterised by frequent passing of watery stool accompanied by nausea and vomiting. Skin
elasticity/turgor remains normal; and in children the anterior fontanelle is also normal
1.1.2 Gastroenteritis with Moderate Dehydration
In this condition there is diarrhoea and/or vomiting with increased thirst and irritability. The pulse is rapid
and weak and the patient presents with slightly sunken eyes. There is a slight loss of skin elasticity and the
urine is concentrated.
1.1.3 Gastroenteritis with Severe Dehydration
This condition is characterised by the presence of diarrhoea and/or vomiting accompanied by deeply sunken
eyes and anterior fontanelle. The pulse is rapid, thready and feeble/impalpable.
1. If there is a confirmed community outbreak, the relevant authorities should be notified

as soon as possible
2. Encourage oral fluid intake
3. Administer Oral Rehydration Solutions or sugar salt solution if ORS not available.
4. Moderate-severe cases should be referred to Health Centre
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1. Administer Oral Rehydration Solution
2. Monitor urinary output
4. If there is no response
- Set up IV line of 500ml ringers lactate
- Refer
1. Continue non-pharmacological measures as above
2. Administer IV Fluids and monitor fluid input and output
3. Establish the cause
4. Where an organism has been identified, specific treatment should be

administered
♣ Typhoid Fever:
-Chloramphenicol 500mg 4 times daily (as first line antibiotic) OR

- Ciprofloxacin 500mg twice daily for 7 days.
♣ E. Coli:
-Cotrimoxazole 80/400mg 2 tablets twice daily, orally OR,

-Doxycycline 100mg twice daily, orally for 7 days
♣ Shigellosis:
-Nalidixic Acid 1 gram 4-times daily OR

-Ampicillin 500mg 6-hourly IV OR
-Amoxycillin 500mg 8-hourly OR
-Cotrimoxazole 2 tablets twice daily for 7 days
♣ Protozoal Diarrhoea:
-Metronidazole 400mg 8-hourly for 7 days
-Full blood count; -Urea and electrolytes; -Blood sugar
-Stool-ova; -Stool-culture
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2 HEPATITIS
Hepatitis is an inflammation of the liver cells due to viruses, alcohol, drugs or toxins. There may be no
symptoms or signs or there may be fatigue, right upper quadrant (RUQ) pain, joint pains, complications of
cirrhosis and jaundice.
Viral Hepatitis – viruses A, B, Non-A, Non-B. It presents with minor flu-like illness or fulminant, fatal liver
failure. It is characterized by sudden onset of anaemia, malaise, nausea and vomiting and fever followed by
jaundice.
5. Bed rest
6. Low fat, low protein, high carbohydrate diet
7. Counsel on avoidance of strenuous physical exercise
8. Counsel on avoidance of alcohol
9. Refer all cases
2. Avoid use of medications
3. Vitamin B-complex 2 tablets daily for 5 days
4. Refer all cases for investigation
2. Confirm diagnosis
3. Notify the relevant authorities
4. In Severe Cases:
♣ Dextrose 5% IV infusion
♣ Add Vitamin B-complex 2cc IV to each litre of 5% Dextrose solution
♣ Refer all cases with fulminant hepatitis, relapsing hepatitis or other complications
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2.2.4 Prophylaxis
1. High-Risk Groups: Active immunisation with recombinant Hepatitis B Vaccine
2. Persons at Risk: Passive immunisation with Hyper-Immune Serum Globulin
3. Screen all Blood donations
2.3 Key investigations
-Liver function tests; -Serum amylase; -Clotting profile
-Blood Sugar; -Full Blood Count; -Ultrasound
-Urea and Electrolytes
3 NON VIRAL HEPATITIS
This could be due to alcohol, drugs or other toxins
Patient develops jaundice with no preceeding flu-like syndrome. There may be history of ingestion of
substances like alcohol or use of traditional medicines or other drugs like T.B. drugs etc.
1. Bed Rest
2. Withdraw the offending agent
3. Avoid strenuous physical exertion
4. Encourage Alcohol cessation
5. Restrict protein in diet
6. Refer
2. Vitamin B-complex 2 tablets daily, orally
3. Refer
71
1. Correct any electrolyte imbalances
2. Vitamin B-complex 1-2cc into 1 litre 5% Dextrose solution PLUS,
3. Vitamin B-12 1 000 micrograms daily, IM
4. Vitamin K 5-10mg daily IM or IV
5. Folic Acid 5mg daily, orally
-Liver Function tests; -Serum amylase; -Clotting profile
-Blood sugar; -Full blood count; -Ultrasound
-Urea and Electrolytes
4 LIVER CIRRHOSIS
Liver cirrhosis is a chronic liver disorder characterized by disorganization of liver architecture by wide spread
fibrosis resulting in nodule formation. 4 Alcohol is one of the common causes. The other causes are liver
infections especially viral hepatitis and herbal medications.
The presentation is varied. The patient may present with malaise, anorexia, vomiting or jaundice. Finger
clubbing with hepatomegaly and splenomegaly and ascites may be present. Some cases may present with
haematemesis and/or melaena or stupor with encephalopathy. Skin lesions such as palmar erythema and
spider angiomata may be also be present.
1. Avoid the use of hepato-toxic agents such as alcohol, herbal medications or other unnecessary
drugs
3. Encourage high carbohydrate, low fat, low protein diet
4. Refer patient
1. Reinforce management as described above.
4 In this condition, the resultant damage to the architecture of the liver is essentially irreversible
72
3. Refer for further investigations
2. Establish the cause
3. Manage any complications present
4. For Ascites:
♣ Therapeutic ascitic tap if respiratory difficulties caused by ascites are present
♣ Frusemide 40mg daily, orally PLUS,
♣ Spiranolactone 25mg 3-times daily (for children: 1-3mg/kg/24-hourly in 2-3 divided

doses)
5. For Hypoalbuminaemia:
♣ Albumin 20% IV
6. For Hypoglycaemia
♣ Dextrose 10% IV infusion
7. For Encephalopathy:
♣ Lactulose 10-30ml 3-times daily (5-30ml in children) PLUS,
♣ Neomycin 1-2 grams 6-hourly
8. For Bleeding Oesophageal Varices:
♣ Endocscopic injection Sclero-therapy with Desmopressin
♣ Variceal ligation where indicated
♣ Propranolol 40mg daily, orally
9. For Bleeding Diathesis:
♣ Vitamin K 5-10mg IV STAT
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4.3 Key Investigation
-Liver Function tests; -Ascitic Tap; -Blood Sugar
-Full blood count; -Ultrasound; -Urea and Electrolytes
5 PEPTIC ULCER DISEASE
Peptic ulcer is a circumscribed ulceration of the mucous membrane of the gastrointestinal tract penetrating
through the muscularis mucosa and occurring in areas exposed to acid and pepsin. Duodenal ulcer and
gastric ulcer are the two commonest types. The causes of duodenal and gastric ulcers may differ. Gastric
ulcers unlike duodenal ulcers tend to develop later in life and are not associated with increased acid secretion.
The usual peptic ulcer has a chronic and recurrent cause.
9.1.2. Duodenal Ulcers
The patient typically presents with epigastric pain that is described as gnawing or burning and is relieved by
eating. The pain is usually at its most severe at night
5.1.2 Gastric Ulcers
In some cases the patient may be asymptomatic. Where symptoms are present they typically consist of
epigastric pain (indistinguishable from that of other causes) that is usually worsened by eating. There may be
associated weight loss where the condition is chronic
1. Avoid any food that worsens symptoms. Also eat a little at a time but often and avoid eating
just before bedtime (acid secretion is highest at night)
2. Stop smoking (smoking increases relapse rates in duodenal ulcer and slows healing rates in
gastric ulcers)
3. Refer if no improvement
1. Reinforce conservative management as described above
2. Medication
♣ Cimetidine 400mg orally STAT, then 200mg AM and 400mg PM for 6 weeks
♣ Aluminium Hydroxide/Magnesium Trisilicate 20ml STAT then, 15ml 4-times per day
3. Refer
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1. Reinforce conservative management as described above
2. Medication
♣ As above PLUS,
♣ Cimetidine 400mg STAT then 200mg AM and 400mg PM for 2 weeks PLUS
♣ Amoxycillin 500mg-1 gram 3 times daily for 7 days
♣ Metronidazole 400mg 3 times daily for 7 days
3. The following categories of patients are to be referred
♣ Resistant Ulcer
♣ Upper Gastro-intestinal Bleeding
♣ Perforation
♣ Oesophageal Stenosis
♣ Suspected Malignancy
-Full blood count; -Blood X-match; -Blood sugar
-Serum amylase; -Gastroscopy
6 ACUTE PANCREATITIS
This is a medical emergency caused by the inflammation of the pancreas. Biliary tract disease and alcoholic
toxicity account for the majority of hospital admissions.
Sudden onset of severe abdominal pain that reaches maximum intensity within minutes is a common
presentation. The patient is acutely ill and sweaty with tachycardia and respirations are shallow and rapid.
Nausea and vomiting is usually present. There may be mild to moderate muscular rigidity in the upper
abdomen. Typical signs include local or generalised abdominal pain with peri-umbilical discolouration
(Cullen’s Sign) or discolouration at the flanks (Grey Turner’s Sign)
1. Health education about the dangers of alcohol abuse
75
2. All suspected cases should be referred without delay
1. Set up IV Line – Ringers Lactate or Normal Saline
2. Record and monitor Vital Signs
3. Administer Diclofenac 75mg IM STAT
1. Cease/Discontinue oral food intake
2. Insert Naso-gastric Tube (NG-Tube)
3. Insert IV line for parenteral fluids
5. Give nothing by mouth
6. Oxygen
7. Catheterise
8. Give antibiotics if there is fever with high white cell count
♣ IV Ampicillin 500mg 6 hourly for 7 days PLUS
♣ Pethidine 50-100mg IV 6-hourly
♣ Cimetidine 200mg IV 6-hourly
9. Correction of Electrolyte Disturbance:
♣ For Hypocalcaemia: Calcium Gluconate 10% 10ml IV as bolus infusion over 10 minutes
♣ For Hypomagnesaemia: Magnesium Sulphate 25-50ml infusion IV
10. Refer the following for specialist intervention (See chapter six)
♣ Acute Renal Failure
♣ Pseudocyst
♣ Disseminated Intravascular Coagulation (DIC)
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7 APPENDICITIS
It is characterised by an inflammation of the vermiform appendix and is most commonly caused by bacterial
infections. It is most common in adolescents and young adults.
The condition typically presents with a central abdominal pain that eventually shifts to become localised in
the right lower quadrant (RLQ). Anorexia is invariably present but nausea and vomiting may be present,
though not prominently. Tenderness and guarding are present in the RLQ (at McBarney’s Point). A positive
Psoas sign (i.e., pain on passive hyper-extension of the thigh) strongly favours the diagnosis.
1. All suspected cases should be referred immediately for review
3. Refer
1. Emergency surgical intervention is indicated
2. Metronidazole suppositories in children
-Full blood count; -Blood sugar; -Urea and Electrolytes
8 ACUTE PERITONITIS
This is an inflammation of the visceral and parietal peritoneum. The most common cause is bacterial
infection. It may occur secondary to complications of abdominal surgery, pelvic infection or ruptured ectopic
pregnancy.
The patient typically presents with severe, localised or diffuse abdominal pain with associated rebound
tenderness. The patient is often febrile with tachycardia and tachypnoea.
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2. Do not feed
2. Insert IV line Ringers Lactate or Normal Saline
3. Administer Diclofenac 75mg IM STAT
4. Do not feed
5. Refer
1. Maintain on IV fluids
2. Institute early surgical intervention where indicated
3. Medications:
♣ Ampicillin 500mg – 1 gram IV, 6-hourly PLUS,
♣ Gentamycin 80mg IV, 8-hourly PLUS,
♣ Metronidazole 500mg IV, 8-hourly
♣ Third generation caphalosporin
-full blood count; -Urea and electrolytes; -Blood sugar
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CHAPTER 6
Genito-Urinary Disorders
1. URINARY TRACT INFECTIONS
This is an infection of the bladder and urethra. It is confirmed by the presence of microorganisms in a urine
culture.
This condition presents with lower abdominal pains, fever and frequency of micturition. There is usually pain
on passing urine, and this pain tends to be more severe towards the end of micturition. In addition, there may
be associated blood and/or pus in the urine. At times UTI is asymptomatic. The presentation in neonates
may be that of fever, poor feeding, failure to thrive, accompanying signs of renal failure, vomiting, jaundice,
and hypothermia.
1. Encourage high oral fluid intake
2. Counsel on improved personal hygiene
3. Refer all cases
1. Non-pharmacological interventions as described above
2. Medications:
♣ Cotrimoxazole 80mg/400mg 2 times daily for 7 days (see 1.2.3.2 below for children
doses)
♣ Paracetamol 500mg – 1 gram 6-hourly for 5 days adults
♣ Paracetamol 125mg-250 mg 3 times daily for 5 days children
3. Refer all neonatal cases OR cases that do not respond to medication
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2. Medication:
♣ Neonates and Infants:
-Gentamycin 2.5-5mg/kg 8-hourly for 5 dayss (2.5mg/kg for Premature Babies)

PLUS
-Ampicillin 50mg-100mg/kg in 4 divided doses, for 7 days
♣ Older Children:
-Amoxycillin 20-40mg/kg in 4 divided doses or,
-Cotrimoxazole 200/40mg 2 times daily for 7 days
♣ Adults with Uncomplicated Cystitis:
-Amoxycillin 500mg 3 times daily OR,
-Cotrimoxazole 80/400mg, 2 tabs twice daily PLUS,
-Potassium Citrate 10ml 3 times daily for 7 days
♣ Complicated, Severe UTI:
-Ampicillin 500mg IV, 8-hourly for 7 days
♣ Non-responsive, Severe UTI:
-Ofloxacin 400mg 2 times daily for 7 days OR
-Ciprofloxacin 500mg 2 times daily for 7 days
-Urine microscopy/Culture/Sensitivity; -Full blood count
-Urea and electrolytes; -Blood sugar
2 PYELONEPHRITIS
Pyelonephritis is the inflammation/infection of the kidneys. In some instances the rest of the urinary tract
may be involved. In a high percentage of cases of chronic pyelonephritis, vesico-ureteric reflux is or was
present. The disease may be unilateral or bilateral.
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The patient presents with fever and renal angle tenderness. There may be kidney swelling as well. In some
cases symptoms and signs of urinary tract infection may be present.
1. Encourage increased oral fluid intake
2. Counsel on improvement in personal hygiene
3. Refer all cases
1. Non-pharmacological interventions as described above
2. Medications:
♣ Ampicillin 250-500mg 6-hourly for 7 days PLUS
♣ Paracetamol 500mg – 1 gram 6-hourly (10-15mg/kg/dose in children) for 7 days
♣ Refer all cases
2. Establish the cause of the infection
3. Medications: 500mg I
♣ Ampicillin (50-100mg/kg 6-hourly in children)500mg IV 6hourly for 7 days
♣ Paracetamol ( 10-15mg/kg/dose in children)500mg – 1 gram 8-hourly for 5 days
♣ Severe Infection:
• Add Gentamycin 80mg IV 8-hourly for 5 days (2.5mg/kg/dose in

children)
3 GLOMERULONEPHRITIS
Glomerulonephritis is a disease of the kidney that affects the glomeruli. The disorder is due to the deposition
of immune complexes in the glomerular basement membrane. The commonest type is acute post-
Streptococcal glomerulonephritis.
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The condition presents as painless haematuria with peri-orbital or generalized oedema and hypertension. In
some instances there is low urinary output.
1. Restrict fluid intake
3. Record and Monitor fluid intake and output
4. Refer all cases
1. Record and Monitor body weight
3. Record and Monitor vital signs
4. Restrict salt and fluid intake
5. Refer all cases
1. Manage as above
2. Strict bed rest during the acute phase
3. Weigh patient daily
4. High carbohydrate, low protein and low fat diet
5. Medications:
♣ Pen VK 250mg-500mg, 6-hourly orally for 7 days
♣ Pen VK 50-100mg/kg/24-hours orally in children for 7 days
6. Oedema and Hypertension
♣ Frusemide 40-80mg orally daily
♣ Hydralazine 1-5mg/kg in 4 divided doses (children)
Hydralazine 25mg 8- hourly orally daily (adults)
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7. Pulmonary oedema (see management of pulmonary oedema in chapter 3)
-Urine-Urinalysis/Microscopy; -Urea and electrolytes; -Full blood count
-Ultrasound; -Renal Biopsy
4 NEPHROTIC SYNDROME
Nephrotic syndrome is a kidney disorder characterized by proteinuria, oedema, hypoproteinaemia and

hyperlipidaemia due to excessive loss of protein. In its pathogenesis there are two major categories to note;
minimal change nephrotic syndrome and secondary nephrotic syndrome.
The patient usually presents with a history of insidious swelling of the eyelids, associated abdominal swelling
and swelling of the limbs. Investigations reveal proteinuria and hypoproteinaemia. There is usually also
hyperlipidaemia and hypercholesterolaemia.
3. Refer all patients
1. Manage as above
3. Record baseline weight
4. Refer
2. Medications:
♣ Frusemide( 1-2mg/kg/day in children)
- 40-80mg twice daily for Adult PLUS
83
♣ Spironolactone (1-3mg/kg/day in children)
-25-50mg 8-hourly in Adult
♣ Refer non-responding cases
-Urine –Urinalysis/Microscopy; -Full blood count; -Blood sugar
-Urea and electrolytes; -Ultrasound; -Biopsy
5 ACUTE RENAL FAILURE
Acute renal failure is a clinical condition associated with rapid, steadily increasing azotemia (i.e. rapidly rising
plasma urea or creatinine) with or without oliguria (urine outputs of <400ml per day or <30ml /hour for
three consecutive hours). The cause of acute renal failure can be pre-renal (inadequate renal perfusion), post-
renal (obstruction) and renal (kidney diseases).
The manifestation of the condition depends on the degree of renal dysfunction, the rate of renal failure and
etiological factors.
5.1.1 Pre-renal Acute Renal Failure
Look for causes that may lead to extra-cellular volume depletion, cardiac and liver failure and vasodilatation
from spasm.
5.1.2 Post-renal Acute Renal Failure
History of urine voiding difficulty or urinary stream reduction is valuable in the diagnosis
5.1.3 Renal Acute Renal Failure
This should be deduced from the existence of symptoms related to some known renal pathology such as
nephrotic syndrome, glomerulonephritis etc.
1. Restrict protein, potassium and phosphorus intake
84
2. Closely monitor fluid intake and output
3. Avoid use of drugs excreted through the kidneys
4. Refrain from vigorous correction of dehydration
5. Maintain proper/normal fluid balance, blood volume and blood pressure during and after
operation
6. Hyperkalaemia:
♣ 10% Calcium Gluconate 10-20ml over 2-5 minutes

-0.5ml/kg IV over 10 minutes (children)
♣ MONITOR HEART RATE
♣ Sodium Bicarbonate 8.5 grams (44 milli-equivalents) over 5 minutes (adults)

- 3 milli-equivalents/kg IV (children)
♣ Regular Insulin 10 units in 50-100ml 50% glucose solution (1ml/kg 59% glucose
solution with regular insulin given at a rate of 1unit/5g of glucose)
7. Acidosis (RARELY REQUIRES DRUG THERAPY)
♣ Sodium Bicarbonate 8.5% IV guided by deficit OR, 1 gram orally 3 times per day
♣ In children: if pH < 7.15 use the following formula: mEq NaHCO3 required:
= 0.3 x weight in kg x 12 mEq/L – SeNaHCO3
8. Hypertension
♣ Frusemide 20-40mg daily or

-Frusemide 1-2mg/kg/day (children)
♣ Verapamil 40-80mg 8-hourly
9. Seizures
♣ Phenobarbitone 10mg/kg IV STAT, then 5mg/kg nocte
♣ Sodium Valproate 10-50mg/kg/day in 3 divided doses
10. Anaemia
♣ Transfuse if Hb < 7.0gm/dl
11. Diet
♣ Restrict salt and fluids
85
♣ Restrict fat and carbohydrates in the early stages
12. Institute Dialysis if there is no response, Pulmonary renal failure
-Urea and electrolytes; -Creatinine; -Full blood count
-Blood sugar; -Urine-Urinalysis and microscopy; -Ultrasound
6 CHRONIC RENAL FAILURE
1. Dietary Control
2. Restrict protein, salt and potassium (protein not more than 60gm/day)
3. Avoid magnesium and aluminium-containing substances
4. Hypertension:
♣ Frusemide 20-160g daily AND/OR
♣ Verapamil 40-80mg 8-hourly AND/OR
♣ Ramipril 2.5-10mg daily
5. High Phosphate:
♣ Calcium Carbonate 500mg – 1 gram per day
6. Chronic Anaemia
♣ Treat the underlying cause
7. Hyperparathyroidism
♣ Calciterol 0.25-1 microgram four times a day
8. Aluminium Toxicity
♣ Deferoxamine 1-3mg IV over 2 hours
9. Acidosis
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♣ Sodium Bicarbonate 300-600mg 3 times per day
10. Acute Hyperkalaemia
♣ Treat as indicated under Acute Renal Failure
11. CCF, Fluid Overload
♣ Frusemide 20-240mg twice a day
-Urea and electrolytes; -Creatinine level and clearance
-Full blood count; -Blood sugar; -Urinalysis and microscopy
-Ultrasound
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CHAPTER 7
S e x u a l l y Tr a n s m i t t e d I n f e c t i o n s a n d H I V / A I D S
1 SEXUALLY TRANSMITTED INFECTIONS
Sexually transmitted infections (STIs) are a group of diseases that are spread through sexual intercourse.
They constitute a major public health problem in Lesotho. The need to control them is vital in the wake of
the alarming prevalence of HIV/AIDS, which is wreaking havoc in our community. There is a very close
relationship and association between common sexually transmitted infections and HIV/AIDS. The care and
prevention of STIs is now one of the most important and effective strategies for the control of HIV/AIDS.
Included in this group are the following syndromes.
1. Genital Ulcer Syndrome: May be caused by chancroid, Syphilis, herpes simplex and
Lymphogranuloma venereum., granuloma inguinale
2. Urethral Discharge Syndrome: May be caused by gonorrhoea and non-gonococcal urethritis.
3. Vaginal Discharge Syndrome: Caused by trichomoniasis, candidiasis, bacterial vaginosis and

cervical infection.
1.1.1 Genital Ulcer Syndrome
The presence of small blisters or ulcers or a history of small recurrent ulcers or blisters suggests herpes
simplex. If the condition presents as single small ulcers and painful matted glands the diagnosis is probably
lymphogranuloma venereum, chancroid or syphilis
1.1.2 Urethral Discharge Syndrome
There is a urethral discharge with associated dysuria and/or frequency of micturition
1.1.3 Vaginal Discharge Syndrome
There is often a discharge that occurs in quantities greater than normal. If the discharge is white and thick,
consider candidiasis; if greenish consider trichomoniasis and if yellow consider bacterial infection. The
discharge is often mixed.
1. Health Education on Safe Sex and promote use of condoms
2. Counsel the infected and reinforce the need to bring in the partner for treatment
88
3. Counsel on personal hygiene
4. Refer all cases
1.2.2.1 For Genital Ulcer Syndrome:
1. Reinforce Health Education messages
2. Take blood for VDRL/RPR
3. Treatment:
♣ Genital herpes:
-Counseling on nature of disease with emphasis on possible recurrences
-Lesions should be kept clean and dry, using talcum powder.
-Secondarily infected herpes lesions should be treated.
-Cotrimoxazole (400mg/80mg) 2 tabs p.o 2 times daily for 7 days or
-Erythromycin 500mg p.o 4 times daily for 7 days
-Pain relief if necessary
-Paracetamol 500mg 3 times daily for 5 days
-Primary herpetic episodes treatment
-Acyclovir 200mg 5 times daily p.o for 7 – 10 days
-Famciclovir 250mg p.o 3 times daily for 7 – 10 days
-Valacyclovir 1g p.o 2 times daily for 7 – 10 days.
♣ Genital ulcer syndrome
Treatment of early syphilis
-Benzathine penicillin G L.A. 2.4 IM STAT OR
-Procaine penicillin G 600 000 u. IM daily for 10 days
For non pregnant patients who are allergic to penicillin use:
-Tetracycline 500mg 4 times daily for 15 days OR
-Doxycycline 100mg 2 times daily for 15 days OR
89
-Erythromycin 500mg 4 times daily for 15 days
Treatment for Chancroid
-Erythromycin 500mg 4 times daily for 7 days OR
-Azithromycin 1g p.o STAT, OR
-Ciprofloxacin 500mg 2 times daily for 3 days OR
-Ceftriaxone 250mg IM STAT
Treatment marked are safe for use during pregnancy and breastfeeding
Treatment for early syphilis
-Benzathine penicillin G.L.A 2.4 u IM STAT, OR
-Procaine penicillin G 600 000 u. IM daily for 10 days
PLUS
Treatment for lymphogranuloma Venereum and chancroid
-Erythromycin 500mg 4 times daily for 14 days
♣ Urethral Discharge Syndrome:
-Reinforce Health Education messages; take blood for RPR/VDRL;
- Ciprofloxacin 500mg orally STAT, OR
- Ofloxacin 400mg orally STAT, OR
- Ceftriaxone 125mg IM STAT, PLUS
- Doxycycline 100mg orally 2 times daily for 7 days OR
- Tetracycline 500mg 6-hourly orally for 7 days OR
- Erythromycin 500mg 6-hourly orally for 7 days OR
- Azithromycin 1gm orally STAT
-Ask the patient to return in a week’s time if his symptoms persist.
-Refer if response not satisfactory
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♣ Vaginal Discharge Syndrome:
-Reinforce health education and counselling messages as above
-Take High vaginal swab
-Do PAP smear;
-Ciprofloxacin 500mg orally STAT, OR
-Ofloxacin 400mg orally STAT, OR
-Ceftriaxone 125mg IM STAT, PLUS
-Doxycycline 100mg orally 2 times for 7 days OR
-Tetracycline 500mg 6-hourly orally for 7 days OR
- Erythromycin 500mg orally 6-hourly for 7 days OR
-Azithromycin 1g orally stat
♣ Trichomoniasis and bactrerial vaginosis
-Metronidazole 400mg 2 times daily for 7 days OR
-Metronidazole 2g orally STAT, (less effective than multidose therapy for bacteria
vaginosis) OR
-Tiridazole 500mg orally 2 times daily for 5 days OR
-Amoxycillin 500mg orally 3 times daily for 7 days (active against bacteria vaginosis
only) OR
-Clindamycin 300mg orally 2 times daily for 7 days PLUS
- Nystatin vaginal pessaries 1 000 000 units daily for 2 weeks OR
-Clotrimazole vaginal pessaries 200mg nightly for 3 days
-Refer if no improvement
♣ Topical treatment for candidiasis
-Clotrimazole 200mg pessaries nightly for 3 nights OR (also active against

trichomonas vaginalis ) OR
-Clotrimazole 500mg pessary STAT, OR
-Miconazole 200mg pessaries nightly for 7 nights OR
91
-Nystatin passaries once daily for 14 days OR
-Econazole 150mg ovule STAT on retiring
-Provide appropriate antifungal cream for cases of pruritis vulvae
NOTE: Ciprofloxacin, Doxycycline and tetracycline should not be used during pregnancy or lactation and in
children below 12. Doxycycline should not be used and Ciprofloxacin should not be used in adolescents below
18 years.
♣ Lower abdominal pain syndrome
-Treatment:
-Ciprofloxan 500mg orally STAT, OR
-Ofloxacin 400mg orally stat, OR
-Ceftriaxone 250mg IM STAT, OR
-Cefotaxamine 1g IM STAT, PLUS
Spectinomycin 2g IM STAT, PLUS
-Treatment for Chlamydia
-Doxycycline 100mg orally 2 times daily for 14 days OR
-Tetracycline 500mg orally 4 times daily for 14 days OR
-Erythromycin 500mg orally 3 times daily for 14 days PLUS
-Treatment for anaerobes
-Metronidazole 400mg orally 3 times daily for 14 days
SCROTAL SWELLING SYNDROME
♣ Treatment of epididymo-orchitis
-Treatment for gonorrhoea
-Ciprofloxacin 500mg orally STAT, OR
-Ofloxacin 400mg orally STAT, OR
-Ceftriaxone 125mg IM STAT, PLUS
Treatment for Chlamydia
-Doxycycline 100mg orally 2 times daily for 7 days OR
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-Tetracycline 500mg orally 4 times daily for 7 days OR
-Erythromycin 500mg orally 4 times daily for 7 days OR
-Azithromycin 1g orally STAT
ADD: Scrotal support if necessary pain relief.
1. Reinforce Health Education and Counselling messages as described above
2. Do other investigations in addition to RPR/VDRL, vaginal swab etc.
3. Syndromic management as above
-VDRL/RPR; -HIV test; -Culture and sensitivity
-Microscopy; -Blood sugar; -Full blood count
2. HIV/AIDS
The classification of HIV infection and disease status should be made in accordance with the WHO Clinical
Classification. This is outlined in the section that follows:
1. Stage 1: Positive HIV asymptomatic with or without generalized lymphadenopathy.
2. Stage 2: Positive HIV with symptoms of weight loss; recurrent upper respiratory infection;
minor mucocutaneous manifestations and history of herpes zoster.
3. Stage 3: Positive HIV with weight loss; unexplained chronic diarrhoea; unexplained
intermittent or constant fever; oral thrush; hairy leukoplakia; pulmonary TB; and severe
bacterial infection.
4. Stage 4: Positive HIV with opportunistic infections such as pneumocystis carinii pneumonia;
cryptococcal infection; extra pulmonary TB etc.
1. Educate on safe sexual practices
2. Emphasise the importance of using condoms AT EVERY SEXUAL CONTACT
3. Establish Voluntary Counselling and Testing Centres
4. Emphasis the importance of preventing mother-to-child transmission
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5. Institute Nutritional Support Programmes
6. Educate on the availability of Anti-Retroviral Drugs and their use
7. Manage according to home based care manual
8. Refer all cases
2. HIV tests
3. Training and support of home care giver
4. Manage opportunistic infection
5. Refer
2. For all suspected cases do FBC, differential and ESR; also do investigations to confirm HIV
infection, then do CD4 count
3. If CD4 is above 350 then monitor and repeat 3-monthly
4. If either CD4 < 200 or Lymphocyte count is up to 100 000 OR full blood AIDS is
noted/confirmed, then start on Anti –retrovirals and institute Triple Therapy recommended in
the ARV protocol
-HIV test; -Viral load; -CD4 count
-Full blood count; -Liver function tests; -Lipid profile
3. MANAGEMENT OF OPPORTUNISTIC INFECTIONS
3.1 BACTERIAL RESPIRATORY INFECTION
Lower respiratory tract infections are more frequent and more severe in HIV/AIDS. They may present with
classic lobar pneumonia, broncho-pneumonia or with unresponsive atypical pneumonia.
3.1.1 Recommended Treatment
1. 1st Line: Amoxycillin 500mg 3 times daily for 7 days
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2. 2nd Line: Cotrimoxazole 800mg/160mg 2 times daily for 10 days
3. 3rd Line: Crystalline Penicillin 5 million units IV 6-hourly PLUS,

Chloramphenicol 500mg IV 6-hourly for 7 days
3.2 PNEUMOCYSTIS CARINII PNEUMONIA
This is an opportunistic infection commonly associated with HIV/AIDS. In addition to other common
symptoms patients have shortness of breath and cyanosis.
3.2.1 Supportive Therapy
1. Oxygen
2. IV Fluids
3.2.2 Recommended Therapy
1. 1st Line: Cotrimoxazole 3200/1600mg 3 times daily for 7 days
2. 2nd Line: Clindamycin 450mg 6-hourly OR,
Primaganine 15-30mg daily for 7 days
3. NB: Severely ill patients may benefit from Prednisone 40-80mg daily
3.3 PNEUMOCYSTIS CARINII PNEUMONIA IN PAEDIATRICS
3.3.1 Clinical Features
1. Dry cough
2. Progressive dyspnoea
3. Fever
4. Bilateral instertitial (ground glass) pattern on Chest X-ray 5
5. Absence of purulent sputum
6. LDH < 1 000
7. Hypoxia or desaturation on effort
5 Features 4-7 are considered to be TYPICAL of Pneumocystis Carinii Pneumonia
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3.3.2 Treatment
1. Cotrimoxazole 15-20mg/kg/SMZ 75-100mg/kg/TMP in 6 divided doses (4-hourly).

-This can be given in the intravenous form in severe cases.
-The duration of treatment is 21 days.
-Adjunct therapy recommended in severe cases is as follows:
♣ Methyl prednisolone 2mg/kg/24-hours in 4 divided doses over 5 days.
2. Adjunct Therapy in PCP
♣ Prednisone 2mg/kg/24 hours for the first 7-10 days, followed by tapering then restart on
10th –14th days
Adolescents:
♣ Prednisone 80mg/day on day 1-5, 40mg/day on day 6-10, then 20mg/day on day 11-21,
THEN STOP
3. PCP Prophylaxis
Cotrimoxazole (TMP/SMZ)
Body Weight Dose Given (12-hourly)

<5kg 5ml
5-9.9kg 7.5ml
10-14kg 10ml
15-21kg 15ml or 1 ½ tabs
>22kg 20ml or 2 tabs
3.4 ATYPICAL MYCOBACTERIOSIS
This is an infection that is more common in Western countries than in Africa
1. 1st Line:
-Clarithromycin 500mg 2 times daily OR,
-Ethambutol 15mg/kg daily for 7 days
2. 2nd Line:
-Azithromycine 600mg daily PLUS
-Ethambutol 15mg/kg/day PLUS,
- Nifabutin 450mg daily for 7 days
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3.5 ORAL CANDIDIASIS
This condition also constitutes a common opportunistic infection in HIV/AIDS
3.5.1 Recommended Therapy in Adults
1. 1st Line:
-Clotrimazole Lozenges 5 times daily OR,
-Nystatin Lozenges 200 000 units 5 times daily OR
-Ketoconazole 200mg daily for 7 days
2. 2nd Line:
-Fluconazole 100mg daily, orally OR,
-Itraconazole 100mg daily to gargle with
3.5.2 Therapy Recommended in Children
1. Nystatin Suspension 100 000 units 4 times daily for 7 days
2. Daktarin Gel 4 times daily for 7 days
3. Gentian Violet 0.5-1% for 7 days
4. Ketoconazole 3mg/kg/24 hours orally 7 days
5. Fluconazole 3mg/kg/24 hours orally for 7 days
3.6 VAGINAL CANDIDIASIS
1. 1st Line:
-Fluconazole 100mg single dose orally OR,
-Clotrimazole 500mg single dose vaginally OR,
- Miconazole 200mg once daily vaginally OR,
-Clotrimazole 200mg daily vaginally for 7 days
2. 2nd Line:
-Ketoconazole 200mg 2 times daily OR,
-Ketoconazole 200mg once daily for 7 days
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3.7 OESOPHAGEAL CANDIDIASIS
3.7.1 Recommended Therapy in Adults
1. 1st Line: Fluconazole 200-400mg daily
2. 2nd Line:
-Ketoconazole 200-400mg 2 times daily OR,
-Itraconazole 200mg daily
3.7.2 Therapy Recommended in Children
1. Fluconazole 3mg/kg/day orally for 7 days
2. Ketoconazole 3mg/kg/day orally for 7 days or
3. Ketoconazole 50mg daily for 1-4 years and 100mg daily for 5-12 years for 7 days
3.8 CRYPTOCOCCAL MENINGITIS
3.8.1 Recommended Therapy for adults
1. -Amphotericin B 0.7 – 1.4mg/kg IV daily for 14 days PLUS,
- 5-Fluorocytosin 25mg/kg 4 times per daily, orally for 14 days
2. Fluconazole 400mg orally, daily for 8 weeks
3.8.2 Recommended Therapy for Children
1. Fluconazole 6-12mg/kg/day once daily for 8 weeks
3.9 TOXOPLASMOSIS
This is a condition that is, in all likelihood, under-diagnosed in developing countries due to inadequate
diagnostic facilities
1. Pyramethamine 100mg single dose orally THEN,
2. Pyramethamine 50-100mg 4 times daily for 6 weeks, PLUS,
3. Folinic Acid 10mg orally, daily for 14 days PLUS,
4. Sulphadiazine 2 grams 4 times daily for 6 weeks
3.10 HERPES SIMPLEX
1. Acyclovir 400mg 3 times daily, for 7-10 days OR,
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2. Famciclovir 250mg 3 times daily for 7-10 days OR,
3. Valaciclovir 1 gram 2 times daily for 7-10 days
3.11 HERPES ZOSTER
1. Acyclovir 800mg 5 times daily for 7-20 days OR,
2. Famciclovir 500mg 3 times daily for 7-10 days
3.12 CYTOMEGALOVIRUS INFECTION
3.12.1.1 1st Line Therapy
1. Ganciclovir 5mg/kg 2 times daily IV, for 2-3 weeks
3.12.1.2 2nd Line Therapy
2. Foscarnet 90mg/kg 2 times daily IV for 3 weeks
3. For Cytomegalovirus Retinitis:
-Valganciclovir 900mg 2 times daily for 21 days PLUS
-Ganciclovir Intraocular Implant
3.13 DERMATOMYCOSIS
This presents as a dry and itchy fungal skin rash
3.13.1.1 1st Line Therapy
1. Topical Miconazole 3 times daily for 21 days OR,
2. Topical Clotrimazole 3 times daily for 21 days
3.13.1.2 2nd Line Therapy
1. Ketoconazole 200mg orally, daily for 1-3 months OR,
2. Itraconazole 100mg orally, daily for 1-3 months
-HIV test; -CD4; -Viral load; -Liver function test;
-Urine Urinalysis/microscopy; -FBC; -Culture and sensitivity
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CHAPTER 8
Central Ner vous System Disorders
1. HEADACHE
Headache is a common manifestation of acute systemic or intracranial infections. It is one of the symptoms
in severe hypertension, cerebral hypoxia, head injury or intracranial tumours. It is also a feature in many
diseases of the ear, teeth, throat, nose and eyes. Some patients have none of the above but have migraine,
muscular tension headache or cluster headaches.
The differential diagnosis for headache is wide and varies from minor, to severe and to lethal conditions.
1.1.1. Migraine
Headache generalized or unilateral throbbing accompanied by anaemia, nausea or

vomiting. Prodromal signs of scintillating scotomas or mood changes may be present.
1.1.2. Toxic States
In these conditions the headache is often moderate, generalized, pulsating and constant. A history of
exposure to toxins is usually present.
1.1.3. Expanding Lesions
Headache localised or generalized with progressive weakness of one side or

convulsion. There may be accompanying cerebral changes.
1.1.4. Meningeal Irritation
Headache ranges from dull to severe and radiates to the neck. There is usually an associated fever or other
signs of infection. There may also be neck stiffness.
1.1.5. Subarachnoid Haemorrhage
This is spontaneous bleeding into the subarachnoid space. When it does occur it is a sudden and frequently
catastrophic event. Typical presentation is that of a sudden hemicranial, hemifacial or periorbital pain usually
associated with neck or back pain
1.1.6. Hypertension
Headache is throbbing, paroxysmal, occipital or vertex. There is usually an accompanying history of

cardiovascular or renal disease.
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1.1.7. Extra-Cranial Lesions
Headache is often localized or generalized with symptoms and signs of eye, ear, nose and mouth disorders.
1.1.8. Conversion Hysteria
The headache that occurs in this condition is often “bizarre” and may be made worse by emotional
disturbance.
1.1.9. Muscle Tension
The headache in this condition is intermittent, of moderate severity, fronto-occipital or generalised in location
and has an associated feeling of muscle tightness or stiffness.
1. Minor headaches may be controlled by analgesics:
♣ Paracetamol 500mg - 1000mg 3 times daily
♣ Aspirin 300mg - 600mg 3 times daily
2. Refer if the headache is severe and a cause can not be easily identified
1. Manage as above
3. Refer all complicated cases
♣ Manager as above
♣ Thorough history and clinical assessment
♣ Manage as per cause
♣ Refer complicated cases
1.2.4. Re-assess
♣ Do specialized investigation where indicated
♣ Manage as per cause
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2. MIGRAINE
This is a condition characterized by throbbing headaches that are preceded or accompanied by reversible
symptoms that reflect cortical or brain stem dysfunction. The most common type of aura consists of a
positive visual phenomenon, usually in the form of a scintillating scotoma. An aura may also take the form of
other focal neurologic symptoms or signs, including loss of sensation or weakness in an extremity. In general,
the aura precedes the headache by less than 60 minutes, develops over 4 minutes or longer, and has a
duration of less than one hour.
1. Reassure the patient
2. Advise to minimize tension states
3. Health education regarding the condition
4. Refer
1. Institute non pharmacological measures as above
2. Medications:
♣ Propranolol 20-160mg daily for 2 weeks OR,
♣ Amitriptyline 10-25mg at bedtime for 2 weeks
♣ For Acute Attacks:
– Paracetamol 500mg- 1 gram 4 times daily for 7 days OR,
– Ibuprofen 200-400mg 3 times daily AND/OR,
– Ergotamine tartrate and Caffeine 1mg/100mg taken at the onset of

headache or followed by 1mg/100 every 30 minutes warning symptoms.
(NB maximum six tablets per attack)
1. Institute non pharmacological measures as above
2. For Acute Attacks:
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♣ Dihydroergotamine 1-2mg IM or SC immediately
(repeat every 30 minutes until attack subsides) PLUS,
♣ Carbamazepine 200mg 3 times daily for 2 weeks
-Full blood count; -blood sugar
-X-rays; -CT scan
3. CEREBRO-VASCULAR ACCIDENTS/STROKE
This is a condition that results from a sudden, non-convulsive loss of neurological function due to an
ischemic or hemorrhagic intracranial vascular event. In general, cerebrovascular accidents are classified by
anatomic location in the brain. The risk factors for this condition are hypertension, diabetes mellitus, cigarette
smoking, obesity, excessive alcohol intake, and cardiac and peripheral vascular diseases.
3.1.1. Intra-Cerebral Haemorrhage
This is characterised by a sudden onset of focal neurological deficit with an accompanying severe headache
3.1.2. Thrombotic Infarction
This is characterised by episodes of transient ischaemic attacks followed by gradual development of

neurological deficit
3.1.3. Embolic Infarction
Here there is a rapid or sudden onset of focal neurological deficit that occurs in the presence of cardiac
disease
1. Reduce or stop smoking
2. Ensure adequate control of hypertension and diabetes
3. Physical exercises to be encouraged
4. Stop alcohol intake
5. Prevention of pressure sores
6. Ensure adequate nutrition and fluid intake
7. Physiotherapy to be supported and promoted
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8. Refer all new cases
1. Manage as above
1. Non-pharmacological interventions as above
2. Investigate to determine the cause
3. Treat the underlying cause
4. If a large haematoma is found, surgical intervention may be necessary
5. For a large infarct:
♣ With no oedema present:
-Aspirin 75-150mg daily,
-Physiotherapy and treat underlying cause
♣ With oedema present:
-Manage as above;
-Dexamethasone 8-16mg 3 times daily may be necessary
♣ If Fits Occur:
-Add Carbamazepine200mg OR
-Phenytoin 200mg
-Full blood count; -Blood sugar; -Urea and electrolytes
-X-ray; -ECG; -CT scan; -Echocardiogram
4. PARKINSONISM
Parkinsonism is an idiopathic, slowly progressive degenerative central nervous system disorder characterised
by slowness and poverty of movement, muscular rigidity, resting tremor and postural instability. It is a
relatively common movement disorder. The lesion is in the basal ganglia where there is a loss of the pigment
nervous of the substantia nigra, locus cerulers and other brain stem cell groups.
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1. Resting (pill-rolling) tremor of one hand
2. Lead-pipe or cog-wheel rigidity
3. Slowness and poverty of movement
4. Loss of facial expression
5. Festinating gait
1. Refer for tests to confirm diagnosis and for initiation of therapy
1. Refer as above
2. Do relevant tests to rule out treatable metabolic causes (e.g. Wilson’s Disease)
3. Medication:
♣ Carbidopa/Levo-Dopa 20/100 or 25/100mg 3 times daily (Increase dose gradually until

control is achieved) OR,
♣ Biperiden 2-12mg daily OR,
♣ Trihexyphenidyl 6-20mg daily
5. MOVEMENT DISORDERS-CHOREA, HEMIBALLISMUS ,

MYOCLONUS AND DYSTOPIA
These movements may be seen in some disorders. They need to be differentiated from those that occur as a
consequence of Parkinson’s disease.
5.1.1. Chorea
This presents as continuous, irregular and random movement that appears semi-purposive and fidgety. The
gait has a jerky dance-like quality. These movements may be seen in Huntington’ disease, in some people on
the oral contraceptive pill, in systemic Lupus erythematosa and in Sydenham’s Chorea.
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5.1.2. Hemiballismus
This is characterised by sudden severe and unpredictable throwing movements of one limb. It is usually due
to infarction in one of the subthalamic nuclei.
5.1.3 Myoclonic jerks
These are brief jerking movements of muscle and are usually due to a metabolic disturbance. They are
sometimes likened to the effects of a brief electric shock. These movements are infrequent and
discontinuous. If they occur early in the morning in the young, then they may be suggestive of Juvenile
Mychonic Epilepsy
5.1.4 Dystonia
Here the movements consist of slow, sustained irregular twisting of a limb or of the trunk. Spasmodic
Torticolis is one form of dystonia in which the head turns to one side. The causes are varied and may include
(but are not limited to) drugs and Wilson’s disease or they may be idiopathic.
5.1.3. Supportive Treatment
1. Correct any underlying metabolic disorder
2. Discontinue any drugs that are implicated in the disorder
3. Supportive Counseling
5.1.4. Specific Treatment
1. Sodium Valproate for Myoclonic jerks
2. Clonazepam
3. Carbamazepine
6. EPILEPSY
This is a disorder characterized by recurrent episodes of paroxysmal brain dysfunction due to a sudden,
disorderly, and excessive neuronal discharge. Epilepsy classification systems are generally based upon: (1)
Clinical features of the seizure episodes (e.g., motor seizure), (2) Aetiology (e.g., post-traumatic), (3) Anatomic
site of seizure origin (e.g., frontal lobe seizure), (4) Tendency to spread to other structures in the brain, and
(5) Temporal patterns (e.g., nocturnal epilepsy).
A detailed description from a witness of the fit is vital. It is extremely important not to diagnose epilepsy in
error given that the therapy for this condition (or group of conditions) has significant side effects; also the
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diagnosis is stigmatizing and has implications for employment, insurance and driving. Once the diagnosis is
decided upon it is important to decide what type of epilepsy it is. The onset of the attack is the key to the
decision as to whether the fit is partial or generalised. If the fit begins with focal seizures it is a partial seizure,
however, if it develops rapidly, then it is generalised. The next question to be answered is the nature of the
“triggering event”. Those triggered by external stimuli almost never require drug therapy.
Monotherapy is the recommended treatment approach. If fits are not controlled with even the maximum
dose of a drug then it should be replaced with another. The old drug should be withdrawn in gradually
decreasing doses whilst the new drug is being introduced.
1. Health education on management of fits
2. For known epileptics-encourage regular follow up and use of medication as prescribed
3. Encourage regular visit to anti-natal clinics
4. Refer all new cases
Health centre level intervention
2. Control fits-
-Diazepam 5mg IM STAT
-Phenytoin 300mg -500mg orally STAT
3. Refer for further investigation
2. Investigate every fit fully
3. Manage fits as follows
6.2.3.1 Neonates
1. Phenobarbitone 10-20mg/kg/dose IV STAT
2. Phenytoin 10-15mg/kg/dose infused in Saline solution
3. Then Phenobarbitone Maintenance Dose of 5mg/kg/day nocte
4. AVOID VALIUM
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6.2.3.2 Infants/Children
1. Phenobarbitone 10mg/kg/dose
2. Phenobarbitone Maintenance Dose of 5mg/kg/day nocte
3. Diazepam 0.3mg/kg/dose
4. Phenytoin 10-15mg/kg/dose
6.2.3.3 Anti-Convulsants in Children
I. Grand-Mal
1. Phenobarbitone 5mg/kg/day nocte
2. Phenytoin 5mg/kg/day in 3 divided doses
3. Sodium Valproate 10-50mg/kg in 2-3 divided doses
4. Carbamazepine 10-20mg/kg/day in 2-3 divided doses
II. Petit Mal
Ethosuximide 20-35mg/kg/day in 3 doses or nocte
III. Temporary Lobe epilepsy
Carbamazepine 10-20mg/kg/day in 2-3 divided doses
IV. Myoclonic Jerks/West Syndrome
Sodium Valproate 10-50mg/kg/day in 2-3 divided doses
V. Adjunct Drugs
Clonazepam 0.05mg/kg/day (drops or tablets). Look out for excessive drowsiness
6.2.3.4 Anti-convulsants in adults
I Grand mal
Phenytoin 200 mg - 600 mg daily in divided doses
Carbamazepine 200 mg - 600 mg daily in divided doses
II Temporal lobe epilepsy
Carbamazepine 200 mg - 600 mg daily in divided doses
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III Psychomotor epilepsy
Carbamazapine 200 mg – 600 mg daily in divided doses
IV Status epilepticus
1. Oxygen
2. Diazapam 5mg IV slowly followed by 2mg/im up to 20mg or until fit stops
3. Dextrose 50ml of 50% solution
4. Pheytoin IV 50mg 1min
5. Thiamine 100mg IV if chronic alcohol abuse suspected
6. If fit continue give diazepam IV infusion 100mg in glucose 5% plus

Phenobabitone IV 100mg/min
-Full blood count; -Blood sugar; -Urea and electrolytes
-ECG; -X-ray; -CT scan
-Liver function tests; -Thyroid function tests; -EEG
7 PYOGENIC MENINGITIS
Pyogenic meningitis is an acute septic inflammation of the meninges of the brain and spinal cord. Patients of
all ages are susceptible to pyogenic meningitis but the general incidence and that of each organism varies
widely in different ages. The common causative agents are Streptococcus pneumoniae, Haemophilus
influenzae and Nisseria meningitis. In neonates E.coli is the common agent.
This condition should be suspected in any febrile patient with severe headache, neck stiffness and/or a
reduced level of consciousness. In older children and adults it presents with a severe, “bursting” headache
associated with malaise, nausea, and anxiety. Patients are irritable, tend to resist all movements and have
photophobia.
In young children there is fever with diarrhoea, restlessness and poor feeding. Neck stiffness is not a
prominent feature. The baby’s fontanelle may bulge.
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2. Benzyl Penicillin IM 1.2-2.4million units STAT, PLUS
Chloramphenicol IM 500 mg – 1 gm STAT
3. If severe or comatose then put up IV line of Normal Saline/Dextrose-Saline and give the
above medication IV instead of IM
4. Refer all cases without delay
2. Establish the diagnosis
3. Blood culture and lumbar puncture should be included in the investigations done
4. Put up IV line of Normal Saline/Dextrose-saline for hydration and medication
5. Institute treatment as follows:
A] In adults
I. Where organism cannot be identified:
♣ Crystalline Penicllin 1 million units IV 6-hourly for 7 days OR,
♣ Ampicillin 1 gram IV 6-hourly for 7 days PLUS,
♣ Chloramphenicol 500mg IV 6-hourly for 7 days PLUS,
♣ Gentamycin 80mg IV 8-hourly for 7 days
II. Where the organism is known:
♣ Nisseria mengitidis:
-Benzyl Penicillin 2 million units IV 4-hourly for 14 days
♣ Streptococcus pneumoniae:
-Benzyl Penicillin 2 million units IV 4-hourly OR
-Ampicillin 1 gram IV 6-hourly for 14 days
♣ Haemophilus influenzae:
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-Chloramphenicol 500mg IV 6-hourly PLUS
-Ampicillin 1 gram IV 6-hourly for 14 days
♣ E. Coli:
-Gentamycin 80mg IV 8-hourly for 14 days
-Chloramphenicol 500mg IV 6-hourly for 14 days
♣ Proteus:
-Chloramphenicol 500mg IV 6-hourly for 14 days PLUS,
-Gentamycin 80mg IV 8-hourly for 14 days
III Brain Abscess
♣ Ampicillin 1 gram IV 6-hourly for 14 days PLUS,
♣ Chloramphenicol 500mg IV 6-hourly for 14 days PLUS,
♣ Follow the above management with serial CT scan and surgical drainage if found necessary.
B] In children
I. Treatment in Children ≤ 3 Months Old
Drug Dose/Route Frequency/day Duration

Ampicillin 200-400mg/kg/day in 4 times
+ 4 divided doses 14 days
Gentamycin 5-7.5 mg/kg/day in 3 3 times
divided doses
X-pen 100 000 – 300 000units 4 times
+ per kg/day in 4 divided 14 days
doses 3 times
Gentamycin 5-7.5mg/kg/day
Cefotaxime 200mg/kg/day in 3 3-4 times 14 days for severe

divided doses meningitis or partially
treated cases
Dexamethasone 0.15-0.5mg/kg/day in 4 times For 1st 48 hours

4 divided doses (>6/52 for
Haemophilus)
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II Treatment in Children ≥ 3 Months Old
Drug Dose/Route Frequency/day Duration

Ampicillin 200-400mg/kg/day in 4 times
+ 4 divided doses 14 days
Chloramphenicol 100mg/kg/day 4 times
Benzyl Penicillin 300 000units per kg/day 4 times
+ in 4 divided doses 14 days
Chloramphenicol 100mg/kg/day 4 times
Cefotaxime 200mg/kg/day in 3 3-4 times 14 days for severe

divided doses meningitis or partially
treated cases
Dexamethasone 0.15-0.5mg/kg/day in 4 times For 1st 48 hours

4 divided doses (>6/52 for
Haemophilus)
-Lumber puncture; -Blood culture; -Full blood count
-Blood sugar; -X-ray; -CT Scan; -Urea and electrolytes
8 ACUTE VIRAL ENCEPHALITIS AND ASCEPTIC MENINGITIS
Encephalitis is an acute inflammatory disease of the brain due to direct viral invasion or to hypersensitivity
initiated by a virus or other foreign proteins. If the spinal cord structures are affected the condition is
encephalomyelitis. Aseptic meningitis is diagnosed if there is a febrile meningeal inflammation characterized
by CSF pleocytosis, normal glucose and an absence of bacteria on examination and culture. Aseptic
meningitis may be infectious in origin.
Viral infections of the central nervous system may usually present in one of three ways:
8.1.1. Meningitis
In this condition fever, headache, vomiting, general malaise and neck stiffness are prominent features
8.1.2. Encephalitis
In this condition meningitis may be associated with evidence of cerebral dysfunction such as altered
consciousness, paresis, seizures or cranial nerve abnormalities
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8.1.3. Asymptomatic
Here fever and general malaise may be present in the absence of any meningeal clinical manifestations.
Hyphoritic pleocytosis is present in the cerebro-spinal fluid
2. Institute supportive care
3. Refer to hospital
7 Notify the relevant authorities in order to facilitate appropriate Public Health response(s)
8 Confirm diagnosis with blood culture and CSF results
9 Institute supportive therapy
10 Institute specific therapy where indicated and where organisms have been identified
-Lumbar puncture; -Blood culture; -Full blood count
-Blood sugar; -X-ray; -CT scan
9 SUBACUTE MENINGITIS
This describes meningitis in which the duration of the disease in the absence of antibiotics is more than 2
weeks but less than three months. It may occur in systemic fungal infections, tuberculosis, disseminated
malignant cells such as in the case of leukemia and metastatic carcinomas, syphilis and primary brain tumours.
This is seen in increasing occurrence in association with HIV/AIDS.
In this condition the illness evolves more slowly. Concomitant fever may be minimal and may be associated
with headache and dementia. Cranial and peripheral nerve palsies may be present, especially in neoplastic
meningitis. The differential diagnosis in this instance includes brain tumors, brain abscesses and subdural
effusions.
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1. Refer without delay.
9.2.2 Health centre level intervention
Refer immediately
2. Establish diagnosis using CSF examination results
3. Manage as indicated by the causative agent/organism
4. If diagnosis is still in doubt then refer
-Lumbar puncture; -Blood culture; -Full blood count
-Blood sugar; -X-ray; -CT scan
10 PERIPHERAL NEUROPATHY
Peripheral neuropathy is a syndrome of sensory, motor, reflex and vasomotor symptoms singly or in any
combination produced by disease of a single nerve (mono-neuropathy) two or more nerves in separate areas
(multiple mono-neuropathy) or many nerves simultaneously (poly-neuropathy). Some forms of peripheral
neuropathy are inherited. Leprosy is one of the commonest causes but many other infections; nutritional
deficiency states, toxins and metabolic disturbances may cause a neuropathy or peripheral or autonomic
nerves.
This is a disease complex as opposed to being a disease entity. It is important that clues to systemic disorders
such as hypertension, rash, skin ulcers, weight loss, fever, lymphadenopathy or mass lesions be sought out.
10.1.1 Motor Neuropathies
These usually present with distal weakness of hands and feet accompanied by an inability to grip objects
tightly in the hands
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10.1.2 Sensory Neuropathies
The presentation here is usually one of sensory loss in the hands and feet. There is also an accompanying
tingling sensation as well as a sensation of pins-and-needles in the hands and feet
10.1.3 Other Forms of Neuropathy
These may be associated with symptoms and signs suggestive of autonomic system failure
2. Refer for confirmation
5. Refer for confirmation of diagnosis
–Full blood count; –Urea and electrolytes
–Blood sugar; –Lumbar puncture
11 ACUTE POST-INFECTIOUS NEUROPATHY (GUILLAIN-BARRĔ

SYNDROME)
This is an inflammatory, demyelinating radiculopathy that is usually triggered by infection. It is the most
common acute neuropathy.
The condition typically begins a few days or weeks after surgery, flu-vaccination or infection. The usual
presentation is that an ascending neuropathy occurs. This ascending neuropathy may advance and affect all
limbs at once. Unlike with other neuropathies, here proximal muscles are more affected, and trunk,
respiratory or even cranial nerves may be affected as well. Sensory symptoms are common but signs are
usually hard to detect. The danger here lies in the progressive respiratory involvement that may result.
CSF examination typically reveals elevated proteins with no lymphocytosis.
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11.2.1 Community and Health Centre Level Interventions
1. Monitor respiratory function
2. Ensure normal hydration
4. Institute bladder and bowel care
5. Prevent bed sores
6. Ensure psychological support
7. Institute physiotherapy for chest (secretion mobilisation) and limbs
8. Medications:
♣ Analgesics:
-Paracetamol 500mg -1g 3 times daily for 5 days (adults)
-Paracetamol 125mg-250mg 3 times daily for 5 days (children)
♣ Immunoglobulin 0.4g.kg as a single dose daily for 5 days
9. Ventilate in the event of respiratory paralysis
-Lumber puncture; -Full blood count
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CHAPTER 9
Metabolic Disorders
1. DIABETES MELLITUS
Diabetes mellitus is a syndrome caused by the lack, or diminished effectiveness of endogenous insulin. It is
charaterised by hyperglyacaemia and deranged metabolism. The insulin deficiency that occurs can be primary
or can occur secondary to other factors. There are two types of insulin deficiency to note:
1. Type 1 - There is no adequate insulin and insulin has to be given for survival.
2. Type 2 – There is insulin in the blood but not effective. It is associated with obesity
Diabetes mellitus is diagnosed if a fasting blood sugar is more than 6.2 mmol/L or a two-hour post glucose
challenge blood sugar level is more than 11.1 mmol/L on two separate occasions.
1. Encourage adoption of healthy lifestyles
2. Encourage weight loss if the patient is obese or has body mass index (BMI) of more than 25
3. Reduce intake of fatty foods
4. Avoid the intake of refined sugar
5. Encourage to stop alcohol intake
6. Encourage to stop smoking
1..2 Health Centre Level Interventions
1. Reinforce non-pharmacological interventions as described above
2. Institute dietary control as an initial management (i.e., diet alone with no drugs)
3. If dietary control on its own fails or the blood glucose levels are too high initiate the following:
♣ Glibenclamide 5mg daily if not obese OR,
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♣ Metformin 500-850mg 2 times daily if obese
4. The following categories of patients need to be referred:
♣ Patients with diabetic complications
♣ Patients with uncontrollable blood glucose
♣ Patients who present on at least two occasions with non-responsive infections
5. New diabetic cases
1..3 Hospital Level Interventions
1. Emphasise non-pharmacological control measures
2. Institute dietary control
3. For Non-Obese Patients:
♣ Glibenclamide 5mg 2 times daily OR,
♣ Gliclazide 80mg 2 times daily
4. For Obese Patient:
♣ Metformin 500mg 3 times daily
5. Insulin Injection (indicated in the following):
♣ Type I DM or in uncontrolled DM in spite of the above measures
♣ Severe infection
♣ Hyperglycaemic emergencies
♣ Pancreatitis
♣ Pregnancy
♣ Trauma or Surgery
6. Management of Diabetic Keto-acidosis (see section 2 below)
7. Management of Hyperosmolar non-ketotic coma (see section 3 below)
8. Management of Hypoglycaemia (see section 4 below)
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♣ Key Investigations
-Blood sugar; -Full Blood Count; -Cardiac enzymes
-Urea and electrolytes; -Urine MCS; -Thyroid function tests
-Serum amylase
2(A) DIABETIC KETOACIDOSIS ( ADULTS)
Diabetic ketoacidosis is a medical emergency due to relative or absolute lack of insulin. It occurs commonly
in type 1 diabetes mellitus. The common precipitating factor is infection. Other causes may be surgery,
myocardial infarction and stroke.
This condition may constitute the mode of presentation. There is usually a 2-3 day history of gradual decline
into dehydration, acidosis, and coma. The usual signs are hyperventilation and ketotic breath. In this
condition dehydration is more life threatening than any hyperglycaemia so its correction takes
precedence.
Investigations usually reveal a markedly elevated blood glucose level, acidosis, the presence of ketone bodies
in the urine and hypocalcaemia.
This is a medical emergency that should be treated at the hospital.
1. These should be aimed at stabilising the patient
2. Set up a Normal Saline drip
1. 1st Litre of Normal Saline to “run fast” (i.e., over 30 minutes)
2. 2nd Litre of Normal Saline to run in 1 hour
3. 3rd and subsequent Litres of Normal Saline to run 2-hourly (adjust fluid replacement according
to response)
4. Set up sliding scale for soluble insulin -hourly as follows:
Check blood sugar 2 hourly
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4.1 20mmol/L; give 4 units IM/IV OR
4.2 18-20mmol/L; give 4 units IM/IV OR
4.5 Less 10mmol/recheck blood sugar every 2 hours (with hold insulin)
4.6 Monitor potassium and sodium 4-hourly
4.7 Monitor glucose 2-hourly
N.B Change infusion rate to 5% dextrose 5 drops per minute when blood glucose levels fall
below 15mmol/L
2(B) PAEDIATRICS: DIABETIC KETOACIDOSIS
(I) Treatment guidelines for diabetic ketoacidosis in children
Type I diabetes: characterised by server insulinopenia and dependence on exogenous insulin to prevent
ketosis and preserve life
Type II diabetes: characterised by insulin resistence associated with defect in insulin secretions
DKA is characterised by hyperglycaemia, ketonuria, ketonaemia, acidosis and glycosuria, pre-coma or coma in
addition to clinical features of diabetes mellitus. DKA results from insufficient or lack of insulin production.
Precipitating factors, crentos first presentation include stress, eg trauma, infections, vomiting or psychological
disturbances
(II) Treatment aims
1.1 CORRECT FLUID DEFICITS, ELECTROLYTE IMBALANCES AND METABOLIC ACIDOSIS
1.2 INSULIN THERAPY TO CORRECT ONGOING KETOGENESIS AND LOWER PLASMA

GLUCOSE
1.3 DETERMINE AND TREAT PRECIPITATING CAUSE (S) OF DKA
1.4 MONITOR RENAL FUNCTION, BLOOD PRESSURE, HYDRATION, BLOOD GLUCOSE,

UREA AND ELECTROLYTES AND ACID-BASE STATUS
(III) Fluid therapy
I. Patient in shock: assume 10% dehydration.
♣ Give N/saline 20mls/kg over one hour.
♣ Re-asses after one hour and repeat 20mls/kg N/saline over one hour if still shocked. Then
continue as for non-shocked patient
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II. Non-shocked patient
♣ If serum sodium is < 150mmol/L, give N/saline
♣ If serum sodium is >150mmol/L, give ½ normal saline
♣ Change to half-strength Darrow’s solution when blood sugar is between 10-15mmol/L
Volume of fluid to give =

replacement fluid to correct 10% dehydration + maintenance fluid according to age + ongoing losses
Volume of fluid according to age
Maintenance fluid volume

Solution Age
per 24 hours
N/Saline 20mls/kg over 1 hour ≤ 1 year 120mls/kg

if in shock repeat as needed
1-2 years 100mls/kg
or N/saline if (serum sodium)
se nut 450mmol/L or as half 2-4 years 85mls/kg
N/Saline if (serum sodium) se
nut>150mmol/L in absence of 4-10 years 70mls/kg
shock
> 10 years 2-3litre
Change to a dextrose-
containing solution if serum Give50% of volume in first 12
glucose is 10-15mmol/L e.g hours and the remainder over
half-strength Darrow’s solution the next 24hours.
5% dextrose/saline
Potassium supplementation
Potassium supplementation (mmol/L) per

Serum potassium mmol/L
litre of fluid
<3 40
3-4 30
4-5 20
>5-6 10
>6 None
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(IV) Insulin therapy
♣ Use short acting insulin 0.1unit/kg IV hourly or by constant IV infusion if insulin pump is available.
♣ Monitor blood sugar hourly
♣ When acidosis has been corrected (base deficit <5) and blood sugar is 0.2-0.4 units/kg every 6 to 8
hours unit the child can fully tolerate food. The total 24 hours short acting insulin given serves as a
guide to the subsequent 12hourly dose, 2/3 to be given in the morning and 1/3 in the evening.
♣ Monitor blood sugar before each dose and two hours after the meal.
♣ In a known diabetic with DKA, change to usual bd insulin dose when acidosis has been corrected
and blood sugar is 10mmol/L.
♣ Give insulin before breakfast, and before evening meal, adjust the dose according to blood sugar.
(V) Nutritional Requirements
Carbohydrate 55%
Fat 30%
Protein 15%
♣ Involve dietitian.
♣ The child must eat six times a day, breakfast, mid-morning snack, lunch, mid-afternoon snack, dinner
and 10.00 pm (late night) snack.
CALORIE NEEDS FOR CHILDREN
Age Kcal requirement/kg body weight
0-12month 120
1-10years 100-75
11-15years(f) 35
11-15years(m) 80-50
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♣ Educate the older child, parent or guardian about the disease, treatment and complications.
♣ Emphasise follow up. School teacher to be informed about the child illness
-Blood sugar; -Full blood count; -Urea and electrolytes
-Urinalylisis; -X-ray; -ECG; -Glycolated Hb
3. HYPEROSMOLAR NON-KETOTIC COMA
Hyperosmolar non-ketotic coma is common in type II diabetes mellitus and is characterised by markedly
increased plasma glucose with no ketonuria or acidosis. It may be precipitated by factors such as myocardial
infarction.
The history is longer than with ketoacidosis and is characterised by marked dehydration and a markedly
elevated blood sugar. Acidosis is absent because there has been no switch to ketone metabolism. The
patient with this condition is often old and is presenting for the first time (as a DM patient). The risk of DVT
has been found to be high in this condition and full heparin anticoagulation is recommended as part of the
management. There is usually a 5-6 day history of being unwell before sliding into a coma.
The management of this condition is undertaken only within an institutional setting. None of the
interventions required can be undertaken in the community setting
2. Set up IV line normal saline (5% dextrose if blood sugar is not known)
3. Refer without further delay
1. IV Fluids as in DKA (if blood sugar is not known then give 5% dextrose initially and other
fluids to be administered as per laboratory results).
2. This condition is more sensitive to insulin and smaller amounts of Rapid Acting (soluble)
insulin should be used
3. Monitor electrolytes and blood glucose levels
4. Watch for thrombotic complications. Full heparin therapy may be part of management if
indicated.
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-Blood sugar Urea and electrolytes; -Full blood count
-Cardiac Enzymes; -X-ray; -ECG
6 HYPOGLYCAEMIA
Hypoglycaemia is very low blood sugar. This is a condition that occurs commonly in people with diabetes
mellitus who are on hypoglycaemic treatment. It is a well-recognized occurrence in those on sulphonylurea
therapy. Insulin therapy remains the commonest cause of hypoglycaemia. The other causes of hypoglycaemia
are alcohol or aspirin overdose in children and insulinoma.
Patients typically present with a history of odd behaviour (usually inappropriate aggression), heavy sweating,
tachycardia, seizures and coma of rapid onset. The condition is to be suspected in patients on high insulin
doses or in those who have had low food intake following insulin therapy and who present with the above
signs and symptoms. The key lab finding is a blood glucose level less than 2.1mmol/L.
1. Early recognition is essential
2. Give sugar or sugary drinks if the patient is conscious
3. Refer immediately if unconscious
1. Monitor blood glucose levels
2. Administer 20ml of Dextrose 50% solution 6 as a bolus dose, IV in a large vein.
3. Set up IV drip of 5% Dextrose
4. Refer
1. Administer 20ml of 50% dextrose solution as a bolus dose, IV
2. Start on 10% Dextrose infusion
3. With all of the above, recovery should be prompt.
6 This harms veins and it should therefore be followed by a 0.9% Saline Flush
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4. If not, then give dexamethasone 4mg 4-hourly to combat cerebral oedema that occurs
subsequent to prolonged hypoglycaemia.
5. Set up IV infusion with 5% Dextrose and admit.
-Blood sugar; -Full blood count; -Urea and Electrolytes
7 ENDEMIC AND MULTINODULAR GOITRE
Multi-nodular goitre is a commonly seen and endemic condition. It is due to low iodine in the diet. Most
patients with endemic goitre are euthyroid. Excessive growth may occur in pregnancy. Very large multi-
nodular goitre causes compression symptoms. Some patients may become hypothyroid while others may
develop hyperthyroidism.
This is a condition that is commonly widespread in communities that eat foods low in iodine. The usual
presentation is that of a large, often multi-nodular swelling of the thyroid gland. As stated above, patients are
usually euthyroid, but hyperthyroidism may develop. Hypothyroidism and malignancy occur only very rarely.
5.2.1 Community Level and Health Centre Interventions
1. Encourage the use of iodated salt
2. Refer the patient if the swelling is very large and there are compression symptoms
3. Also refer if Hyper- or Hypothyroidism is suspected
2. Investigate blood for TSH, T3 and T4 levels
3. Refer if Hyper- or Hypothyroidism is suspected or if Thyroidectomy is indicated
-Thyroid function tests; -Blood sugar; -Full blood count
6 HYPOTHYROIDISM
This is a condition that occurs commonly and is easy to treat. It is a clinical state that results from a decreased
production or secretion of thyroid hormone. The most common cause is iodine deficiency. It may result from
previous treatment for hyperthyroidism or as a consequence of autoimmune disease.
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Symptoms consist of cold-intolerance, lethargy and fatigue, constipation and weight gain. Memory may be
impaired and there may be a degree of mental impairment (“slowness”). As the condition progresses the
patient may develop/notice puffiness around the eyes and a thickening of the lips and tongue. Hair and skin
changes may also appear at this time.
All cases should be referred to hospital for management
1. Do Investigations (TSH, T3 and T4 Levels)
2. Medication:
♣ L-thyroxine: start with 25 mg – 50 mg per day and increase in stages up to 100 mg -

200mg daily
-Thyroid function tests; -Blood sugar; -Full blood count
7 THYROTOXIC CRISIS
Thyrotoxic crisis is a life-threatening emergency that is often precipitated in severe hyperthyroidism by a

major stress such as an injury, an infection or surgery.
The patient has severe hyperthyroidism, which under stress presents with marked anxiety and agitation.
There is pronounced tachycardia, tremor, fever, dehydration and cardiac failure and sometimes coma.
7.2.1 Community level interventions
Refer immediately
7.2.2 Health Centre Level interventions
1. Paracetamol 500mg-1g STAT
2. Set up IV line of Normal Saline and Ringer’s Lactate
This is an emergency requiring expert intervention in a hospital
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1. IV infusion of 0.9% Normal Saline, 500ml 4-hourly
2. Antipyretic drugs:
♣ Diclofenac 50mg 3 times daily OR,
♣ Paracetamol 500 mg -1 g 3 times daily
3. Specific Medications:
♣ Carbimazole 60 mg -120 mg orally
♣ Propranolol 1 gram -2 grams IV 6-hourly
♣ Propylthiouracil 25mg 4 times daily orally
♣ Potassium Iodide 10mg 4-hourly
♣ Dexamethasone 8mg IV 8-hourly
-TSH levels; -T3 and T4 Levels; -FBC
-ECG; -Chest X-ray
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CHAPTER 10
Nutritional Disorders
1. PROTEIN ENERGY MALNUTRITION (PEM)
Protein Energy Malnutrition (PEM) describes a nutritional disorder wherein the intake of proteins and/or
energy and other nutrients is below the minimal requirements for health, development and normal growth.
The condition includes kwashiorkor, marasmus, marasmic-kwashiorkor and underweight-for-age.
1. Kwashiorkor: There is oedema and body weight is between 60-80% of the expected weight for
the child’s age
2. Marasmus: There is no oedema but body weight is below 60% of that expected for the child’s
age
3. Marasmic-Kwashiorkor: There is oedema plus a body weight 60% below that expected for
the child’s age
4. Underweight-for-age: There is no oedema but the body weight is 60-80% of that expected
for the child’s age
1.1.1 Kwashiorkor and Marasmic-Kwashiorkor
1. Usually occurs in a child of 9-24 months of age and presents as follows:
♣ Generalised pitting oedema
♣ Growth failure
♣ Muscle wasting
♣ Hypo- and hyper-pigmented, desquamated, ulcerative or weeping skin lesions
♣ Apathy, irritability and poor appetite
♣ Repeated infections
♣ Sparse, thin and reddish/grey hair discolouration
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1.1.2 Marasmus
1. This condition usually occurs during the first year of life. It presents as follows:
♣ Emaciation with significant loss of subcutaneous fat
♣ Growth retardation
♣ Recurrent infections
♣ Oedema absent
1. Exclusive breast feeding for 6 months
2. Encourage mothers to breast feed their children for up to two (2) years
3. Introduce weaning diet at 6 months
4. Immunise and monitor the child’s growth monthly
2. For the sick child give small frequent meals, gradually increasing calories and proteins
3. Give ORS if there is diarrhea and vomiting
1. Conservative measures as above
2. Management of Acute Phase:
♣ Treat complications e.g dehydration, shock, infections, hypothermia, hypoglycemia and

electrolyte imbalance
♣ Give F75 with less calories every 2 hours for the first 48 hours. Stop all other foods (see
annex for volumes)
♣ After 48 hours give F100 3 hourly. (see annex for volumes)
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3. Management of Recuperation Phase:
♣ Give high energy foods to enhance growth
♣ Educate mother/care-giver on proper nutrition and food preparation
♣ Educate mothers about proper nutrition
♣ Stimulation and play therapy for the child
-Liver function tests; -Blood sugar; -Full blood count
2. PELLAGRA
This condition occurs due to lack of Nicotinic Acid. Other nutritional disorders are likely to be present as
well. It is commonly seen in alcoholics and in people who persistently eat an unbalanced diet.
The classical triad of signs is diarrhoea, dementia and dermatitis. Other signs include neuropathy, depression,
tremor, rigidity, ataxia and fits. Patients typically present with dark, dry scaling skin on areas of the body
exposed to the sun. The tongue is large and red. diarrhoea is common and there may be manifestations of
mental disorders ranging from depression to frank psychosis.
1. Health education about the benefits and importance of a balanced diet
2. Encourage adequate food intake before ingestion of alcohol
3. Manage alcohol abuse
2. Give Nicotinamide 100mg three times daily
3. Refer severe cases or those with complications such as psychosis
2. Niacin 100mg three times daily
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3. Give specific treatment for complications such as dementia or psychosis
-Liver function tests; -Blood sugar; -Full blood count
3. OBESITY
This is defined as an increase in body weight beyond skeletal and physical standards as the result of an
excessive accumulation of fat in the body. More than two times the ideal weight is considered OBESITY.
This condition is most common in females in their middle ages. The commonest cause is overeating. In some
instances the obesity may occur secondary to other disorders or conditions such as hypothyroidism,
Cushing’s disease or trauma. In some cases it occurs secondary to the (prolonged) use of drugs such as
corticosteroids.
1. If Body Mass Index (BMI) 7 > 25
2. The above may be accompanied by breathlessness on even minor exertion, heat intolerance,
menstrual disorders or even psychological problems such as depression
1. Health education regarding the benefits of healthy lifestyles
2. Encourage regular exercise
3. Advocate for behaviour modification
1. Conservative management as described above
2. Anaelgesics for osteoarthritis or other sources of pain
3. Refer if complications are present
2. Manage associated features such as hypertension, ischaemic heart disease, etc.
3. There is normally no indication for drug therapy except in special cases where Diethylproprion
75mg daily may be given as short term therapy to support dietary restrictions.
7 BMI = body weight divided by the square of the individual’s height (Weight/Height2)
131
-Lipogram; -Blood sugar; -Full blood count
-Cardiac enzymes; -ECG
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CHAPTER 11
Obstetrics and Gynaecolog y
1. ANAEMIA IN PREGNANCY
Anaemia in pregnancy is a common dietary disorder, may be due to low dietary iron intake that is aggravated
by increased iron demand because of the presence of foetus. It is important to bear in mind and rule out
other causes of anaemia
♣ DIAGNOSTIC CRITERIA
It may be asymptomatic or present with tiredness and weakness with pale mucous membranes and nails. If
severe, additional symptoms such as tinnitus may be present. Frank heart failure may also be present if the
condition is severe. Laboratory value for diagnosis (WHO)
Haemoglobin< 11.og/dl is regarded as anaemia
Haemoglobin 9-10g/dl = mild
Haemoglobin 7-8.9/dl = moderate
Haemoglobin<7g/dl= severe.
♣ TREATMENT GUIDELINES
1..1 Community Level Interventions
1. Advice on increasing intake of foods rich in iron such as fresh, green, leafy vegetables, beans,
peas and meat
2. Prophylactic intake of iron supplements, folic acid and vitamin c
3. Refer
2. Ferrous Sulphate/Fumerate 200mg 3 times daily PLUS
3. Folic Acid 5mg daily PLUS
4. Vitamin C 10mg 2 times daily
5. Encourage ante-natal-clinic attendance
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6. Refer if the anaemia is severe or if it is associated with another medical disorder
4 Conservative management as above
5 Establish the cause of the anaemia and manage appropriately
6 Correct the anemia as appropriate
7 Manage complications such as heart failure if they are present
1.3 Key Investigations:
-Full Blood count; -Blood x-match
-Film appearance; -Blood sugar
2. ABORTION
Abortion is a common gynaecological problem. It is defined as an expulsion of the products of conception

before 28 weeks of gestation. There are two major categories that need to be recognized:
1. Spontaneous Abortion: It happens on its own
2. Criminal Abortion: It happens because there has been some interference by instrumentation
or drugs
Forms of Abortion include
1. Threatened abortion- There is mild bleeding per vaginum with no

abdominal pain and cervix is closed.
2. Inevitable abortion- bleeding per vaginum, associated with abdominal pain

and opened cervix.
3. Complete abortion- When there is complete expulsion of the products of

conception.
4. Incomplete abortion-When only part of the product has been expelled
5. Missed abortion –when there is death and retention of the product of

conception
6. Recurrent-when there has been three or more consecutive spontaneous

abortion
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There is always a history of missed periods with vaginal bleeding and abdominal cramps. There is no fever
unless an infection is present. In this instance there is usually an accompanying foul smelling vaginal
discharge. Pregnancy test is positive.
1. Health Education regarding sexuality
2. Encourage safe sexual practices
3. Stress importance of seeking medical help early for vaginal bleeding that follows periods of
amenorrhoea
4. Refer
1. Manage as above
2. For Mild Vaginal Bleeding with no Fever:
♣ Ergometrine 0.5mg IM STAT
♣ Refer if bleeding persists after 24 hours
3. For Moderate or Severe Bleeding WITH NO TEMPERATURE:
♣ Ergometrine 0.5mg IM STAT PLUS,
♣ IV Line with 5% Dextrose in Normal Saline if patient is in shock
♣ Refer immediately
4. If there are signs of infection:
♣ Benzyl Penicillin 1.2 million unit IM stat PLUS
♣ Metronidazole 400 mg 3 times daily for 7 days
5 If the internal Os is open
♣ This may indicate a “threatened” abortion or
♣ It may indicate a “complete” abortion
♣ Manage as appropriate
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♣ In both above scenarios Ergometrine is not indicated
6 If internal Os is open
♣ Refer patient for evacuation
♣ Administer Ergometrine 0.5 mg IM STAT
♣ Put up IV line if ringer lactate or 5% Dextrose in Normal Saline
♣ Refer
2. Evaluate the uterus to determine if products of conception are still present
3. For Severe Infection:
♣ Ampicillin 1 gram IV STAT then, 500mg IV 6-hourly for 7 daysPLUS,
♣ Metronidazole 500mg IV 8-hourly for 7 daysPLUS,
♣ Key Investigations:
-Full Blood count; -HCG; -X-match; -Blood sugar
3. ECTOPIC PREGNANCY
Ectopic pregnancy is a gynaecological emergency that may present as an acute abdomen. In this condition
pregnancy implants outside the uterus and commonly in the fallopian tube, a situation that may lead to
rupture. This is a fatal condition.
There may or may not be a history of missed periods associated with abnormal vaginal bleeding history of 1
or 2 missed periods with mild vaginal bleeding and lower abdominal pain. There may also be marked
tenderness with or without rebound tenderness. In severe cases the patient may be very pale, may have a
distended abdormen and refuse to straighten her hips and may be in shock. It is a great masquerader and high
index of suspicion is needed. Pregnancy test is usually positive.
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2. Set IV line with 1 Litre of Normal Saline or Ringer Lactate
3. Advise patient not to eat or drink anything
2. IV line with normal saline
3. Confirm diagnosis (history with or without ancilliary investigations)
4. Emergency laparatomy
♣ Key Investigations:
-HCG; -Ultrasound; -Full Blood count
-Blood X-match; -Blood sugar
4. ANTE-PARTUM HAEMORRHAGE
Ante-partum haemorrhage is an obstetric emergency defined as bleeding per vagina after 28th week of
gestation. It is an obstetric emergency. The most dreaded causes of ante-partum haemorrhage are:
1. Placenta Praevia: In this condition the placenta is located in the lower segment of uterus (i.e.,
away from the fundus).
2. Placenta Abruption: Here there is early separation of part of the placenta before delivery. This
results in the bleeding that is characteristic of this condition
♣ DIAGNOSTIC CRITERIA 8
4..1 Placenta Praevia
There is usually painless vaginal bleeding with bright red blood.
4.1.2 Abruptio placentae
In this condition the patient has severe abdominal pains with marked tenderness on palpation. Where vaginal
bleeding does occur, the blood is dark red in colour. The uterus, on palpation is found to be “woody hard”.
8 In both the conditions discussed herein, severe bleeding is accompanied by weakness/lethargy, thirst and shock
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1. Refer immediately.
2. Put up IV line with Normal saline or Ringer’s Lactate
3. Advise the patient not to eat or drink anything
4. Refer Immediately
4.2.3 Health level interventions
1. Asses clinical condition
3. Set up IV line of Normal saline or Ringer’s Lactate
4. Emergency ultra sound to confirm diagnosis
5. No oral feeds
6. Appropriate Obstetric intervention
-Full blood count; -Blood X-match
-Blood sugar; -Ultrasound
5. POST-PARTUM HAEMORRHAGE
Post-partum haemorrhage refers to blood loss, per vagina, of more than 500 cc in the period immediately
following delivery. This blood loss may be due to genital tract lacerations, retained placenta or uterine inertia.
5..1 Uterine Inertia
In this condition the uterus is soft with no genital lacerations. The placenta is usually expelled complete
without any parts being retained in the uterus. The problem here is an inability of the uterus to contract post-
delivery. It is a problem usually encountered after a prolonged labour. Other causes include grand multiparity
or grossly distended uterus secondary to multiple pregnancy.
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5..2 Retained Placenta
In this condition parts of the placenta (products of conception) are retained in the uterus secondary to
abnormally adherent placenta or other causes during delivery. The uterus is then not able to contract fully and
bleeding results. There are usually no genital lacerations. The placenta on inspection is found not to be
complete
5..3 Genital lacerations
In this condition the uterus is fully contracted and the bleeding occurs from cervical or vaginal tears acquired
during delivery
1. If the uterus is found, on examination, to be soft then do a “uterus rub” to induce/stimulate

the uterus to contract
2. Put in-place a vaginal pack
1. Uterine Inertia:
♣ Catheterise the bladder
♣ Uterine rub
♣ Ergometrine 0.5mg IM and repeat 10-20 minutes later.
♣ Put up an IV line of Normal saline or Ringer’s Lactate
♣ Refer if uterus does not contract
2. Genital Laceration:
♣ Suture the lacerations
♣ If suturing is not possible pack the vagina and refer
3. Retained Placenta
♣ Put IV line of Normal Saline or Ringer’s Lactate
♣ If the placenta is incomplete, then refer
♣ If the entire placenta is still in the uterus, attempt manual removal. If the removal fails or
the staff is inexperienced, then refer
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♣ Reassess and set up an IV line of Normal saline or Ringer’s Lactate
♣ Give nothing by mouth
♣ Catheterise bladder
1. Uterine Inertia
♣ IV line with Normal saline or Ringer’s Lactate
♣ Ergometrine 0.5mg IV STAT then repeat in 5 minutes
♣ If Ergometrine is not successful follow up with Oxytocin ( 10-20 units IV)
2. Genital Laceration
♣ IV line with Narmal saline or Ringer’s Lactate
♣ Suture the lacerations under local/general anaesthesia
♣ Give antibiotics
- Ampicillin 500 mg 4 times daily for 7 days PLUS
- Metronidazole 400mg twice a day for 7 days
3. Retained Placenta
♣ IV line with Normal saline or Ringer’s lactate
♣ Empty the bladder with catheter
♣ Sedate patient and attempt manual removal
♣ If not successful refer for specialist care
♣ Give
-Ampicillin 500 mg IV6 hourly PLUS
-Metronidazole 500mg IV 8 hourly for 7 days

-Full Blood; -Blood Grouping and X-Match; -Blood sugar
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6. PERPERAL SEPSIS/PYREXIA
Puerperal pyrexia is a persistently elevated temperature of 380 C (or more) occurring within the first 10 days
of the post-partum period. This may be due to puerperal sepsis that results from urinary tract infection,
mastitis, thrombo-phlebitis or other systemic infections such as tuberculosis.
6..1 Pueperal Sepsis
Characterised by high temperature associated with lower abdominal tenderness and a foul-smelling vaginal
discharge. There is also tenderness on bi-manual examination of the uterus
6..2 Urinary Tract Infection
Characterised by high fever with frequency of micturition and dysuria and renal angle tendeness
6..3 Mastitis
Characterised by high temperature in the presence of a swollen and painful/tender breast(s)
6..4 Thrombo-phlebitis
Characterised by high temperature accompanied by pain in the leg or thigh
6..5 Other Systemic Infections
There is high temperature associated with signs and symptoms suggestive of systemic infection
1. Give paracetamol 500mg -1gm stat
2. Refer
1. For Pueperal Sepsis:
♣ If no shock: Amoxycillin 500mg orally four times daily for 7 days/
-Ampicillin 500mg orally four times daily for 7 daysPLUS,
-Metronidazole 400mg orally three times daily for 7 days
♣ If shock present: Benzyl Penicillin 1.2 million units IM STAT;
♣ start IV infusion of Normal saline or Ringer’s lactate
♣ Elevate legs,
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♣ Refer immediately
2. For Urinary Tract Infection:
♣ See section on UTI
2. For Mastitis
♣ Give analgesic:
-Paracetamol 500 mg -1 gm 3 times daily for 5 days
♣ Antibiotic:
-Cloxacillin 500mg 6hourly for 7 days
♣ Continue expressing breast milk
♣ If abscess forms, Refer
3. Thrombo-phlebitis
♣ Apply firm crepe bandage and refer
6..3 Hospital Level Interventions/Specialist
6..3.1 Pueperal Sepsis
♣ Resuscitate patient
♣ Antibiotic
-Ampicillin 500mg IV 6 hourly for 7 days
-Gentamycin 80mg IV 8 hourly for 7 days
-Metronidazole 500 mg IV 8 hourly for 7 days
♣ If no improvement Refer
♣ Key Investigations
-Full Blood Count; -Blood culture
-Ultrasound; -Vaginal swab
7. HYPERTENSION IN PREGNANCY
Hypertension disorders of pregnancy are a leading cuase of maternal morbidity. Early detection and timely
intervention is essential to prevent maternal and prenatal complications.
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A diastolic blood pressure (BP) of 90mmHg or more, on 2 occasions at least 4 hours apart. It can be with or
without proteinuria (presence of 2 proteins or more on reagent strip (dipstick) testing on 2 midstream urine
specimen at least 4 hours apart; or ≥ 300mg protein in 24 hours specimen of urine.)
Refer without delay
1.2.2 Health Centre Level Intervension
♣ Record and monitor vital signs
♣ If diastolic blood pressure is 90-109mmHg refer immediately
♣ Give Diazepam 10mg STAT orally
♣ If diastolic blood pressure is ≥ 110mmg or patient has symptoms of headache, visual

disturbances, epigastric pain, hyperreflexia, dizziness, fainting or vomiting,
♣ Start iv drip with Ringer’s lactate, give
-Hydrallazine 6.25mg IM, OR
-Nefedipine 5mg S/L STAT, PLUS
-Diazepam 10mg IM STAT
♣ Transfer to hospital
♣ Record and monitor vital signs
♣ Iv infusion of ringer’s lactate
♣ Manage with reference to guidelines or arrangement of hypertensive disorders in Lesotho.
8 DIABETES MELLITUS
It is a medical condition complicating pregnancy, characterised by hyperglycaemia and deranged metabolism

due to absolute or relative lack of insulin
TYPES INCLUDE
3.2.4 Established diabetics- These are pregnant women already known to have diabetes mellitus and
on either insulin or hyperglycaemic agents treatment
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3.2.5 Gestational diabetes - These are woman who developed symptoms of diabetes mellitus or
deranged sugar metabolism during pregnancy
Diabetes mellitus is diagnosed if a fasting blood sugar level is >8mmol/L or a two-hour post-glucose
challenge blood sugar level is more than 11.1mmol/L
♣ Refer to chapter on metabolic disorders (Diabetes)
♣ Refer patient immediately.
♣ Refer to chapter on management of diabetes
♣ Do not give oral hypoglycaemia drugs in pregnancy
♣ Refer patient
♣ Refer to chapter on management of Diabetes mellitus
♣ Do not give oral hypoglycaemias agent
♣ Refer patient to specialist center
♣ Refer to chapter on diabetes mellitus
9 PELVIC INFLAMMATORY DISEASE
Pelvic inflammatory disease refers to any infection and resultant inflammation of the female genital tract.
There are four distinct stages to the infection:
1. Stage 1: Acute salpingitis where there is local adnexal tenderness without rebound involvement
2. Stage 2: Acute salpingitis with peritonitis. In this stage there is local adnexal tenderness with
guarding and rebound tenderness.
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3. Stage 3: Acute salpingitis with tubo-ovarian complex. This is a palpable tubal mass that is highly
tender
4. Stage 4: Tubo-ovarian complex with peritonitis. In this condition there is septicaemia with or
without shock
The patient presents with fever and lower abdominal pains with or without guarding or rebound tenderness.
In some cases pain may be dull with pelvic tubal mass easily detectable by ultra sound. In acute PID ectopic
pregnancy and appendicitis have to be ruled out.
1. Supportive Care
2. Paracetamol 500mg-1g orally STAT
3. Refer
1. Supportive Care
2. Counselling about sexually transmitted infections
3. Remove ( IUCD ) if patient has one in place
4. Medications:
♣ Erythromycin 500mg 6-hourly orally for 7 days
♣ Doxycycline 200mg STAT then 100mg 2 times daily orally for 7 days
♣ Metronidazole 400mg 8hours orally for 7 days orally
♣ Paracetamol 500mg – 1 g 8-hourly for 5 days
5. Refer severely ill patients or those who do not respond well to treatment
Supportive care as above
1. Stage 1:
♣ Ciprofloxacin 500mg orally, STAT OR
♣ Ofloxacin 400mg orally STAT, PLUS
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♣ Doxycycline 200mg orally STAT, then 100mg 2 times daily for 7 days OR
♣ Tetracycline 500mg 6-hourly for 7 days PLUS
♣ Erythromycin 500mg 6-hourly orally for 7 days OR
♣ Ceftriaxone 500mg - 1g STAT, PLUS
♣ Metronidazole 400mg 8-hourly orally for 7 days
2. Stage 2:
♣ Metronidazole 500mg IV 8 hourly for 7 days PLUS
♣ Augmentin 1.2 grams IV 8-hourly for 7 days
3. Stage 3:
♣ To the above treatment add Gentamycin 80mg IV 8-hourly for 7 days
4. Stage 4:
♣ In addition to antibiotic therapy, it may be necessary to do an exploratory

laparascopy/laparatomy

-Full blood count; -Urea and Electrolytes; -Ultrasound
-Blood culture; -Blood sugar
10 PROBLEMS OF THE NEWBORN
Safe and supervised delivery is fundamental. This minimises problems related to birth injuries. A newborn
with low Apgar scores who manifests signs of inactivity such as inability to cry, difficulty in breathing,
reduced spontaneous movements and refusal to eat has to be identified and managed promptly.
The common causes are birth asphyxia, neonatal infection, prematurity, maternal sedation during labour,
metabolic disorders and congenital malformations in the newborn.
1. Low Apgar score
2. Pallor or cyanosis
3. Jaundice
4. Bradycardia or tachycardia
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5. Heart murmurs
1. Basic Newborn care (keep baby dry and warm, etc)
1. Basic newborn care
2. Administer oxygen if indicated and available
2. Administer oxygen as indicated
3. IV line: 5%-20% Dextrose
4. Investigate and determine underlying causes
5. Refer if cause identified requires specialist care

-Full blood count; -Blood culture; -Random blood glucose
-Chest X-ray; -Urine culture; -Lumbar puncture
The major objective is to identify and treat the cause promptly and adequately. It should be emphasized that
all high risk obstetric cases should be advised to deliver in the hospital or specialised hospital where indicated.
11 PREMATURITY
Prematurity is defined as the birth of an infant before 37completed weeks of gestation. Associated with this is
a birth weight of less than 2.5kg. Factors associated with prematurity are antepartum haemorrhage,
infections, multiple pregnancy and early rupture of membranes.
1. Infant born before completing 37 weeks of gestation
2. Birth weight of less than 2.5kg
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2. Breast feed starting 2-6 hours after birth (feeds should be frequent)
3. If the baby is unable to feed then feed expressed breast milk via a naso-gastric tube
4. Refer if any complications of prematurity manifest
1. Admit
2. Nurse in incubator or infant crib with overhead heater
3. Record and monitor vitas signs
4. Feed via NG-Tube using breast milk expressed from child’s mother
5. Administer warm, humidified oxygen
6. Treat infection promptly
7. Administer Vitamin K 0.5-1mg IM STAT
8. Give oral vitamin supplement (syrup form)
9. Ensure that baby is immunised before being discharged
10. Refer complicated cases

-Full blood count; -Blood glucose
-Urea and Electrolytes; -Liver function tests
11.3.1 Comment
The main objective in the care of infants born prematurely is to provide stable temperature, feed adequately
and to prevent and treat complications or diseases of prematurity.
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12 NEONATAL JAUNDICE
Neonatal jaundice may develop as a result of liver immaturity and therefore be self-limiting. But severe
neonatal jaundice due to excess hyperbilirubinaemia on the brain of the newborn infant (kernicterus) may
cause death or be associated with cerebral palsy. Neonatal jaundice therefore may be physiological or
pathological.
12.1.1 Physiologic Jaundice
In this condition the jaundice usually appears around the 2nd day after birth. The newborn usually shows no
signs of anaemia or other illness. The condition results from a rise in the levels of un-conjugated bilirubin
12.1.2 Pathologic Jaundice
Here the jaundice appears within the 1st 24-hours after birth. The baby is often sick and appears unwell. The
condition may result from a rise in the levels of both conjugated and un-conjugated bilirubin.
12.2.1 Community Level and Health Centre Interventions
1. Refer all jaundiced newborn children
1. Admit
2. Determine and treat the underlying cause
3. Administer Phototherapy if the cause is a rise in un-conjugated bilirubin
4. Refer for specialist care if the cause is not clear

-Liver function tests; -Random blood glucose; -Urea and Electrolytes
It should be noted that in cases of neonatal jaundice the risk of brain damage is increased in the presence of
by hypoxia, hypoglycaemia, acidosis, prematurity, hypothermia, hypo-albuminaemia and haemolysis.
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CHAPTER 12
Psychiatric Disorders
1. ACUTE PSYCHOTIC DISORDERS
This very common condition seen in medical and psychiatric practice covers a wide range of disorders of
emotional and behavioural function. These disorders are characterised by an acute onset of symptoms such as
restlessness, aggressive behaviour, change of mood and change in cognitive functioning. They may include
conditions such as delirium (which itself may be due to infection, head injury, drug intoxication, renal
dysfunction or the post-ictal state). It may also be associated with other functional disorders such as acute
transient psychotic disorder, acute polymorphic psychotic disorder and schizophrenia-like psychosis)
1.1.1 Community and Health Centre Level Interventions
1. Supportive Restraint
2. Open communication
3. Refer
1. Medications:
♣ Haloperidol 5-10mg 8-12 hourly orally or I.M for sedation
♣ Thioridazine 25-50mg 12-hourly, orally
♣ Chormethiazole especially in alcohol-related mental disorder
NB: Manage the acute functional psychotic disorder as appropriate; treat epilepsy where/if present. Give low
doses of non-phenothiazine e.g Haloperidol neuroleptics and anti-depressants in epileptic cases so as not to
precipitate fits.

-Full blood count; -Urea and Electrolytes; -Chest X-ray
CT-Scan when indicated (especially where organic brain disorder is suspected)
-Liver function tests; -ECG
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2 ANXIETY DISORDERS
This is a group of disorders in which anxiety is a common feature. When it occurs as the primary symptom it
is referred to as “Generalised Anxiety Disorder”. Other disorders associated with anxiety symptoms are
phobias, obsessive-compulsive disorder, and agroraphobia with or without panic, panic disorder and Post-
Traumatic Stress Disorder. By far the most common is Generalised Anxiety Disorder.
2.1.1 Phobic Disorders
These are characterised by the presence of irrational or exaggerated fear of objects, situations or bodily
functions not inherently dangerous or appropriate as a source of the anxiety.
2.1.2 Post-Traumatic Stress Disorder
This is usually precipitated by experience of an overwhelming near-death situation such a Road Traffic
Accident, Rape or experience/involvement in war. The main features include recurrent episodes of intrusive
recollection of the stressful event, anxiety, palpitations, nightmares and an inability to cope with situations
that remind the individual of the stressful event.
2.1.3 Obsessive-compulsive Disorders
These are characterised by the recurrence of intrusive ideas, fantasies and actions that the patient realises as
his thoughts and also recognises them as being irrational and embarrassing. The patient finds it difficult to rid
his/her mind of these due to antecedent internal resistance. The disorder is usually associated with severe
anxiety and may lead to impairment of social and occupational functioning.
1. Non-pharmacological measure
2. Teach and encourage adoption of relaxation techniques
3. Encourage regular physical exercise
4. Discuss the underlying source of the anxiety
5. If the condition manifests in a severe manner, refer
2. Institute counselling and other supportive measures
3. Add medication.
♣ Diazepam 5-10mg nocte for one week (Adult) OR,
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♣ Propranolol 20-40mg if troublesome palpitations are present
♣ If the condition is severe, then refer
2. Institute counseling and other supportive measures + Counselling + and Drug therapy can be
started concurrently.
3. Drug therapy (4-6 weeks)
4. Medications:
♣ Diazepam 5-10mg nocte for one week (Adult) OR
♣ Propranolol 20-40mg twice daily OR
♣ Imipramine 50 -75mg nocte
♣ If the condition is severe, refer

-Full blood count; -Cardiac enzymes; -Chest X-ray
-Thyroid function tests; -ECG
3. PANIC DISORDER
This is an anxiety state associated with intense fear, palpitations, tremors and a sensation of shortness of
breath.
The patient may complain of chest pains, dizziness and fainting spells. Numbness and a tingling sensation in
the limbs may be reported as well as a degree of abdominal discomfort.
All treatment interventions are instituted under the guidance of hospital level personnel.
1. Re-breathing exercises
2. Relaxation Training
3. Involve a Clinical Psychologist in the management of the patient
4. Eliminate from the diet foods that are prone to precipitating palpitations (caffeine-containing
foods such as coffee, tea, coca cola and cocoa)
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3.2.1 Community level interventions
Refer
3.2.2 Health Center level
1. Non-pharmacological measures
2. Give:
♣ Diazepam 5-10mg nocte PLUS,
♣ Imipramine 50-75mg twice daily
3. Refer
None
4. ALCOHOL RELATED MENTAL DISORDERS (ALCOHOLISM)
These include alcohol abuse, alcohol dependence, intoxication, withdrawal. There is an increasing incidence
of female drinking that has become a major problem. Alcohol abuse is associated with a lot of neuro-
psychosocial problems.
1. Subjective compulsion to drink alcohol
2. Drinking at the expense of other important activities
3. Development of a stereotyped pattern of drinking
4. Increased tolerance of alcohol
5. Experiencing withdrawal symptoms if unable to drink for 2-3 days
1. Individual counselling
2. Group therapy
3. Couple or family counselling
4. Establishment of voluntary therapy
5. Refer
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1. Reinforce the need to stop drinking
2. Establish the need to stop drinking
3. Emotional support
2. Manage delirium tremens and alcohol withdrawal symptoms
♣ Diazapam 5-10mg P.O/I.V slowly every-6-8hrs titrating against the response
♣ Reduce the dose by 20% daily
♣ Discontinue after 5-7 days
OR
♣ Chlordiazepoxide 25 – 50 mg
♣ Increased or decreased by 20% depending on the state of the patient
♣ Tapered over 5 days
3 Refer for detoxification where appropriate
4 Detoxification:
♣ Chordiazepoxide 30-40mg per day in divided doses
♣ Carbamazepine 200mg 8-hourly
♣ Thiamine and Nicotinic acid as supplements to all patients; 100mg daily
♣ Monitor fluid and electrolyte balance
5 Management of lifetime abstainers
Antabuse may be helpful if patient is cooperative
Carbamazepine/Lithium carbonate if secondary to mood disability
Behavior Therapy
Relaxation training, assertiveness training, self control skills
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-Alcohol Anonymous

-Full blood count; -Blood glucose; -Liver function tests
-Chest X-ray especially if malnourished; -ECG
11 DELIRIUM, DEMENTIA AND OTHER COGNITIVE DISORDERS
These were formally known as “Organic Brain Syndrome”. They present with transient or permanent brain
dysfunction and cognitive impairment of varying degrees. Functional disorders such as depression, anxiety
and irritability are frequently present. Behavioural disturbance may include problems of impulse control,
attention deficit and depression.
5.1.1 Delirium
This is a state of impaired consciousness associated with a disturbance of behaviour, affect, thought and
perception. It develops suddenly and often gets worse at night. Hallucinations and illusions are common and
are usually visual in nature.
5.1.2 Dementia
This is a syndrome presenting as an acquired global impairment of higher mental functions occurring in clear
consciousness. The most common symptoms are poor memory, gradual deterioration in social, intellectual
and occupational functioning. These changes may also be associated with anxiety, depression or psychotic
symptoms.
5.1.3 Amnesic Syndrome
This is characterised by an impairment of memory, particularly short-term memory, as the primary symptom.
It occurs in clear consciousness and confabulation may be present. The characteristic feature is the inability to
lay down new memory with a variable degree of retrograde amnesia and peripheral neuropathy.
5.1.4 Organic Personality Disorder
This is a disorder characterised by general irritability and a low frustration threshold. It is often accompanied
by verbal and physical aggressive behaviour
1. Nutritional education
2. Avoidance of alcohol
3. Community trauma reduction efforts
4. Health Education regarding alcohol and substance abuse
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5. Refer severe cases
2. Control confusional state with:
-Diazepam 10mg OR
-Lorazepam 2-4mg orally daily
3. Refer
1. Non-pharmacological support as described above
2. Establish the diagnosis
3. Manage according to the diagnosis
5.2.4 Delirium Tremens
♣ Chlordiazepoxide 25-75mg orally daily
♣ Diazepam 5-10mg IM or IV 6-8 hourly.
♣ Omit dose if patient is sedated
5.2.5 Dementia
Social support
Occupational therapy assessment
Thioridazine 25-50mg 2 times daily OR,
Haloperidol 1.5-2.5mg 3 times daily
5.2.6 Amnesic Syndrome
♣ Exclude irritable cause
♣ Thiamine 100mg 3 times daily
5.2.7 Organic Personality Disorder
♣ Behaviour therapy
♣ Carbamazepine 100mg 3 times daily OR,
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♣ Sodium valproate 200 mg 2 times daily
6 SCHIZOPHRENIA
This is a commonly occurring psychotic disorder. It constitutes a major distress to the individual sufferer and
to the family as a whole. It is a syndrome characterised by a fundamental disturbance of the personality
associated with a loss of reality. It has a tendency to run a chronic course in the absence of identifiable
organic disease.
1. Auditory hallucinations such as audible thoughts or thought echo, running commentary and
paranoia
2. Passivity-feeling, impulse feeling, thought withdrawal, thought broadcasting or somatic

passivity
3. Delusional perception
4. Form of thought block, irrelevant speech and loosening of association
5. Affect incongruence and flattening or blunting of affect
6. Lack of volition
1. Counselling
2. Family therapy
3. Occupational rehabilitation
4. Refer all newly diagnosed/suspected cases
2. Medication:
♣ Chlopromazine50-300mg daily in divided doses
3. If not manageable refer
♣ Haloperidol 5-10mg IM or PO. Repeat every 4-6hrs
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♣ When calm and manageable, do physical examination
♣ Start oral medication if co-operative
-Chlopromazine 75-300mg daily in divided doses
♣ Inj. Akineto 5mg IM if develops extra pyramidal symptoms
♣ Refer to specialized care hospital if the patient does not improve
7. DEPRESSIVE EPISODE
A depressed mood and loss of interest or pleasure are the key symptoms of depression. Patient may say they
feel hopeless, helpless and worthless. There are three degrees of depression with psychotic symptoms.
1. Reduced attention and concentration
2. Lack of self esteem
3. Ideas of guilt, black views of future
4. Disturbed sleep and appetite
5. Vague underlying somatic complains
6. Psychotic Depression
7. Delusion- involves ideas of sin, poverty, imminent disasters, e.t.c.
8. Olfactory hallucination
9. Severe psychomotor retardation
a. TREATMENT GUIDELINES
1. Early detection of symptoms
2. Counselling/support
3. Steps to avoid suicidal attempts
4. Refer
7.2.2 Health Centre Level
1. If there is attempt of suicide refer immediately to Hospital
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2. Reinforce above
3. Start anti depressant drug treatment
♣ Amitriptyline or Imipramine 50-75mg orally daily
♣ Diazepam 5-10mg nocte for 5-7 days if there is restlessness, agitation or insomnia
4. Do not give Drugs to suicidal patient, always advise relative to keep medicine with them.
5. Counselling/support to patient and family members
6. Explore family/psycho-social factors in history/counseling
7.2.3 Hospital Level
1. Medical Treatment if there is suicidal attempt
2. Start anti depressive drugs treatment as above; continue for 4-6 month
♣ Imipramine/Amitriptyline 25-75mg daily
3. Continue with counselling/support
4. Consider family/behaviour therapy-as changing behaviour is considered the effective way to

alleviate depression
5. If no response refer to tertiary care level
-Full blood count; -Blood sugar
8. MOOD (AFFECTIVE) DISORDERS
In these disorders, the fundamental disturbance is a change in mood or affect. This mood change is normally
accompanied by a change in the overall level of activity and symptoms are wither secondary or easily
understood in context of such changes.
MANIC EPISODE:
Underlying characteristics of this disorder are elevated mood and an increase in the quantity and speed of
physical and mental activity. Three degrees of severity are specified e.g. Hypomanic without psychotic
symptoms; manic without psychotic symptoms and manic with psychotic symptoms.
8.1 DIAGNOSTIC CRITERIA:
1. Persistent elevation of mood
2. Increased energy and activity/decreased need for rest and sleep
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3. Over talkativeness
4. Grandiosity, excessive optimism
5. Flight of ideas, pressure of speech
6. Speech becomes incomprehensible
7. Delusions, hallucinations
8. Aggression, violence, self neglect.
8.2.1 Community level
Early detection of symptoms
1. Protective restraint if violent
2. Safety of others and patient
3. Family Support
4. Referred to Health Centre
8.2.2 Health Centre level Intervention
1. Reinforce above
2. Medication
♣ Chorpromazine 50-300 mg orally daily in divided doses
3. If not manageable refer
1. Haloperidol 5-10mg I/M or
2. Repeat every 4-6hrs
3. Start oral medication if co-operative
♣ -Inj. Akineton 5mg I/M if develops extra pyramidal symptoms
4. Refer to specialist hospital if patients does not improve
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CHAPTER 13
Ear, Nose and Throat Disorder s
1. EPISTAXIS
Nose bleeding is a very common condition. The bleeding can be unilateral or it can be bilateral. It may be due
to local causes such as trauma, repeated nose picking, infections such as rhinitis or sinusitis, etc. It can also
occur secondary to systemic causes such as hypertension, bleeding disorders, anaemia, leukaemia, etc.
Epistaxis can also be due to hormonal factors (puberty and pregnancy) or to environmental factors such as
high altitude or extremes of temperature.
It should be remembered that the aim here is to stop the bleeding.
1. With the patient breathing through the mouth pinch the nostrils for 5-10 minutes
2. Apply a cold water pack or an ice pack
1. Manage as above
2. Pack nose with ribbon gauze dipped in adrenalin, liquid paraffin or nitrofurazone
3. If the patient is hypertensive do not use adrenalin
1. Manage as above
2. Anterior nasal packing/Posterior nasal packing
3. Investigate further if cause not immediately clear/obvious
4. Ligation or cautery of nasal blood vessels
5. Refer if bleeding is part of head injury and give
♣ Chloramphenicol 500mg IV 6 hourly PLUS
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♣ X-pen 2 mega units 6 hourly
-Full blood count; -Clotting profile; - X-ray
2 ALLERGIC RHINITIS
This is quite common throughout the year, but is particularly so during spring. It is a symptom complex that
includes hay fever and perennial rhinitis. It is characterised by seasonal or perennial sneezing, nasal
congestion, pruritis and often conjunctivitis and pharyngitis. Perennial allergic rhinitis may be due to inhalant
substances such as house dust, carpet fibres, smoke and spores; or it may be due to ingested substances such
as milk, fish, cheese, drugs, etc.
The condition can also be precipitated by an acute viral respiratory tract infection. Dental infections may lead
to chronic maxillary sinusitis.
The skin over the area of the sinus that is involved may be tender and swollen. In addition there may be a
persistent fever that is associated with a nasal discharge. The nasal mucous membranes is red and may be
covered with a muco-purulent discharge. The pain in the sinuses is worsened by stooping or coughing.
2.1.1. Frontal Sinusitis
In this condition the pain is localised in the frontal area of the head and there is a persistent frontal headache
2.1.2. Maxillary Sinusitis
Here the pain is felt in the cheek area below the eyes. There may be an associated toothache and a frontal
headache
2.1.3. Ethmoidal Sinusitis
This is characterised by pain seeming to be situated behind and between the eyes and is accompanied by a
“splitting headache”
2.1.4. Sphenoiditis
Here pain is referred to the vertex or the patient may complain of a severe occipital headache.
1. Steam inhalation to promote drainage of blocked sinuses
2. Analgesics to relieve pain and headache
3. Refer if there is no improvement
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1. Manage as above
2. Rule out dental infections
3. Initiate antibiotics for at least 7 days
♣ Pen VK 500mg 4 times daily OR,
♣ Erythromycin 500mg 4 times daily
1. Manage as above
2. Antibiotics
3. Antihistamines:
♣ Chlopheniramine 2-4mg 3 times daily OR
♣ Astemizole 10mg OD
4. Nasal Decongestants:
♣ Oxymetazoline or Xylometazoline nasal drops
5. Steam inhalation using Benzoin tincture.

-Full blood count; -X-rays of Paranasal Sinuses
3. VESTIBULITIS
This is a diffuse infection of the skin of the anterior nares and may occur due to frequent trauma such as
occurs in constant nose picking. Persistent nasal discharge leads to excoriation and infection of the skin of the
nasal vestibule
1. Counsel on avoidance of nasal picking or forceful blowing of the nose
2. Analgesics for pain control
♣ Paracetamol 500mg-1g 3 times daily for 5 days
3. Refer if condition does not improve
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1. Institute antibiotic therapy
♣ Pen VK 500mg 4 times daily for 7 days OR
♣ Erythromycin 500mg 4 times daily for 7 days
♣ Paracetamol 500mg -1g 3 times daily for5 days
3. Nasal decongestants
♣ Oxymetazoline or Xylometazoline
4. Refer if condition deteriorates
3.1.3. Hospital and Specialist Interventions
1. Manage as above
2. Local application of Neomycin or Polymyxin with Hydrocortisone ointments is indicated
3. Treat underlying cause (i.e., infective agent)
4. EXTERNAL OTITIS
This is an inflammation of the skin lining the external auditory canal. It can be acute (furuncle/pimple) or it
can be chronic. This condition usually comes about when a patient scratches his/her ear with a sharp object
resulting in lacerations that then become infected
Typical presentation is that of pain and swelling over the pinna and external auditory canal. (It)The may or
may not be an associated ear discharge.
- Paracetamol 500mg-1g 3 times daily for 5 days or
- ASA 300mg-6oomg 3 times daily for 5days
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2. Keep ears dry and do not scratch
1. Manage as above
2. Institute antibiotic therapy
–Adults:
♣ Erythromycin 500mg 4 times daily for 7 days or
♣ Cotrimoxazole 800/160 mg 2 times daily for 7 days
-Children:
♣ Pen VK 125mg 4 times daily
♣ Erythromycin 125 mg 4 times daily or
♣ Cotrimoxazole 5 ml-7.5 ml 2 times daily
4.2.3. Hospital Level/Specialist Interventions
1. Analgesics for pain management as above
2. Antibiotics as above
3. Clean ear of debris and pack with Beclamethasone or Hydrocortisone ointment
4. Abscess may require Incision and Drainage
-Full blood count; -Pus swab
-Blood sugar; -X-ray
5. OTITS MEDIA
Acute otitis media is a pyogenic bacterial infection in the middle ear. It usually occurs secondary to upper
respiratory infections. It is most common in young children. The common causative bacteria isolated tend to
differ depending on the age of the patient.
165
Patients usually present with a severe headache associated with fever. Nausea and vomiting may also occur.
The tympanic membrane is found to be erythematous and may be bulging. Ear discharge follows perforation
of the tympanic membrane. The child is often crying and is irritable.
1. Tepid sponging to reduce temperature
-Adults:
♣ Paracetamol 500mg-1g 3 times daily or
♣ ASA 300mg- 600mg 3 times daily
-Children:
♣ Paracetamol 2.5ml-5ml 3 times daily
3. Advice on maintenance of the child’s nutrition and hydration
4. Refer
1. Manage as above
2. Medication: - give antibiotics for 7 days
♣ Pen VK 125-250mg 3 times daily in children
♣ Pen VK 500mg 3 times daily in adults OR,
♣ Amoxycllin 125-250mg 3 times daily in children
♣ Amoxycillin 500mg 3 times daily in adults OR,
♣ Erythromycin 125-250 mg 3 times daily in children
♣ Erythromycin 250-500mg 3 times daily in adults
3. Refer if there is poor response or if complications 9 develop
9 The usual complications in this condition are: Acute Mastoiditis, Facial Palsy and Meningitis
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1. Manage as above
2. Treat complications if any develop
-Full blood count; -Pus swab
-Blood sugar; -X-ray
6. MASTOIDITIS/MENINGITIS
6.1.1. Routine Treatment
1. Ampicillin 125-500mg IV 6-hourly PLUS,
2. Cloxacillin 50-100 mg/kg 6-hourly PLUS,
3. Metronidazole 7.5mg/kg 8-hourly
6.1.2. Treatment in the Presence of Penicillin Allergy
1. Erythromycin 25-50mg/kg 6-hourly PLUS,
2. Metronidazole 7.5mg/kg 8-hourly orally
6.1.3. Treating an Abscess
1. Drain the abscess
2. Institute antibiotic therapy as above or as per culture and sensitivity
7. TONSILLITIS
Acute tonsillitis is mainly a disease of childhood but is also frequently seen in adults. It constitutes an acute
inflammation of the tonsils. The main organism implicated in the causation of this condition is β-Haemolytic
Streptococci. Tonsillitis accounts for approximately 5% of outpatient morbidity and 25% of ENT
consultations in the country.
The patient presents with a sore throat and difficulty and pain on swallowing. Physical examination reveals
enlarged and inflamed tonsils. There may be multiple white spots on the inflamed tonsillar surface. A sudden
onset fever is also typical of this condition.
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The main aim with treatment is to eradicate the infection and prevent the development of complications such
as acute rheumatic fever and acute glomerulonephritis.
1. Gargle with warm saline
♣ Paracetamol 500 mg -1g 3 times daily in adults OR
♣ ASA 300mg -600 mg 3 times daily for 5 days
♣ Paracetamol 125 mg-250 mg 3 times daily in children for 5 days
3. Refer all cases
1. Reinforce non-pharmacological management as described above
2. Emphasise the importance of completing any medication prescribed
3. Medication:
♣ Pen VK Syrup 125mg -250mg 6-hourly for 7 days in children
♣ Pen VK tabs 500mg 6-hourly for adults OR,
♣ Erythromycin syrup 125mg -250mg 6-hourly for 7 days for children
♣ Erythromycin 250mg -500mg 6-hourly for adults
♣ Analgesics for pain control as above
4. Refer any cases where complications 10 are present
1. Reinforce above management
2. Where Organism has not been isolated:
♣ Benzyl Penicillin IV 250,000 units/kg/24hrs in 4 divides doses for 7 days plus
10 The “usual” complications here are rheumatic fever, Glomerulonephritis anaerobic Organism: Metronidazole 400mg s,
h/o rhematic fever or rheumatic heart disease, peri-tonsillar abscess or other localised complications
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♣ Metronidazole 7.5mg/kg 8hly for 7 days (Children)
♣ Metronidazole 400 mg thrice daily for 7 day (Adults)
3. Where organism is known
Streptococci: Benzyl Penicillin as above or
♣ Pen VK 125ml- 250ml 6 hourly orally for 7 days in children
♣ Pen VK 500mg-1gm 6 hourly orally for 7 days in adults
Staphylococci :
♣ Cloxacillin IV 50-100mg/kg/24hrs in 4 divided doses for 7 days (Children)
♣ Cloxacillin 500mg 3 times daily for 7 days (Adults)
♣ Flucloxacillin 125mg-250mg6 hrly for 7 days (Children)
♣ Flucloxacillin 500mg 4 times daily for 7 days (Adults)
Anaerobic:
♣ Metronidazole as above
Haemophilus Influenza:
♣ Ampicillin 50mg-100mg /kg/24hrs iv in 4 divided doses for 7 days (Children)
♣ Ampicillin 500mg-1gm IV 6hrly for 7 days (Adult)
♣ Amoxycillin 125mg-250 mg 8 hrly for 7 days (Children)
♣ Amoxycillin 500mg 4 times daily for 7 days (Adult)
3. In the presence of Penicillin Allergies
Streptococci:
♣ Erythromycin 25mg -50mg /kg/24hrs im/iv 4 divides drops for days
♣ Erythromycin 500mg thrice daily for 7 days ( Adult)
Staphylococci:
♣ Clindamycin 10mg-40mg /kg/24hrs IV 3 divided doses for 7 days (Children)
♣ Clindamycin 15mg-25mg /kg/24hrs oral..
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Haemophilus Influenza:
♣ Cefotaxime 50-100mg /kg/24hrs iv in 3 divided doses for 7 days OR
♣ Cefotaxime 1gm thrice daily in 7 days (Adult)
4. In the presence of Penicillin and Cephalosporin Allergies
♣ Chloramphenicol 50mg-100mg 1kg/24hrs IV/orally in 4 divided doses for
7 days (Children)
♣ Chloramphenicol 500mg-1gm thrice daily in 7 days (Adults)
5. For Peri-tonsillar or Retropharyngeal Abscesses
♣ Incision and Drainage
♣ Antibiotics as indicated above
6. Tonsillectomy where indicated once the infection is under control

-Full blood count; -Throat swab
8 PHARYNGITIS
This is an inflammation of the pharyngeal mucosa following a common cold or mucosal irritation by irritants
applied locally.
The patient complains of a sore throat and fever. Examination reveals a diffuse congestion of the pharyngeal
wall, uvula and adjacent tissues.
♣ Paracetamol 500mg-1g 3 times daily for 5 days (adults) OR
♣ ASA 300mg-600mg 3 times daily for 5 days
♣ Paracetamol 125mg-250mg 3 times daily 5 days (children)
2. Warm saline gargles
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1. Manage as above
2. Antibiotics if infection is present
♣ Pen VK 500mg-1gm 4 times daily for 7 days (adults)
♣ Pen VK 125mg-250mg 4times daily (children) OR
♣ Erythromycin 500 mg 4 times daily for 7 days in (adults)
♣ Erythromycin 125mg-250mg 4 times daily for 7 days (children)
1. Determine underlying cause and treat as appropriate
-Full blood count; -Throat swab; -Blood sugar
9 LARYNGITIS
Acute Laryngitis usually follows viral infections of the upper respiratory tract. Bacteria are secondary invaders.
Predisposing factors include excessive vocal use, smoking, exposure to irritant fumes, intubation procedures
and others.
The patient typically presents with a hoarse voice and discomfort in the throat. A dry cough may occasionally
be present. Dyspnoea may be seen in severe cases
1. Rest the voice
2. Steam inhalation
3. Analgesics
♣ Paracetamol 500mg-1g 3 times daily for 7 days (adults) OR
♣ ASA 300 mg - 600 mg 3 times daily for 7 days
♣ Paracetamol 125mg-250mg 3 times daily for 7 days (children)
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1. Manage as above
2. Institute antibiotic therapy if indicated
♣ Pen VK 500mg-1g 4 times daily for 7 days (Adults)
♣ Pen VK 125mg-250mg 4 times daily for 7 days (children) OR
♣ Erythromycin 500mg 4 times daily for 7 days (adults)
♣ Erythromycin 125mg -250mg 4 times daily for 7 days (children)
9.2.3 Hospital Level/Specialist Interventions
1. Manage as above
2. Do indirect/direct laryngoscopy to ascertain the cause
3. Administer steroids (locally/spray or IV)
♣ Hydrocortisone 100 mg IV 8 hourly 2 days
♣ Prednisone 20 mg-30 mg orally daily for 5 days and taper accordingly
4. Treat the cause
5. Perform a Tracheostomy in severe cases
10 VERTIGO
Meticulous history-taking is an important tool as far as vertigo is concerned. The first order of business is to
determine whether there is really vertigo, or whether what presents is a syncopal attack (patient gets a
blackout, falls momentarily and quickly regains consciousness) or just giddiness. In vertigo there may be
rotating sensation associated with vomiting.
Vertigo in the presence of an ear discharge indicates labrynthitis. Vertigo of central origion is associated with
other neurological features. Positional vertigo is seen in critical patients only. Upper respiratory Catarrh
followed by vertigo may be indicative of labrynthitis. Patients on ototoxic medication may also get vertigo.
Vertigo associated with hearing loss and tinnitus may be due to Miniere’s disease. Vertigo can also present as
one of the complications in hypertension.
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1. Calm the patient
2. Refer
1. Institute Vestibular Suppressants
♣ Promethazine 12.5-25mg 2 times daily OR
♣ Prochloperazine 5mg-10mg 3 times daily for 5 days
2. Refer for further management if no response
10.2.3 Hospital Level/Specialist Interventions
1. Identify the cause of the vertigo and manage accordingly
- Full blood count; -X-ray
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CHAPTER 16
Dental Disorders
1. BACTERIAL INFECTIONS
1. DENTAL CARIES:
Is a bacterial destruction of the tooth substance caused by acids as a co-product by bacterial plaque and
carbohydrates.
Clinically in its early stages, can be seen as a white spot on the smooth surface of the tooth. In a later stage
appears as a black spot, or even a cavity in the tooth surface. Patient normally complains of pain on hot/cold
intakes. Pain persists for a short time or subsides immediately after the removal of the stimulus.
1.2.1 Community Level:

Health Education on: reduction of sugar intake, intake of optimum level of fluoride in water, fluoridated-
toothpaste, milk, or salt.
1.2.2 Health Centre:

• As above.
• Analgesics Paracetamol 250/500mg tds.
• Referral to Dentist.
1.2.3 Hospital:/Dentist
• History taking.
• X-Ray.
• Filling.

-x-ray
-Full blood count
-Blood sugar
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2 PERIODONTAL DISEASES:
A: Chronic periodontal diseases
B: Acute periodontal diseases
A. CHRONIC PERIODONTAL DISEAES:
1. CHRONIC GINGIVITIS:
It is a bacterial infection of the gingival tissues.

The clinical feature is characterized by the triad of swelling, redness and bleeding of the gingiva in gentle
probing.
1.2 TREATMENT GUIDELINES:
1.2.1 COMMUNITY LEVEL:

Health education on proper oral hygiene, smoking cessation, and regular visits to dental services.
1.2.2 HEALTH CENTRE:

• As above.
• Clorhexidine gluconate 0.2% mouth rinse OR.
• Hydrogen peroxide mouth rinse.
• Tetracycline 250 mg qds for 5 days (avoid in pregnancy and teeth calcification period) OR
• Erythromycin 250/500 mg qds for 5 days. OR
• Phenoxymethyl penicillin Tabs 250/500 mg qds for 5 days PLUS
• Metronidazole 200 mg tds for 5 days.
• Ibuprofen 400mg tds for 5 days.
1.2.3. HOSPITAL LEVEL
• As above.
• Scaling (professional removal of calculus).
• Advanced cases need surgical management.

-Full blood count
-Blood sugar
3. CHRONIC PERIODONTITIS:
Is a bacterial infection of the periodontal tissues (soft and hard tissues, which support the teeth).
3.1. DIAGNOSTIC CRITERIA:

Clinically characterized by development of periodontal pockets, resorption of the alveolar bone (seen on the
X-ray), and mobility of teeth in advance cases.
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3.2. TREATMENT GUIDELINES:
3.2.1. COMMUNITY LEVEL:

Health education on: proper oral hygiene, smoking cessation, and regular visits to dental services.
3.2.2. HEALTH CENTRE:
• As above.
• Clorhexidine gluconate 0.2% mouth rinse OR.
• Hydrogen peroxide mouth rinse.
• Tetracycline 250 mg qds for 5 days (avoid in pregnancy and teeth calcification period). OR
• Erythromycin 250/500 mg qds for 5 days. OR
• Phenoxymethyl penicillin Tabs 250/500 mg qds for 5 days PLUS
• Metronidazole 200 mg tds for 5 days.
• Ibuprofen 400mg tds for 5 days.
• Refer to dentist
3.2.3 HOSPITAL LEVEL

• As above.
• X-Rays.
• Scaling (professional removal of calculus).
• Advanced cases need surgical management (extractions, splinting)
3.3. KEY INVESTIGATIONS

-X-ray
-Full blood count
-Blood sugar.
B. ACUTE PERIODONTAL DISEASES:
1. ACUTE NECROTISING ULCERATIVE GINGIVITS (ANUG):
Is a bacterial infection caused by fusoobacterium and borellia Vincent.

Characterise by: painful papillary yellowish-white ulcers, which bleed readily. Patients also often complain of a
metallic taste and the sensation of their teeth being wedged apart. Regional lymphadenitis, fever, and malaise
may occur in some cases. It is associated with poor oral hygiene.
• Health education on: proper oral hygiene, smoking cessation, and regular visits to dental services.
• Refer to Health centre
.
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• As above.
• Analgesics, Paracetamol 250/500 tds for 5 days.
• Metronidazole 200/400 mg tds for 5 days.
• Refer to Dentist if persists.
♣ As above.
♣ Thorough Debridement

-Full blood count
-Blood sugar
-Biopsy (where indicated )
5. ACUTE PERIODONTITIS (PERIODONTAL ABSCESS):
It is a localized collection of pus within a periodontal pocket. It occurs either due to the introduction of
virulent organisms into an existing pocket or decreased drainage potential. May also occur due to impaction
of a foreign body such as a fishbone in a pre-existing pocket or even in an otherwise healthy periodontal
membrane.
Characterized by a collection of pus in the buccal sulcus near an affected tooth/teeth.Need to distinguish
from apical abscess.
Apical abscess Periodontal abscess

Non-vital Usually vital
TTP Pain on lateral movements
May be mobile Usually mobile
Loss of lamina dura on X-Ray Loss of alveolar crest on X-Ray
1.2. TREATMENTGUIDELINES:

• Refer to Health centre.

As above.
Emergency; incision and drainage under LA.
Debridement of the pocket.
Systemic antibiotic, e.g. metronidazole 400 mg tds &/or amoxycillin 250-500 mg tds for 5 days.
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• As above.
• Conventional treatment for periodontal pockets, combined periodontal-endodontic lesion.

-Full blood count
-Blood sugar
6. DENTO-FACIAL INFECTIONS:
The vast majority of infections in this area requiring surgical treatment are bacterial, usually arising from
necrotic pulps, periodontal pockets, or pericoronitis. Rarely, can be life threatening if allowed to progress, e.g.
to the fascial spaces of the neck or the cavernous sinus, or as a focus for subacute bacterial endocarditis.
Need to differentiate between a cellulitis and an abscess.
DIFFERENCES BETWEEN CELLULITIS AND ABSCESS:
Characteristic Cellulitis Abscess

Duration Acute Chronic
Pain Severe Mild
Size Large Small
Location Diffused Localised
Palpation Daughy-indurated Fluctuant
Degree of seriousness Greater Less
Presence of pus No Yes
Bacteria Aerobic Anaerobic
PRINCIPLES OF THERAPY OF ODOTOGENIC INFECTIONS:
I. Determine the severity of the infection.

II. Evaluate the status of the patient’s host defence mechanism.
III. Determine whether a general dentist or specialist should treat the patient.
IV. Treat the infection surgically. [Incision & Drainage].
V. Support the patient medically. [Intake of fluids].
VI. Choose and prescribe the appropriate antibiotic.
VII. Evaluate the patient frequently.
Criteria for referral to a specialist:
1. Rapidly progressive infection. 2. Difficulty in breathing.3. Difficulty swallowing. 4. Fascial space

involvement. 5. Elevated temperature [greater than 101 F]. 6. Severe jaw trismus. [Less than 10mm]. 7. Toxic
appearance. 8. Compromised host defences
Indications for use of antibiotics:
1. Acute –onset infection. 2. Diffuse swelling. 3. Compromised host defences.

4. Involvement of Fascial spaces. 5. Severe pericoronitis. 6. Osteomyelitis
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6. DENTO-FACIAL ABSCESS:

Is usually simple and clinically based on pain, swelling, hotness, and discharge of pus.
• Refer to Health centre.
6.2.3 HEALTH CENTRE LEVEL:

As above.
Incision and drainage.
Antibiotics, Amoxycillin OR Phenoxymethyl penicillin 500 mg qds 5/7 days.
Metronidazole 400 mg tds 5/7 days.
Paracetamol 500 mg tds 5/7 days.
6.2.4 HOSPITAL LEVEL:

As above.
Incision and drainage.
Antibiotics, Amoxycillin OR Phenoxymethyl penicillin 500 mg qds 5/7 days.
Extraction of the causing tooth/teeth.

-Full blood count
-Blood sugar
7. LUDWING’S ANGINA:
It is an emergency and life threatening condition. Aetiology: Periapical infection and pericoronitis around
lower third molars, it spreads to sublingual space the to opposite sublingual space, sub mental space is
infected by lymphatic spread.
It is a massive firm cellulitis affecting the submandibular + sublingual + sub mental spaces bilaterally. Signs
and symptoms: External massive firm bilaterally submandibular swelling with some extension down the
anterior part of the cheek to the clavicles. Internal swelling develops rapidly and involves the sublingual
tissues, the floor of the tongue raised to the palate and more extent is protruded from the mouth –illness and
pyrexia, deglutition and speech are difficult, dyspnoea, oedema of the glottis and resurging obstruction within
12-24h.
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• Refer immediately to Health centre.

As above.
Immediately Incision and drainage.
Antibiotics, Amoxycillin 500mg tds, OR Phenoxymethyl penicillin 500 mg IV qds 5/7 days.
Metronidazole IV 400 mg tds 5/7 days.
7.2.3. HOSPITAL:
As above.
Immediately Incision and drainage with U shaped incision of submandibular region.
Antibiotics, Amoxycillin 500 mg tds, OR Phenoxymethyl penicillin 500 mg qds 5/7 days.
Extraction of the causing tooth/teeth.
3. VIRAL INFECTIONS
AN APPROACH TO ORAL ULCERATION:
Oral ulceration is probably the commonest oral mucosal disease seen; it may also be the most serious.
Therefore, to facilitate diagnosis, there is a need for asking about the following:
DURATION: If more than 3 weeks, referral for biopsy is mandatory.

If for recent onset, ask whether blistering preceded it. Are the ulcers multiple? Is any other part of the body is
affected and have similar ulcers been experienced before? Then look at the site &/or distribution of ulcers.
BLISTERING preceding the ulcers suggests herpetic gingivostomotitis. Blistering with lesions elsewhere in
the body suggests erythema multiforme, or hand foot and mouth disease.
DISTRIBUTION: Limited to the gingival suggests acute narcotising ulcerative gingivitis. Unilateral
distribution suggests herpes zoster. Under a denture or other appliance suggests traumatic ulceration.
RECURRENCE of ulcers after apparent complete resolution is characteristic of recurrent aphthae.
PAIN: The presence or absence of pain is not particularly useful diagnostically, although the character of pain
may be of value.
ULCERS WHICH NEED EARLY DIAGNOSIS include:
Herpes Zoster As early aggressive treatment with Acyclovir may reduce post-herpetic neuralgia.
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Erythema multifome In order to avoid re-exposure to the antigen.
Erosive Lichen Planus As this may benefit from systemic steroids.
Oral Squamous Cell Carcinoma is for obvious reasons.
PRIMARY HERPETIC GINGIVOSTOMOTITIS:

Presented as a widespread stomatitis with vesicles, which break down to form shallow painful ulcers;
enlarged, tender cervical lymph nodes; fever and general malaise for 10-14 days.

• As above.
• Topical and systemic analgesia.
• A soft or liquid diet with high fluid intake.
• Clohexidine mouthwash tds for 7 days.
• Acyclovir lozenges 200 mg 5 times’ daily for 5 days. OR
• Severely ill patients or immunocompromised patients should be referred to hospital.

• As above.
• Severely ill patients or immunocompromised patients should receive Acyclovir tablets 200/400 mg 5
times daily for 5 days.
2. HERPES LABIALIS/ COLD SORES:

Usually occurs on the skin of lip or nose supplied by one branch of trigeminal nerve, classically at the
mucocutaneous junction, or rarely as intra-oral blister.
2.2 TREATMENTGUIDELINES:


• As above.
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• A soft or liquid diet with high fluid intake.
• Clohexidine mouthwash tds for 7 days.
• Acyclovir cream 5% 5 times daily for 5 days.
2.2.3 HOSPITAL:
• As above.
3. HERPES ZOSTER:
The virus responsible for herpes Zoster (herpes virus varicella) is a DNA virus and responsible of two
completely dissimilar diseases in humans–chickenpox and herpes zoster. There is little evidence that contact
with one of these diseases is responsible for the initiation of the other.
The characteristic superficial lesion of herpes zoster is a vesicular eruption in an area of distribution of a
sensory nerve. When the eruption affects the trigeminal nerve, the facial skin and the oral mucosa in the
sensory area may be affected. Ophthalmic division is more affected division. The initial symptoms are of pain
and tenderness in the affected area, the prodromal phase may last for 2-3 days and is succeeded by
appearance of resides in a rash, and this mark the secondary infection. When the ophthalmic division is
involved there may be coned ulceration, the distribution of resides intra-orally. Unilateral and often confined
to the area of a single branch of trigeminal nerve. If untreated the resides and oral ulceration fade over a
period of 2-4 weeks, following fading of the masks the major complication of the condition – post – herpetic
neuralgia and may persist for a year.


• As above.
• A soft or liquid diet with high fluid intake..
• 2% tetracycline mouth wash qds for 7 days.
• For the ulceration of the skin is the use of 90%. Idoxyunidine.
3.2.3 HOSPITAL:
• As above.
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4. FUNGAL INFECTIONS
1. ACUTE CANDIDIASIS:

It appears as creamy lightly adherent plaques on erythematous oral mucosa, usually on the cheek, palate, or
oropharynx. Occasionally symptom-less, but more commonly causes discomfort on eating. The plaque can be
gently stripped off, leaving a raw under surface.

• As above.
• Nystatin sugar free suspension 100000 units rinsed, then swallowed qds for 10 days. OR
• Nystatin pastille 1 qds for 10 days.
• Clohexidine mouth wash qds for 7 days.
• Refer to hospital if persists.
1.2.3 HOSPITAL:
• As above.
• Investigate immunosuppression and treat accordingly.
• Fluconazole 50 mg OD for 10 days.
2. ANGULAR CHEILITIS:

It appears as red-cracked, macerated skin at the angles of the mouth, often with a gold crust.
2.2 TREATMENTGUIDELINES :
2.2.1 COMMUNITY LEVEL


• As above.
• Miconazole cream for 10 days.
2.2.3 HOSPITAL:
• As above.
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• Miconazole cream for 10 days.
• Fluconazole tablets 50/100 mg OD for 10 days.
3. RECURRENT APHTHOUS STOMATITIS
(a) MINOR APHTHOUS ULCERS:

Usually appear as a group of 1-6 ulcers at a time of variable size (2-5 mm). They last about 10 days and heal
without scaring. Mainly occur on buccal or labial mucosa, floor of the mouth or tongue, and extremely rarely
on the attached gingival or hard palate. Prodromal discomfort may precede painful ulcers
(b) MAJOR APHTHOUS ULCERS:
A more severe variant with fewer, but larger ulcers (up to 10 mm), which may last 5-10 weeks. They are
associated with tissue destruction and scarring and any site in the mouth and oropharynx may be affected.
• As above.
• Clohexidine 0.2% mouth wash qds for 7 days.
• Analgesics topical/systemic.
• Hydrocortisone lozenges dissolved in the mouth qds for 5 days.
3.2.3 HOSPITAL:
• As above.
• Systemic steroids Prednisolone 30 mg as enteric coated tablets. Regimen dependent on the condition
treated.
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5. TRAUMATOLOGY
TOOTH TRAUMA:
1. TOOTH CONCUSSION:

It is the injury to supporting tissues of tooth, without displacement.
1.2 TREATMENTGUIDELINES;

• Health education on: proper oral hygiene.
• Reassurance and advice soft diet intake.
• Refer immediately to health centre.

• As above.
• Paracetamol 250/500 mg tds for 5 days.
• Thymol mouth wash.
1.2.3 HOSPITAL:
• As above.
2. LUXATION:
Displacement of tooth (laterally, labially, or palatally).

• Reassurance and advise soft diet intake.

• As above.
• Refer immediately to hospital.
2.2.3 HOSPITAL:
• As above.
• Re-position tooth as soon as possible under LA.
• Splint the tooth/teeth for 2-3 weeks.
• Keep under review.
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• Root canal treatment may be needed.
3. SUBLUXATION:

Actually means partial displacement, but is commonly used to describe loosening of a tooth without
displacement.
3.2.1 COMMUNITY LEVEL.

As above.

If minor, as above.
If mobile, splint for 1-2 weeks and watch vitality.
4. INTRUSION:

Is displacement of tooth into its socket. Often accompanied by fracture of alveolar bone.


• As above.

• Teeth with immature roots (X-RAY) are likely to erupt and therefore no immediate treatment is
required.
• Teeth with closed apices need orthodontic treatment to facilitate RCT.
• Extirpation and placement of ZOE dressing is advisable.
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SOFT TISSUE INJURIES
Abrasion: does a friction between an object and the surface of the soft tissue cause a wound. This wound is
usually superficial, denudes the epithelium, and occasionally involves deeper layer.
Contusion: is more commonly called a bruised and indicates that some amount of tissue disruption has
occurred within the tissues, which resulted in subcutaneous or submucosal haemorrhage without a break in
the soft tissue surface.
Laceration: is a tear in the epithelial and sub epithelial tissues. It is perhaps the most frequent type of soft
tissue injury, is caused most commonly by a sharp object.


• As above.
5.2.3 HOSPITAL:
• As above.
• Cleansing of the wound.
• Debridement of the wound.
• Haemostasis in the wound.
• Closure of the wound.
• Prophylactic Antibiotics
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CHAPTER 17
Eye Diseases
1. CONJUNCTIVITIS
Conjunctivitis is an inflammation of the eye conjunctiva. Bacterial or viral infections, allergic reaction,
chemical irritant, foreign body, and systemic infections may cause it.
Conjunctivitis presents with red, mildly irritable conjunctiva and photophobia. There is excessive lacrimation.
Normal vision is preserved in this condition (i.e., there is no visual impairment). There may also be present a
discharge which may be yellow (bacterial), mucopurulent (viral) or mucoid and strings or watery (allergic
reaction). The cornea is clear and pupils are normal.
1 Refer all cases
1. Cleanse the affected eye
2. Medication:
♣ Tetracycline eye ointment OR,
♣ Chloramphenicol eye ointment
3. For the Newborn
♣ Cleanse both eyes
Medication:
♣ Chloramphenicol eye ointment PLUS
♣ Benzyl Penicillin
♣ Parents should be treated for syphilis
4. In both Cases refer if there is no improvement
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1. Manage as above
2. Remove any foreign objects that may be in the eye
3. Administer antibiotic eye ointment and apply an eye patch
2. STYE
Stye is an infection associated with abscess formation of either the sebaceous glands (internal stye) or a hair
follicle (external stye) along the margin of the eyelid.
The condition typically presents as a red, tender swelling along the margin of the eyelid (external stye) or on
the inside of the eyelid (internal stye or meibonian stye). In both cases the eyelid is extremely painful.
1. Apply hot water compresses on the affected eye three to four times a day
1. Manage as above
2. Tetracycline eye ointment 3 times daily OR,
3. Chloramphenicol eye ointment 3 times daily
1. Manage as above
2. Give systemic antibiotic
♣ Amoxycillin 500mg 3 times daily for 7 days
♣ Erythromycin 500mg 4 times daily for 7 days
3. Drain abscess if all else fails
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3. EYE INJURIES
Trauma to the eye or adjacent structures is a common occurrence. It requires meticulous examination in
order to accurately determine the full/true extent of any injury. Conjunctival and corneal injuries by foreign
bodies are the most common eye injuries. These can be serious if ocular penetration is unrecognized or if
secondary infection follows a corneal abrasion.
1. History of injury to the eye followed by the sensation of “something being in the eye”
2. Blurry vision
3. Conjunctiva is red/bloody
1. Irrigate eye and remove any foreign bodies with moist, sterile cotton wool
2. If unable to remove FB and corneal injury is suspected refer at once
1. Look for foreign body and remove if possible
2. Apply Tetracycline eye ointment or Chloramphenicol eye ointment if possible
3. Apply an eye pad
4. Refer
1. Manage as at Health Centre
2. Refer for specialist attention if unable to remove foreign body or if unsure about corneal injury
3.2.4. Anterior Chamber Haemorrhage
This is a serious condition that may be followed by recurrent bleeding, glaucoma or blood staining of the
cornea.
1. Bed rest
2. Binocular bandage
3. Sedative-Diazapam 2.5, to 5, three times a day for 5 days
4. If intra-ocular pressure rises, administer Acetazolamide 250mg – 1g daily in divided doses
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3.2.5. Trauma to Globe
This may result in severe damage to internal structures. It constitutes an emergency that should only be
treated by an ophthalmologist.
3.2.6. Eyelid Burns
1. Cleanse with sterile isotonic saline solution
2. Apply petrolatum gauze or antibiotic eye ointment
-Tetracycline or chloramphenicol eye ointment 3 times daily for 7 days
3. Apply sterile pressure dressing
4. Refer to ophthalmologist for further evaluation
3.2.7. Chemical Burns
1. Copious irrigation with water or other bland fluid
2. Administer long-acting cycloplegic drops
3. Antibiotic eye ointment
-Tetracycline or chloramphenical eye ointment 3 times daily for 7 days
4. Eye pad for protection
5. Administer analgesic
-Paracetamol 500mg-1g 3 to 4 times daily for 5 days
6. Refer to ophthalmic nurse or ophthalmologist
4. GLAUCOMA
This is an ocular disease, occurring in many forms, having as its primary characteristics an unstable or a
sustained increase in the intraocular pressure, which the eye cannot withstand without damage to its structure
or impairment of its function.
The consequences of the increased pressure may be manifested in a variety of symptoms, depending upon
type and severity, such as excavation of the optic disk, hardness of the eyeball, corneal anaesthesia, reduced
visual acuity, seeing of coloured halos around lights, disturbed dark adaptation, visual field defects, and
headaches.
-Acute glaucoma presents as a sudden-onset pain in the eye associated with nausea and vomiting and
blurred vision. The conjunctiva is red with a clear watery discharge, whilst the cornea is cloudy with a
dilated oval pupil.
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-Chronic simple glaucoma presents as a gradual loss of peripheral vision in association with headache on
and off ±4% of the population above the age of 35 years is prone to chronic simple Glaucoma.
-Congenital glaucoma with tearing, large corneas
-Secondary glaucoma follows after trauma, tumours, surgery, with pain and increased pressure
-Absolute glaucoma presents with pain and blindness when treatment has either not been given or it has
failed
4.2.1. Community and Health Centre Level Interventions
ALL PATIENTS SHOULD BE REFERRED WITHOUT DELAY
1. Administer two drops of 2% pilocarpine and apply an eye pad
2. Diamox 250mg (T)9 I.D. for one week
3. Refer
4.2.3. Specialist Level Interventions
1. Pilocarpine Drops 1-2% 3 times daily OR,
2. Pilocarpine Gel 4% at bedtime OR,
3. Timolol eye drops AND,
4. Acetazolamide 250mg 3 times daily, orally
5. Mannitol 1.5-2mg/kg as 15-25% solution IV, over thirty minutes in the care of acute angle
glaucoma
6. Operations (trabeculectory) in the case of congenital glucomas, and chronic simple glucoma
5. IRITIS
This is an inflammation of the iris, ciliary body and choroids. Presentation is with reduced vision,
photophobia, pain, red eye. Findings: are flare, fear of torch light or slit lamp light, keratic precipitates (white
blood cell deposits on the corneal endothelium), adhesions of the iris on the lens (synechiae)
1 Refer all cases
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2. Apply eye pad
3. Refer
1. Administer steroid eye drops FML, predforte, spersadex or a combination with antibiotic,
maxitrol, spersadex comp.
2. Atropinise the involved eye with atropine to ease off adhesions of the iris from the lens
3. Give analgesics
4. Investigate in order to justify any need for systematic antibiotics. Include full blood count,
differential and ESR. Check serology as well and x-ray.
5. Keep the eye padded.
-Full and differential blood count; -ESR
-HIV; -blood sugars
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DIFFERENTIAL DIAGNOSIS OF A RED EYE AND TREATMENT
Acute Angle
Conjunctivitis Uveitis Corneal Ulcer Foreign Body
Glaucoma
Redness Diffuse Circum Corneal Circum Corneal Circum Corneal Circum Corneal
Discharge Watery/Purulent Nil Nil Watery/purulent Watery/purulent
Pupil Normal Mid-dilated Irregular Meiotic (small) Meiotic (small)
Normal Normal response Photophobia Slight Slight

Light
response to light Photophobia Photophobia
Pain Nil Present +++ Present +++ Present +++ Present +++
Visual Acuity Normal Abnormal (low) Abnormal (low) Abnormal (low) Abnormal (low)
Karatic Nil Nil Present +++ Nil Nil

Precipitates
(Endothelial
cell deposits)
Flare Nil Nil Present +++ Nil Nil
1) Decongestant 1) Pilocarpine 4% eye 1) Steroid eye 1)Broad 1) Removal of

eye drops for drops drops spectrum foreign body
viral conditions antibiotic and
and allergic 2)Glycerol p.o. 2) Mydriatic eye PAD 2) Eye ointment
conditions. Mannitol i.v drops (broad spectrum
Treatment 2) If viral refer to and PAD)
2) Antibiotic eye 3) Surgery by 3)Analgesic ophthalmologist
drops for Ophthalmologist 3) If difficult
Bacterial 4) Refer for refer to
purulent further Ophthalmologist
infection investigations
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CHAPTER 18
Skin Disorders
1. ECZEMA
Eczema is a pruritic papulovesicular dermatitis occurring as a reaction to many endogenous and exogenous
agents. It may be aggravated by the ingestion of certain foods, or due to perspiration, irritation by clothes or
by emotional stress.
The condition presents with a dry, papular, scaly rash with thickened skin at the wrists, elbow creases and
behind the knees. In infants the cheeks, scalp and neck may also be involved. Intense itchiness and
scratching occurs.
2. Avoid skin irritation (such as occurs when scratching) or excessive exposure to the sun
3. Avoid offending foods or other materials known to cause allergic reaction
4. Encourage personal hygiene
5. Saline swabs
2. Apply saline swabs
3. For Vesicular Lesions:
♣ Betamethazone ointment
♣ Chlorpheniramine 4 mg 3 times daily for 7 days
♣ Promethazine 10 mg 3 times daily for 7 days
4. For Chronic Dry Lesions
♣ Liquid paraffin PLUS/OR,
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♣ Mepyramine Cream
5. Oozing Lesions
♣ Calamine lotion
6. Infected Lesions
♣ Add Pen VK 500 mg 4 times daily for 7 days (Adults)
♣ Pen VK 125 mg -250 mg 4 times daily for 7 days (Children) OR
♣ Erythromycin 500 mg 4 times daily for 7 days (Adults)
♣ Erythromycin 125 mg -250 mg 4 times daily for 7 days (Children)
-Usually not useful; -RAST or skin test; -Full blood count
2 CONTACT DERMATITIS
This is an acute or chronic inflammation, produced when substances such as necklaces or metal compounds,
cosmetics, industrial agents etc. come into contact with the skin. It is characterized by sharply demarcated
skin rash in predisposed people.
It presents with an itchy, burning or stinging sensation in the affected areas. Early eruption may be red and
raised followed by rea, macules, papules or versicles or bullae.
1. Remove/avoid irritant
2. Saline swabs
1. Remove/avoid irritant
2. Administer cool compressions with saline water
3. Apply
♣ Calamine lotion OR
♣ Mepyramine cream AND
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♣ Betamethazone ointment if the condition is severe
4. Refer complicated cases or those that do not respond to treatment
1. Manage as above
2. For severe and extensive cases administer Prednisone 40 mg daily, then taper accordingly
-Usually laboratory investigation not useful
-RAST or skin test; -Blood sugar
3 DRUG REACTION
It is an acute or chronic inflammatory skin reaction to a drug. This is most commonly seen with penicillins
and sulphonamides but it can occur with various other drugs.
Typically there is development of itching followed by red raised wheals with a sharp border that may fade
after few hours. In the case of a very severe reaction with dyspnoea or collapse, wheezing or rhonchi may
occur.
1. In the case of a mild reaction withdrawal of the drug will, in a few hours, result in a cessation of
the allergic reaction
2. Stop all medicines if patient on drugs
3. Refer if the reaction is severe
1. Discontinue the offending drug
2. Give oral fluids
3. Note on the patient’s Bukana in red ink, the name of the drug that caused the reaction
4. Medications:
♣ Adrenaline 1:1 000 0.5 ml IM stat PLUS,
♣ Promethazine 12.5mg-25mg IM stat
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5. Refer severe cases
1. Manage as above
2. Treat as for Erythema multiforme/Stevens-Johnson Syndrome
-Usually laboratory investigation not useful
4 ERYTHEMA MULTIFORME/STEVEN’S-JOHNSON SYNDROME
This is inflammatory eruption characterized by systemic erythematous, edematous or bullous lesions of the
skin or mucus membranes. In over 50% of cases there is no cause found. In some cases drugs, x-ray therapy
and infectious causes are implicated. It should be remembered that almost any drug can cause erythema
multiforme e.g. penicillin, sulfonamide and barbiturates.
Stevens Johnson Syndrome: This is a severe form of erythema multiforme. It is characterised by the
development of bullae on the oral mucosa, pharynx, ano-genital region and the conjunctiva.
1. Frequent mouthwashes if the affected area is oral mucosa or pharynx
2. Analgesics
♣ Paracetamol 500 mg -1g 3 times daily for 7 days (adults)
♣ Paracetamol 125 mg -250 mg 3 times daily for 7 days (children)
3. Refer
1. Manage as above
2. Institute liquid diet and warm water mouth washes with 10% Sodium Bicarbonate Solution if
indicate
3. Analgesics
♣ Paracetamol 500 mg - 1g 3 times daily for 7 day (adults)
♣ Paracetamol 125 mg – 250 mg 3 times daily for 7 days (children)
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4. Promethazine 12.5 mg IM stat
5. Refer
1. Manage as above
2. Medication for severe cases
♣ Promethazine 5ml per day for 7 days (children)
♣ Promethazine 25mg 3 times daily for 7 days (adults)
♣ Prednisone 1 mg - 2mg/kg hourly for 7 days (children)
♣ Prednisone 40 mg – 60 mg daily for 7 days (adults)
♣ Hydrocortisone 100 mg – 200 mg iv 8 hourly for 2 days
♣ Amoxycillin 125 mg – 250 mg 8-hourly for 7 days (children)
♣ Amoxycillin 250 mg -500 mg 8-hourly for 7 days (adults)
♣ 10% sodium bicarbonate where indicated
-Full blood count; -Urea and electrolytes; -Blood sugar
5 ACNE
This is a chronic disorder of the pilosebaceous apparatus associated with an increase in sebum secretion. It is
characterized by the development of open comedones (blackheads), closed comedones (whiteheads), and
pustular nodules. The cause is unknown, but heredity and age are predisposing factors.
The lesions may present as blackheads, whiteheads pustules and tender red swellings on the face, chest, back
or shoulders. In severe cases scarring may be seen. They may be painful and itchy.
1. Encourage patient not to squeeze or scratch the lesions
2. Wash affected area two to three times daily
3. Avoid using oily creams
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4. Refer if severe
1. Manage as above
2. Doxycycline 100 mg 2 times daily for 14 days, then 2 times daily for 2 months PLUS,
3. Mepyramine Cream
4. Refer if severe
5.2.3 Hospital/Specialist level
NB Acne is normally managed outside hospital
♣ Manage as above
♣ Manage complications appropriately
-Full blood count; -Blood sugar; -Pus swab where indicated
6 BOILS
Boils are localized painful infections of the hair follicles. They usually occur in the hairy parts of the body.
Boils vary in size. They may present either as red papules or as large red macules. In both instances they are
tender. Although firm at first the lesions may become soft and develop a yellow centre that may open or
rupture spontaneously.
1. Wash with soap twice a day
2. Do not pinch or squeeze the lesions
3. Paracetamol 500mg-1g 3 times daily for 5 days
4. Refer
1. Manage as above
2. Check for and rule out conditions such as Diabetes Mellitus
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3. Medications:
♣ Pen VK 250mg-500mg 6-hourly for 7 days OR,
♣ Erythromycin 250mg-500mg 6-hourly for 7 days
♣ Paracetamol 500mg-1gm three times daily for 5 days
6.2.3 Hospital/Specialist level
N.B- Boils are mainly managed outside the hospital unless there are complications
-Manage as above
-Treat the complications accordingly
-Full blood count; -Blood sugar; -Pus swab
7 CELLULITIS, ERYSIPELAS AND IMPETIGO
Cellulitis is an infection of the skin and subcutaneous tissue. It may be preceded by skin infections such as
impetigo, folliculitis or erythema. Superficial or penetrating wounds have also been implicated as possible
causes.
1. Nutritional Education
2. Analgesics
♣ Paracetamol 500mg 1g 3 times daily for 7 days (adults)
♣ Paracetamol 125mg-250mg 3 times daily for 7 days (children)
3. Elevate affected part if possible
4. Refers
1. Manage as above
2. Medications:
♣ Pen VK 250mg-500mg 6-hourly for 7 days OR,
201
♣ Erythromycin 250mg 6-hourly for 7 days
♣ Paracetamol 500mg-1g 8-hourly for 7 days OR,
♣ Aspirin 300mg-600mg 8-hourly for 7 days
3. Refer if severe or if complications develop
1. Manage as above
2. Medications:
♣ Ampicillin 500mg IV 6 hourly for 7 days
♣ Cloxacillin 500mg I.V 6 hourly for 7 days
♣ Oral Erythromycin 500mg 4 times daily for 7 days
8. PSORIASIS
Psoraisis is a common genetically determined, chronic, inflammatory skin disease characterized by rounded
erythematous, dry, scaling patches.
The lesions have a predilection for nails, scalp, genitalia, extensor surfaces, and the lumbosacral region.
Accelerated epidermopoiesis is considered to be the fundamental pathologic feature in psoriasis.
The condition may be precipitated by local trauma, severe sunburn, irritation, the use of topical medication
etc. Complications associated with this condition include psoriatic arthritis, exfoliative psoriatic dermatitis and
pustular psoriasis.
1. Health Education
2. Daily warm baths
3. Refer new cases
1. Manage as above
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2. Betamethazone or other steroid creams and/or ointments
3. Refer if complications are present
8.2.3. Hospital Level nterventions
NB: The condition is normally managed outside hospital
-Full blood count; -Blood sugar; -Skin biopsy
9. PEDICULOSIS
Pediculosis is an infestation by lice. It affects the genital area (pediculosis pubis), the body (pediculosis
humanus corporis) or the head (pediculosis humanus capitis). The condition is commonly seen where there
is overcrowding or inadequate facilities for proper personal hygiene or clean clothing. It is important to note
that the body louse is a vector of the organisms that cause epidemic typhus, trench fever and relapsing fever.
9.1.1. Pediculosis capitis
This condition presents as severe itchy scalp with attendant excoriation. It may present with secondary
infection
9.1.2. Pediculosis corporis
The body louse commonly inhabits the seams of clothes. Lesions are found on the shoulders, buttocks and
abdomen.
9.1.3. Pediculosis pubis
These are usually transmitted during sexual intercourse. They present with itching on the ano-genital hairs.
The important sign of infestation is the scattering of louse excreta on the undergarment.
1. Educate on the need for proper personal hygiene
2. Encourage patient to wash with soap and water
3. Avoid sharing combs with other people
4. Wash all garments with hot water and dry in sun
5. Shave hairs
6. Refer
203
1. Treat the patient and all other household members
2. Shave hair
3. Bath and apply benzyl benzoate from the neck down. Repeat after 3 days
4. Wash all garments with hot water and dry in sun
NB: The condition usually managed outside hospital
1. Manage as above
2. Treat secondary infection with antibiotics
3. Pen VK 250mg-500mg 4 times daily
4. Erythromycine 250mg-500mg 4 times daily
-Full blood count; -Blood sugar; -Microscopy
10. SCABIES
Scabies is a contagious cutaneous inflammation caused by the bite of the mite SARCOPTES SCABIEI. It is
characterized by pruritic papular eruptions and burrows and affects primarily the axillae, elbows, wrists, and
genitalia, although it can spread to cover the entire body.
Scabies presents as marked pruritis that is most intense when the patient is in bed. The inflammatory skin
lesions occur predominantly on the finger webs, the flexor surface of the wrist, lower limbs and buttocks.
1. Advice on the need for frequent washing of clothes
2. Advice on the need for proper personal hygiene
1. Manage as above
2. Advice all household members to wash twice daily and apply benzyl benzoate Lotion
3. For Secondary Infection:
204
♣ Pen VK 250mg-500mg 6-hourly orally for 7 days OR,
♣ Erythromycin 250mg-500mg 6-hourly orally for 7 days
-Full blood count; -Blood sugar; -Swab for microscopy
CHAPTER 19
Neoplasms
1. TUMOURS
Neoplasms are abnormal tissue growths that affect various parts of the body. They may present as benign or
malignant tumours. The aim is to detect early malignant changes and manage accordingly. The common
malignancies are carcinoma of the breast, cervix, skin, oesophagus, prostate and lung.
1. Refer any abnormal swellings, growths or ulcerations early
1. Health Education regarding common malignancies and their presentation
2. Early detection
3. Refer
1. Re-emphasize early detection
2. Screen for malignancies
1.1.3.1. Carcinoma of the cervix:
1. Regular PAP smears
2. If PAP smear is positive, refer the patient
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1.1.3.2. Breast carcinoma:
1. Breast palpation to detect the presence/absence of tumours
2. Excise and send tumour for histology
3. If malignancy is confirmed, then refer
1.1.3.3. Carcinoma of the prostrate
1. Regular PR examination in elderly males
2. Prostate specific antigen( PSA) levels for suspect cases
3. Refer if PSA is over 5ng/ml
1.1.3.4. Carcinoma of the bronchus
1. Chest X-ray for all patients presenting with haemoptysis
2. Refer all suspicious cases
1.1.3.5. Carcinoma of the oesophagus
1. Refer all patients experiencing difficulty in swallowing
1.1.3.6. Hepatoma
-PAP smear; -Prostrate specific antigen(PSA); -X-Ray
-Bronchoscopy; -Gastroscopy; -Barium swallow
-CT scan; -Biopsy
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CHAPTER 20
Tr a u m a
1. LACERATIONS , WOUNDS AND FRACTURES
Wounds caused by mechanical agents, chemical agents, human and animal bites are commonly seen in various
health institutions. Wounds may be superficial or deep. Some may be associated with broken bones.
There is usually a history of injury to the site affected. The patient presents with pain around the area of
injury and there may be associated bleeding.
If bleeding is present, apply pressure (see community health workers manuals)
Splint any suspected long bone fractures
Check for other injuries
If suturing is required, dress the wound and refer without delay
1. Clean and debride wound
2. Suture if the wound is less than 6 hours old and there are no complications except for:
♣ Gunshot wound
♣ Compound fracture
♣ Dog or
♣ Human bite
Paracetamol 500 mg – 1 g 3 times daily
3. Refer all dog or human bite and gunshot wounds
207
1. Clean and debride wound
2. Suture if the wound is fresh
3. If infected, do secondary suturing after infection has been controlled. In the meantime do daily
dressing
4. Manage shock if patient is in shock
5. Give antibiotics if infection is present
♣ Amoxycillin 500 mg -1 gm 3 times daily for 7 days OR
♣ Erythromycine 500 mg 3 times daily for 7 days OR
♣ Chloramphenicol 500 mg 4 times daily for 7 days
6. For Human Bite
♣ Clean thoroughly and dress DO NOT suture
♣ Amoxycillin 500 mg 3 times daily for 7 days OR
♣ Chloramphenicol 500 mg 4 times daily for 7 days PLUS
♣ Metronidazole 400 mg 3 times daily for 7 days
♣ Analgesics for pain control as above
♣ Tetanus prophylaxis if available
♣ Secondary suturing after infection has cleared if indicated
7. Other Animal Bites
♣ Clean thoroughly and do not suture
♣ Antibiotic therapy as above
♣ Dress daily until healed
-Full blood count; -X-ray; -Blood sugar
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2. MAJOR TRAUMA
Major trauma is associated with fractures, multiple lacerations and other major injuries. Major trauma may
occur as a result of motor vehicle accidents or fights. The aim in handling major trauma is to look for life-
threatening complications which if missed may endanger the patient’s life.
There is usually a history of trauma or accident. If the patient is conscious he/she may complain of pain at
specific places on his/her body. Some patients may present with confusion, some semi-conscious and others
may be in coma and/or shock.
1. Clear airway
2. Minimise bleeding and dress wounds
3. Assess cardiac function
4. Administer analgesics for pain control
♣ Paracetamol 500 mg – 1 g 3 times daily for 7 days
5. Splint long bone fractures
6. If unconscious put in coma position and protect the spine.
7. Refer
1. Manage as above
2. Catheterise bladder in unconscious patient.
3. Set up IV line normal saline or ringer’s lactate
4. Do not feed patient
5. If there are open wounds clean and dress and give IV ampicillin 500 mg 6 hourly or
chloramphenicol 500 mg 6 hourly
6. Refer
1. Manage as above
2. Search systematically for any signs of major injury such as:
209
♣ Head injury
♣ Eye injury
♣ Dental trauma
♣ Fractured spine
♣ Chest injuries
♣ Internal Abdominal injuries
3. Manage accordingly
4. Refer if specialist intervention is required
-Cross match; -X-ray; -CT scan
3. ACUTE ABDOMINAL-TRAUMA
Studies have shown that trauma alone constitutes about 4.2% of all casualty cases seen at Queen Elizabeth II
Hospital. It represents a significant cause of morbidity and mortality at this Hospital and in the country. Many
of the patients who presents with trauma have trauma to the abdomen. These guidelines are intended to help
with the management of the condition at all levels. Acute abdominal trauma may be divided into blunt and
penetrating, trauma to abdomen.
Acute abdomen trauma has to be suspected and ruled out in all patients who present with trauma. The signs
of acute abdominal trauma include movement of abdomen, distension, guarding, tenderness and rebound
tenderness. It is important to note that all the signs may be present. Depending on the severity the patient
may be distressed with pallor and tachycardia. There may be bruising or/and tenderness over the kidneys,
spleen and liver areas. There may be associated injuries such as pelvic fracture or rib fracture
At all levels obtain as accurate as possible history from the patient or who ever is accompanying the patient if
he/she is a child or is unconscious.
A. Blunt Abdominal Trauma
Refer immediately
3.2.2 Health center interventions
210
Detailed history about the mechanism of injury (i.e how did it happen, when, any vomiting). Then or later
nature of vomitus, find if flatus or stool has been passed since the injury, nature of urine passed, location and
radiation of pain
1. Check vital signs and record them (i.e blood pressure, pulse, temperature and respiration)
2. Note the general conditions such as pallor, dehydration and distress
3. Put up IV line of normal saline/or ringer’s lactate with a large bore needle
4. Refer at once
3.2.3 Hospital level intervention/filter clinic
1. Note detailed history as above
2. Examine the patient completely with particular reference to other injuries, hand injury,
neck/spine injury and limb injuries. Look for “tell tale” bruising on abdomen, back or renal
angle.
3. If acute abdomen-trauma suspected
♣ Give nothing by mouth
♣ Set up IV line with Ringer’s Lactate/or Normal Saline with a wide bore needle (i.e not less than
18G).
NB If at filter Clinic transport as comfortably as possible to the nearest hospital.
4. If patient unconscious assume cervical injury until proven otherwise
5. Move patient carefully and apply rigid cervical collar (improvise one).
6. If the patient is in shock resuscitate
N.B. Do not transport an inadequately resuscitated patient and ensure that the patient is
accompanied by a nurse with a running IV line.
7. Start appropriate antibiotics if perforation of bowel, bladder rupture or renal injury is

suspected e.g. small bowel perforation.
♣ Ampicillin 500mg-1g IV 6 hourly OR
♣ Gentamycin 80 mg IV 8hourly PLUS
♣ Metronidazole 500mg IV 8 hourly PLUS
♣ Cefotaxime 1gm IV 12 hourly for 7 days
-Urinary Tract Injury:
211
♣ Ampicillin 500mg-1g IV 6 hourly PLUS
♣ Gentamycin 80mg 8 hourly IV for 7 days
8. Give oxygen (N.B oxygen is a therapeutic modality and will benefit patient with shock,
peritonitis and head injury.)
9. Refer
B. Penetrating Abdomen trauma
(e.g. Stab wound by knife or other instruments; Gunshot wound)
3.2.1 (1) Community Level
Refer immediately
3.2.2 (2) Health Centre intervention
1. Detailed history
2. Check and record vital sign
4. If transport journey to nearest hospital more than 2 hours give analgesic
♣ Paracetamol 500 mg -1g STAT
♣ Diclofenac 75 mg IM STAT
N.B As above avoid narcotic analgesic for patient with suspected head injury.
5. Insert an IV line of Ringer’s lactate or Normal saline with a wide bore needle.
7. Clean if gunshot wound thoroughly with saline and dress prior to transport
8. Stab wound may be cleaned and closed if the clinic has the capacity or else just clean and
dress
9. Herniated bowel must be covered with sterile (if possible) or clean abdominal swabs.
10. Refer
3.1.3 (3) Hospital Level Intervention
1. History and examination as above
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3. Stab wound:
♣ Insert IV line Ringer’s lactate or Normal saline
♣ Under local anaesthesia- clean and excise edge and close.
♣ Stab wound with bowel hermiation-examine it and close any perforation you see with 2.0G
or vicryl.
♣ Reduce bowel into abdomen even if you have to increase the stab wound and close skin only
♣ Give analgesic
-Diclofenac 75 mg IM, STAT
♣ (Avoid narcotics in suspected head injury)
♣ Refer without delay.
4. Gunshot wound
♣ Clean and dress wounds
♣ NB Do not suture
5. If bowel is hemiated out manage as above
6. Administer analgesics:
-Diclofenac 75 mg IM, STAT
7. Insert a nasogastric tube
8. Catheterise patient
10. Give antibiotic as above
11. Refer
-Full blood count; -Blood x-match; -Blood sugar
213
N.B Queen Elizabeth II Hospital Casualty Doctor to inform doctor covering surgery or consultant directly if
patient critical {Patient is under care of casualty officer until surgical doctor is available to see patient}.
4. HEAD INJURY
Definition: Any episode of trauma to the head. We will exclude maxillo-facial injuries and eye injuries from
this discussion.
Epidemiology: In Lesotho trauma of all kinds accounts for about 40% of all casualty patients, and is therefore
the single highest cause of emergency admissions. 1998 to QEII (It may now be superceded by HIV – related
illness). Every doctor working in a hospital in this country must of necessity therefore have a clear idea how
to manage all kinds of physical trauma. 2 main causes of head injuries are:
Assault - usually with sticks or knobkiere
Road traffic accidents
Head injury may be associated with ophthalmic ENT and dental injuries which are discussed in appropriate
sections (see appropriate paragraphs).
It is classified into two: 1. Involving scalp only; 2. Traumatic brain injury
Mild head injury
-80% of cases
-Glasgow coma scale 13-14
-Involves a “brief” period of loss of consciousness
-Good progress with minimal or no long term sequelae
4.1.2 Moderate Head Injury
- Glasgow coma scale 9-12
-Confused patient with focal neurological deficits but able to follow simple commands
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-Good prognosis
-Some mild long-term sequelae
4.1.3 Severe head injury
- Glasgow coma scale <8 (This is the definition of coma)
-Unable to follow commands initially
- Significant long-term disability
4.2. CLINICAL GUIDELINES
4.2.1. Community level Interventions
1. Clean and dress any wound
2. If unconscious, ensure airway is patent
3. Keep patient warm
4. Put in coma position
5. Prevent spinal injury
4.2.2. Health Centre Interventions
1. Take full history from patient, relatives or whoever has brought patient where indicated
2. Clean and suture wound as appropriate
4. Inset IV line Normal saline or Ringer’s lactate
5. Catheterise
6. Refer
215
1. History as above
2. Examine patient thoroughly and note level of consciousness
USE GLASGOW COMA SCALE
MOTOR
SCORE SCORE VERBAL SCORE EYE
RESPONSE
obeys verbal Oriented and Eye open

6 command 5 Converses 4 spontaneously
command
Localises painful Disoriented and Eye open to verbal

5 4 3
stimulus converses command
Flexes limb to Inappraite words Eye open to pain

4 3 3
painful stimulars
Abnormal flexion Inappropriate sound Eye open to pain

3 2 2
painful stimulare
. Extension to No response
2 painful 1
stimulus
1 No response
3. Clean and suture wound as appropriate
4. Manage as above
5. Refer if indicated especially moderate and severe head injury
Key Investigations
216
-Full blood count; -Blood sugar; -X-ray
-CT scan; -Urea and electrolytes
5. COLD INJURIES
Cold injury is defined as injury by cold causing structural and functional disturbances of small blood vessels,
cells, nerves and skin or a generalized lowering of body temperature. Hypothermia occurs when the body
cannot maintain normal temperature. Inadequate clothing, substance abuse or debility may enhance this. The
falling core temperature leads to lethargy, clumsiness, mental confusion, irritability and hallucination followed
by slow respiration and slow irregular heartbeat. Frostbite on the other hand is limited to an exposed area that
becomes hard, white and anaesthetic. On warming the area becomes red, swollen and painful.
There is usually a history of exposure to extremes of cold. Physical examination reveals low temperature, very
slow pulse rate and slow respiration.
5. Wrap patient up in warm blankets
6. Move to a warm environment
7. Clean and dress frostbites or cold injured areas
8. Refer
1. Manage as above
2. Place in warm room
3. monitor vital signs for 4 hours
4. Give warm drinks if patient is conscious and can swallow and vital sign s are stable in 4 hours
5. Relieve pain
♣ Paracetamol 500 mg -1g 3 times daily.
6. Refer if vital signs are abnormal
1. Keep patient warm
217
3. Manage as indicated
5.3 Key investigations: None
6 BURNS
Burns are defined as skin and tissue damage caused by fire, hot liquid, chemical agents, electrical current or
hot metallic or non-metallic objects. They may be superficial or deep. The early sequelae of severe burn
injuries are hypovolaemia and shock due to loss of water, plasma, third space losses and destruction of the
red cells.
6.1.1 Superficial burns
These are painful first-degree burns with dry minor blisters and erythema. There also may be an associated
painful loss of epidermis.
6.1.2 Deep burns
These are characterised by a complete loss of skin. They are painless, dry, charred and whitish third-degree
burns
1. Leave blisters intact
2. Put burnt area under cold water tap soon after they happen if they are due to hot liquids or
steam
3. Refer
1. Remove clothing and gently clean the wound with water
2. Remove loose skin and debride dead tissue
3. Assess the extent of the burns
4. Minor Burns:
♣ Leave blisters intact
♣ Puncture with sterile needle and keep blister skin intact
♣ Apply 1% Silver Sulphadiazine for all burns or furacin or paraffin gauze for full-thickness
burns
5. Refer all major burns
218
1. Gently clean the burns and remove loose skin and debride dead tissue
2. Full-thickness Burns:
♣ Cover facial burns with 1% Silver sulphadiazine
♣ All other burns cover with 1% silver sulphadiazine or paraffin gauze
♣ Change dressings daily
3. If Patient is in Shock
♣ Fluid resuscitation with Ringer’s Lactate
♣ Record and monitor fluid input and output
♣ Calculate/estimate daily protein and energy needs and support accordingly
♣ Administer systemic antibiotics on the basis of culture and sensitivity (C&S)
♣ Analgesics for pain control (Paracetamol if pain mild-moderate; pethidine if severe)
♣ For circumferential 3˚ burns fasciotomy is indicated
4. Refer if burns are extensive

-Full blood count; -Urea and Electrolytes
-Blood, urine and wound cultures; -Blood sugar
5.4 Comment
All burns involving the hand, face, eye, ear, feet, perineum, or neonates must be referred. Major burns,
electrical and chemical injuries as well as inhalation injuries where possible should be referred to specialist
hospital.
7. RETENTION OF URINE
This is mainly an adult male problem. It only rarely occurs in children and female patients.
In middle-aged and elderly patients, the most common cause is enlargement of prostate which is a
physiological change in men.
In young adult and also in middle aged person this is due to stricture of urethra which is commonly due to
STD infection and sometimes due to trauma
219
1. Suprapubic pain which can be agonizing
2. Inability to pass urine or dribbling of urine from distended bladder
3. Palpable mass bladder above the pubic bone
4. Enlarged prostate by rectal examination
5. Patient may present with pus discharging sinus in the perineum which is certainly due to
stricture of the urethra
7.2. CLINICAL GUIDELINES
7.2.1. Community and health center level intervention
1. Ask the patient to relax do not force and pass urine standing while a water tap is opened for
running water. This running water sound sometimes assist them to pass urine
2. A hot bath also sometimes help the patient to pass urine
3. If no progress refer to the district hospital
7.2.2 Hospital interventions
1. Try the above methods again
2. If not successful catheterise the patient with 18 or 20 G foley catheter. In most of the cases
with prostate hyprotrophy it is successful.
3. If not successful try to pass a rigid feeding tube of size 12f
4. If patient has perineal sinus do not attempt to catheterise
5. If all procedure are unsuccessful the patient will need suprapubic cystostomy
6. In distended bladder it is an easy procedure and all district medical officer should be familiar
with this
7. If doctor is not familiar with suprapubic cystotomy then he/she should relieve distention of
bladder by suprapubic puncture by 14-16 G canulae and transfer the patient
8. Refer all cases with prostate enlargement, malignant, urethral stricture
220
-Prostate specific antigen; -X-ray
1. GUIDELINES FOR REFERRAL OF A PATIENT WITH ACUTE ABDOMEN
Defination:- In case of blunt or penetrating abdominal injuiry- trauma management guideline

should be followed, as the first step.
-The referring doctor should take detailed history from the patient or relatives in
case of infants and patient with mental comfusion/coma from any cause.
Histrory of intake of traditional medicine, operation,recent trauma or
haemorrhage must be sought and documented.
-The referring doctor must perform a through clinical examination which should
always include a rectal examination and note down his findings in detail.
-Two peripheral I.V line should be secured with wide bore( not less than 18G in
adult) cannulae and Ringer’s Lactate or Normal Saline solution drips be infused;
but with great caution in infants, children or elderly patients where over
hydration carries grave consequences
-A wide bore naso-gastric tube must be inserted and attached to a drainage bag
to drain freely.
-The patient must be catheterized (in the absence of urethral trauma) for
accurate measurement or urinary output( at hospital only).
-The following investigations must be done and result recorded in the referral
note:
♣ HB
♣ PCV
♣ WBC
♣ Urea and electrolytes
♣ Random blood glucose
♣ Serum amylase and L.F.Ts( may be indicated in individual)
♣ Urinalysis (microscopy,glycosuria, protienuria )
-The following radiograph must be taken at the reffering hospital:
221
♣ Chest radiograph ( erect PA film)
♣ Scout abdominal film(erect and supine)
♣ If the patient is unable to sit up, a lateral decubitus instead of erect is

satisfactory
-An experienced nurse,who should at least ensure the patency of IV line and
management of IV fluid on the way,must accompany the referred patient.
-The patient should be referred to the Casualty Department and NOT to the
Surgical Out Patient Department of Queen Elizabeth II Hospital Maseru.
2. CASUALTY PROTOCOL FOR COMPOUND (OPEN) FRACTURE.
Assess the WHOLE patient and give priority to head injury and spine injury. Set into
resuscitation before going for the fracture
Always do the following:
♣ Check the distal blood supply. Use nail bed capillary refilling to assess.
Remove all encircling rings and other ornaments worn on an injuiry limb.
♣ Assess the size of the wound and look for exposed bone. Classify into;less
than 5cm and greater than 5cm.
♣ Suture clean puncture wound and clean wound of about 2cm after cleaning
and irrigating Suture loosely, you do not need tight skin closure. A few suture
will do. Then apply a POP BACKSLAB not full plaster.
♣ Severe wound with exposed bone should be thoroughly irrigates with AT

LEAST 2 LITRES of Normal Saline or sterile/boiling water. Scrub with
gauze while irrigating.
♣ Leave the wound open, dress with sterile gauze, add orthopaedic wool
padding and bandage on the backs
♣ lab.
♣ Admit the patient, start intravenous( give adult cloxacillin 500 IV 6 hourly a s
a stat dose at casualty) and make sure the limb is elevated.
♣ Always inform the surgeon on call about any compound fracture with a
wound greater than 5cm+ exposed bone( i.e any type II fracture with
contamination and ALL type III wound)
NEVER do following:
♣ Suture gunshot wound
222
♣ Suture a wound that has not been irrigated
♣ Apply a full POP to fresh compound fracture
♣ Use tap water to irrigate a wound, unless boiling first and cooled.
Solution of preference is Normal Saline.
♣ Send the patient to the ward without a plaster support. Fractures

are VERY painful.
♣ If you are in any doubt, PLEASE ASK SOMEONE Department

of Surgery, QE II Hospital
3. CASUALTY PROTOCOL FOR COMPOUND (OPEN) FRACTURES
Trauma continue to form the bulk of casualty work and ultimate outcome with these patients
depends on how well the 1st contact care is carried out. This is the casualty.
Proper initial management of a compound fracture determines if the patient will go home soon, lose
the limb or live with year of osteomyelitis. You as the casualty doctor who receives the patient are
just as important as the surgeon who finally manages the patient
A compound fracture is any fracture with an overlying wound in which there is a communication between the
fracture site and the outside, A gunshot wound with a fracture is a compound fracture.
They are classifield as follow:
• Type I-The wound is less than 2cm long and is relatively clean.
• Type II-The wound is 2-5cm long and fairly contaminated with soil,
grass,clothing, car paint, and e.t.c
• Type III-The wound is greater than 5cm, bone is exposed,severely

soiled with soft tissue damage. There may be vascular or/and nerve
injuiry.
This classification determines the management
A. BLOOD GIVING SET 10 DROPS/ML (ADULT)
TO GIVE SET COUNT IN

DROPS/MIN
223
1 Llitre/4hrs 250/hr 40 drops/min
1 litre/6hrs 100mls/hr 27 drops/min
1 litre/8hrs 125mls/hr 20 drop/min
B. SOLUTION GIVING SET 15 DROPs/MIN
TO GIVE SET COUNT IN DROPS/MIN
1L/4hrs 60 drops/min
PAEDS
BLOOD GIVING SET 60 DROPS/min
TO GIVE SET COUNT DROPs/Min
150mls/kg/24hrs
Eg 3kg=450mls/24hrs=18.7 or 19mls/hrs
224
CHAPTER 21
Medical and Surgical Emergencies
1. CARDIAC ARREST
Cardiac arrest is defined as sudden loss of consciousness with absent femoral or carotid pulses. The
commonest cause is ventricular fibrillation.
2. Thump the sternum firmly
3. Clear the airway
4. Start ventilation and chest massage
5. Defibrillate if a defibrillator is available; start with 200 Joules
6. Attach to ECG monitor if one is available
7. Administer oxygen
1.1.1 Ventricular Fibrillation/Tachycardia with no Pulse (if no response after 400 Joules)
2. Adrenaline 1mg IV in 10 units of 1:10 000 solution/ml??
3. Counter shock if there is still no response
4. Lignocaine 100mg as an IV bolus (10ml of 1% solution)
5. Sodium Bicarbonate 50mmol IV over 10 minutes (i.e., 50 ml of 8.4% solution)
1.1.2 Asystole
2. Adrenaline 1mg IV followed by atropine 1 mg IV
3. Sodium Bicarbonate as above
225
4. Pacing if available
226
1.1.3 Bradycardia
1. Administer Atropine 1 mg IV and repeat as required
2. Start Isoprenaline IV infusion 2-20mg in dextrose 5% solution or in Normal Saline solution
3. Pacing if available
1.1.4 Electromechanical Dissociation
2. Adrenaline 1 mg IV and repeat as required
3. Calcium Chloride 10ml of 10% solution over 5 minutes
4. Sodium Bicarbonate 50mmol IV over 10 minutes
1.15.1 Rule Out the Following
2. Tension Pneumothorax
3. Cardiac Tamponade
4. Severe Hypoxia
5. Hypovolaemia from massive haemorrhage
6. Severe acidosis
-ECG
-ECG Monitor
2. ANAPHYLACTIC SHOCK
This is shock due to an acute hypersensitivity reaction secondary to exposure to a previously encountered
antigen. The reaction may include rapidly progressing urticaria, respiratory distress, vascular collapse, systemic
shock, and death.
1. Adrenaline 0.5-1mg IV or IM stat PLUS,
2. Hydrocortisone 200mg IV STAT
3. Chlorpheniramine 10mg IM over 1 minute and repeat 8-hourly if necessary
4. If systemic BP is less than 90mmHg, start up a drip and administer an infusion of colloid
227
3. SHOCK
Shock is a state of circulatory collapse that leads to reduction in delivery of oxygen and other nutrients to vital
organs which if prolonged leads to irreversible multiple organ failure. This is caused by excessive
haemorrhage or fluid loss or acute myocardial infarction.
3.1.1 Hypovolaemic Shock
1. Insert large line cannula and give IV fluids quickly
2. Ringer’s Lactate or Sodium Chloride 0.9% (if colloid is available, it can also be given in order to
raise blood pressure quickly)
3. Give oxygen via nasal line or via face mask
4. Insert urine cather in order to monitor fluid output
5. Record and monitor blood pressure and pulse
3.2 key investigations
-ECG; -ECG monitor
CHAPTER 22
Poisoning
1. POISONING
Poisoning whether accidental or intentional is a common problem.. It is often seen in the family setting
following family quarrel.
228
1.1. ORGANOPHOSPHATE POISONING
Ingestion of organophosphate insecticides or rat poisoning is common. The major problem is the inhibition
of cholinesterase enzyme in the body, which results in accumulation of acetylcholine in the muscarinic and
nicotinic synapses. The major complications are respiratory failure, cardiac arrhythmia or coma.
1.1.1. DIAGNOSTIC CRITERIA
Following ingestion one presents with miosis, blurred vision, bradycardia or bronchospasm. There is often
increased bronchial secretion, lacrimation, salivation or sweating. Emesis and hypoglycaemia may occur. The
muscles are weak with fasciculation and cramps. Hypertension or ventricular tachyarrhythmia may occur.
There may be central nervous system effects such as headache, dizziness, restlessness, confusion, seizures or
coma.
1.1.2. TREATMENT GUIDELINES
1. Emergency admission to hospital or specialised centre
2. Frequent suction of secretions
3. Gastric lavage
4. Administer activated charcoal – 300gm
5. Monitor and record vital signs (include pupil size and level of consciousness)
6. Atropine IV (to combat muscarinic effects) and/or Obidoxime to combat cholinesterase

effects
7. Lignocaine IV for Ventricular Tachyarrhythmia
8. Refer to Intensive Care if respiratory and cardiac manifestations are severe
2. PARAFFIN POISONING
A common accidental occurrence in children
2.1.1. DIAGNOSTIC CRITERIA
There is history of paraffin ingestion with paraffin odour. One may later develop fever, nasal flaring with
intercostal retraction and dyspnea coarse crepitations are present. There may be evidence of pulmonary
oedema, bronchopneumonia or atelectasis.
2.1.2. TREATMENT GUIDELINES
1. Admit child and monitor and record vital signs
2. Oxygen if indicated
3. Do not empty stomach
4. Watch for complications such as respiratory failure, pneumonitis or secondary bacterial

infection
229
5. For severe and prolonged respiratory symptoms, cover with antibiotics
3. PARACETAMOL POISONING
Paracetamol ingested in large quantity is highly toxic. It can damage the liver.
Stages of Paracetamol Toxicity have been noted:
1. Stage 1: Presents with anorexia, nausea, vomiting, abdominal cramps, pallor and sweating
2. Stage 2: This is marked by pain in the right upper quadrant due to liver damage
3. Stage 3: There is a peak in liver function enzyme abnormalities secondary to extensive liver
damage
4. Stage 4: There is resolution of liver damage with clinical damage
1. Admit and do gastric lavage
2. Monitor liver function tests
3. Administer Acetylcysteine IV if available
4. SPECIFC POISONS TREATMENT GUIDELINES
4.1. BARBITURATES
The patient presents with headache, confusion, ptosis, excitement, delirium, loss of corneal reflex, respiratory
failure, and coma.
1. Empty stomach up to 24 hours after ingestion of the barbiturates
2. Ipecac emetic (in the period immediately after barbiturate ingestion) OR,
3. Gastric lavage
4. Activated charcoal
5. Oxygen
6. Insert IV Line
7. Support Respiration where indicated
8. Good nursing care
230
4.2. BENZODIAZEPINES
Here the patient usually presents with sedation or coma
1. Ipecac Emesis
2. Gastric lavage
3. Supportive Care
4.3. CARBON MONOXIDE POISONING
This condition presents with headache, vertigo, dyspnoea, confusion, dilated pupils, convulsion, and coma
1. Oxygen 100% by mask
2. Absolute bed rest
3. Support respiration when indicated
4. Watch for cardiac and central nervous system (CNS) complications
4.4. NARCOTICS
May present with pinpoint pupils, drowsiness, shallow respiration, spasticity or respiratory failure
1. No emetics should be given
2. Gastric lavage
3. Administer Naloxone 2-20mg
4. Administer oxygen
5. Respiratory support
6. Insert IV line to support circulation
4.5. ETHANOL POISONING
May present with emotional lability impaired coordination, flushing, nausea and
vomiting, stupor to coma, respiratory depression.
1. Ipecac emesis
2. Gastric lavage
3. IV glucose infusion to prevent hypoglycaemia
5. I.V. Thiamine 100mg
231
4.6. TOBACCO POISONING
Patient presents with excitement, confusion, muscular twitching, weakness, abdominal cramps, clonic
convulsions, depression, rapid respiration, palpitations, collapse, coma paralysis, respiratory failure.
1. Ipecac emesis
2. Gastric lavage and activated charcoal
3. Oxygen
4. Diazepam to control convulsions
5. Supportive care
232
CHAPTER 23
L a b o r a t o r y Te s t s a n d I n v e s t i g a t i o n s
1. INVESTIGATIONS AND LABORATORY TESTS
1.1. HAEMATOLOGY
TEST NORMAL RANGE
Red Cell count 4.5 x 109/L

Haemoglobin 13.0 – 18.0 gm/dl
Haematocrit 0.40 – 0.50/l
Mean Corpuscular Volume (MCV) 81 – 100fl
Mean Corpuscular Haemoglobin (MCH) 28 –35 pg
Mean Corpuscular Haemoglobin Concentration 16 –32 gm/dl
(MCHC)
White Cell Count 4.0 x 109/L
Neutrophils 2.0 – 7.5 x 109/L
Lymphocytes 1.0 – 4.0 x 109/L
Monocytes 0.0 – 0.95 x 109/L
Eosinophils 0.0 – 0.4 x 109/L
Basophils 0.0 – 0.1 x 109/L
Platelets 140 – 420 x 109/L
Partial Thromboplastin Time (PTT) 25-35 seconds
Prothrombin Time (PT) 11-15 seconds
Thrombin Time 24-35 seconds
International Normalised Ration (INR)
Blood Group + Rhesus
Erythrocyte Sedimentation Rate (ESR) 0-10mml/L
Plasma Viscosity 1.5 –1.72 mpas
233
1.2. CHEMISTRY
TEST NORMAL RANGE
Creatinine 80 – 130 micro-mol/L

Urea 2.5 – 6.7 micro-mol/L
Sodium 136 – 144mmol/L
Potassium 3.5 – 5.5mmol/L
Uric Acid
Calcium 2.1 – 2.6mmol/L
Phosphate 0.8 – 1.45mmol/L
Blood Glucose-Fasting
Blood Glucose-Random
Glycosylated Haemoglobin
Triglycerides 0.3-2.3mmol/L
Cholesterol 3.5-5.4mmol/L
HDL Cholesterol 1.0-2.7mmol/L
LDL Cholesterol 1.0-3.3mmol/L
Lactic Dehydrogenase 270-510mmol/L
Total Creatinine Kinase 15-195mmol/L
Creatinine Kinase MB 0-25mmol/L
Alkaline Phosphatase 40-120mmol/L
Aminotransferase-Alanine 10-40mmol/L
Arspatate (AST) 10-40mmol/L
Gamma Glutaryl Transpeptidase (GGT) 5-50mmol/L
Total Bilirubin 2-20 micro-mol/L
Conjugated Bilirubin 0.8 micro-mol/L
Unconjugated Bilirubin 60-80 micro-mol/L
Total Protein 60-80gm/L
Albumin 37-52gm/L
Albumin: Globulin Ratio 0.9-2.7
Amylase 20-110 micro-mol/L
234
1.3. SEROLOGY
♣ Rheumatoid Factor
♣ Anti-Streptolysin-O Titre: 0-200lu/ml
1.4. VIRAL TITRES
TEST NORMAL RANGE
Hepatitis-B Surface Antigen

HIV
Total T Cells 940-2380cmm
CD4 Counts 510-1320cmm
CD4: CD8 Ratio 0.85-3.13
1.5. ENDOCRINE TESTS
TEST NORMAL RANGE
Free Thyroxine (T4) 10-25mmol/L

Triiodothyronine (T3) 3.5-6.5mmol/L
Thyroid Stimulating Hormone (TSH) 0.35 – 5.5 Hiu/L
Follicle Stimuating Hormone (FSH) Varies by cycle
Leutenizing Hormone (LH) Varies by cycle
Progesterone
Oestrogen
Human Chorionic Gonadotropin (HCG)
1.6. TUMOURS
TEST NORMAL RANGE

α-Fetoprotein (AFP)
Prostrate Specific Antigen (PSA)
Acid Phosphatase
235
1.7. MICROBIOLOGY
TEST NORMAL RANGE
Urine Mid-stream Culture and Sensitivity (MCS)

Faeces Culture and Sensitivity
Blood Culture
Pus Swab
Cerebrospinal Fluid Culture and Sensitivity
Stool for Ova and Cysts
Stool for Occult Blood
1.8. OTHER TESTS
TEST NORMAL RANGE
Sperm Count and Motility

Urine Creatinine Clearance/24 hours
Urine-24 Hour Protein clearance
Urine-24 Hour Cortisol Clearance
Urine-VMA Levels in 24 Hours
Widal Test-O Titre
Widal Test-H Titre
Vitamin B-12
Folate
Radiology and Sonar
Ordinary X-rays
Ultrasound-Gynae
Ultrasound-General
Proctoscopy
CT-Scan
Heart Sonar
Gastroscopy
Bronchoscopy
ECG
PAP-Smear
Mammography
Histopathology
236
LESOTHO
ESSENTIAL
MEDICINES
LIST
237
Level Description Dosage form(s)
of care
1. ANAESTHETICS
1.1................................................................................................... General anaesthetics
A Enflurane Solution
A Halothane Inhalation
A Ketamine Injection, 50mg, HCl
A Nitrous oxide Inhalation
B Oxygen Inhalation
Local anaesthetics
B Lignocaine Injection, 1%, 2%, HCl
A Lidocaine + epinephrine Injection 1%, 2% (hydrochloride) +

epinephrine 1:200,000 in vial; dental cartridge 2%
(hydrochloride) + epinephrine 1:80,000
2. ANALGESICS, ANTIPYRETICS, NON-STEROIDAL ANTI-INFLAMMATORY

MEDICINES, MEDICINES USED TO TREAT GOUT
B Acetylsalicylic acid Tablets, 300mg
B Allopurinol Tablet, 100mg
A Colchicine Tablets, 500mcg
A Diamorphine plus
A Diclofenac Tablet, 25mg, 50mg; injection 75mg/3ml
B Ibuprofen Tablets, 200mg, 400mg
A Indomethacin Capsules, 25mg; suppositories 100mg
Morphine Tablets, 10mg Injection, 10mg in 1ml

ampoule (sulphate or hydrochloride)
C Paracetamol Tablets, 500mg Syrup 125mg/ml
A Pethidine Injection, 50mg/ml 100mg/2ml
238
3. ANTIALLERGICS AND MEDICINES USED IN ANAPHYLAXIS
C Calamine Lotion 5%
B Chlorpheniramine Tablets, 4mg (hydrogen maleate); injection, 10mg

(hydrogen maleate) in 1-ml ampoule
A Dexamethasone Injection, 4mg dexamethasone phosphate
B Liquid paraffin Liquid
A Mepyramine Tablet, 100mg
B Promethazine Tablet, 10mg, 25mg (hydrochloride);

elixir or syrup, 5mg (hydrochloride)/5ml;
injection, 25mg (hydrochloride)/ml in 2-ml
ampoule
4. ANTIDOTES
A Acetyl cysteine Injection, 200 mg/ml in 10ml ampoule
B Atropine Injection, 1mg (sulphate) in 1ml ampoule
A Calcium gluconate Injection, 100mg/ml in 10-ml ampoule
C Charcoal, activated Powder, tablet
B Naloxone Injection, 400mcg (hydrochloride) in 1 ml

ampoule
A Obidoxine chloride Injection, 250mg/ml
5. ANTICONVULSANTS/ANTIEPILEPTICS
A Carbamazepine Tablet, scored, 100mg, 200mg
A Chlormethiazole Capsule, 25mg
A Chlorpromazine Tablets, 25mg, 100mg; injection 50mg/2ml
B Diazepam Injection, 5mg/ml in 2-ml ampoule
A Haloperidol Tablet, 5mg; injection, 5mg/ml
B Phenobarbitone Tablet, 15-100 mg; elixir, 15mg/5ml
239
B Phenytoin Tablet or capsule, 25-100mg; injection, 50mg/ml
in 5ml vial (sodium salt)
A Thioridazine Tablet, 25mg, 100mg
6. ANTI-INFECTIVES
Anthelmintics
B Mebendazole Tablet (chewable), 100mg, 500mg
A Niclosamide Tablet (chewable), 500mg
6.2 Antibacterials
6.2.1 Beta lactams (penicillin based)
B Amoxycillin Capsule or tablet, 250mg, 500mg

(HIV*) (anhydrous); powder for oral suspension, 125mg
(anhydrous)/5ml
B Ampicillin Powder for injection, 500mg, 1g (sodium salt)

in vial
B Benzylpenicillin Powder for injection, 600mg (=1 million IU), 3g

(=5 million IU) (sodium or potassium salt)
B Cloxacillin Capsule, 250mg; syrup 125mg/ml; injection,

250mg/ml
A Flucloxacillin Capsule, oral solution, injection
B Phenoxymethylpenicillin Tablet, 250mg (as potassium salt); powder for oral

suspension, 250mg (as potassium salt)/5ml
6.2.2 Other antibacterials
A Amphoterin B Powder for injection

(HIV*) 200mg/5ml
A Azithromycin Capsule, 250mg, 500mg; suspension

(HIV*)
A Cefotaxime Injection, 500mg, 1g (as sodium salt) in vial
A Ceftriaxone Powder for injection, 250mg (sodium salt) in vial
B Chloramphenicol Capsule, 250mg; oral suspension, 125mg (as

palmitate)/5ml; powder for injection, 1g (sodium
240
succinate) in vial; oily suspension for injection,
0.5g (as sodium succinate)/ml in 2-ml ampoule
A Ciprofloxacin Tablet 250mg, 500mg (as hydrochloride)
A Clarithromycin Tablet, 250mg, 500mg (expensive)

(HIV*)
A Clindamycin Capsule, 150mg; injection, 150mg (as

(HIV*) phosphate)/ml
B Doxycycline Capsule or tablet, 100mg (hydrochloride)
A Erythromycin Capsule or tablet, 250mg (as stearate or ethyl

succinate); powder for oral suspension,
125mg/5mg (as stearate or ethyl succinate);
powder for injection, 500mg (as lactobionate) in
vial
A Gentamycin Injection, 10mg, 40mg (as sulphate)/ml in 2-ml

vial
A Nalidixic acid Tablet 250mg, 500mg
A Neomycin Cream, ear or eye ointment
A Ofloxacin Tablet, 200mg, 400mg
B Sulphamethoxazole+trimethoprim Tablet, 100mg+20mg, 400mg + 80mg;

(Co-trimoxazole, HIV*) oral suspension, 200mg + 40mg/5ml; injection,
80mg + 16mg/ml in 5-ml and 10-ml ampoules
B Tetracycline Capsule or tablet, 250mg
A Vancomycin Powder for injection, 250mg (as hydrochloride) in vial
6.2.3 Antileprosy medicines
B Dapsone Tablet, 25mg, 50mg, 100mg
B Rifampicin Tablet, 150mg, 300mg
6.2.4 Antituberculosis medicines
B Ethambutol Tablet, 100mg
B Isoniazid/Rifampicin Tablet, 75mg/150mg (junior strength);

150mg/300mg (adult strength)
B Pyrazinamide Tablet, 400mg
241
A Streptomycin Powder for injection, 1g (as sulphate) in vial
6.3 Antifungal
A Fluconazole Capsule 50mg; injection 2mg/ml in vial;

(HIV*) oral suspension 50mg/5ml
A Fluorocytosin Capsule, 250mg; infusion, 2.5g in 250ml

(HIV*)
B Griseofulvin Tablet, 125mg, 500mg
A Itraconazole Capsule, 100mg (expensive)

(HIV*)
A Ketoconazole Tablet, 200mg

(HIV*)
A Miconazole Topical cream, 200mg/g; oral gel

(HIV*) 20mg/g
B Nystatin Lozenges, oral suspension, ointment, pessaries
6.4 Antiviral medicines
6.4.1 Antiherpes
A Acyclovir Tablet, 200mg; powder for injection 250mg (as

sodium salt)
6.4.2 Antiretrovirals
A Abacavir Tablet, 300mg (as sulphate), oral solution, 100mg

(as sulphate)/5ml
A Efavirenz Capsule, 50mg, 100mg, 200mg
A Lamivudine Tablet, 150mg, oral solution 50mg/5ml
A Nevirapine Tablet, 200mg; oral suspension 50mg/5ml
A Stavudine Tablet, 40mg
A Zidovudine Tablet, 300mg; capsule 100mg, 250mg; oral

solution or syrup, 50mg/5ml; solution for iv
infusion, 10mg/ml in 20-ml vial
Anti-infective medicines for opportunistic diseases are listed under their respective groups, with indication – HIV*
A Acyclovir Tablet, 200mg; powder for injection 250mg (as
242
sodium) in vial
A Famciclovir Tablet, 125mg, 250mg, 500mg
A Foscarnet Injection, 24mg/ml
A Ganciclovir Injection, 500mg in vial
A Valaciclovir
A Valganciclovir
6.5 Antiprotozoal medicines
B Metronidazole Tablet, 200-500mg; injection, 500mg in 100-ml

vial; oral suspension 200mg (as benzoate)/5ml
6.6 Antimalarials
A Chloroquine Tablet, 100mg, 150mg (as phosphate or sulphate);

syrup, 50mg (as phosphate or sulphate)/5ml;
injection 40mg (as hydrochloride, phosphate or
sulphate)/ml in 5-ml ampoule
A Doxycycline Capsule or tablet, 100mg (hydrochloride)
A Primaquine Tablet, 7.5mg, 15mg (as diphosphate)

(HIV*)
A Pyrimethamine Tablet, 25mg

(HIV*)
A Quinine Tablet, 300mg (as bisulphate or sulphate);

injection 300mg (as dihydrochloride)/ml in 2-ml
ampoule
A Sulphadoxine + pyrimethamine Tablet, 500mg + 25mg

(Fansidar)
7 ANTIMIGRAINE MEDICINES
B Acetylsalicylic acid Tablet, 300mg
A Amitriptyline Tablet, 10mg, 25mg
A Carbamazepine Tablet, scored, 100mg, 200mg
A Dihydroergotamine Injection, 1mg/ml
243
A Ergotamine + caffeine Tablet, 1mg+100mg
B Ibuprofen Tablet, 200mg, 400mg
B Paracetamol Tablet, 500mg
A Propranolol Tablet, 20mg, 40mg, 80mg
8. ANTINEOPLASTIC AND IMMUNOSUPPRESIVE MEDICINES
Refer
9. ANTIPARKINSONISM MEDICINES
A Biperiden Tablet, 2mg (hydrochloride); injection, 5mg

(lactate) in 1-ml ampoule
A Levodopa + carbidopa Tablet, 100mg + 10mg; 250mg + 25mg
10. MEDICINES AFFECTING THE BLOOD
10.1 .............................................................................................Antianaemia medicines
B Ferrous sulphate Tablet, 200mg; mixture, 12mg/5ml
B Folic acid Tablet, 5mg
10.2 Medicines affecting coagulation
A Heparin Injection, 5000iu/ml
A Warfarin Tablet, 5mg
11. PLASMA SUBSTITUTES
A Iron dextran Injection 50mg/ml
12. CARDIO VASCULAR MEDICINES
Antianginal medicines
B Aspirin Tablet, 300mg
A Atenolol Tablet, 50mg, 100mg
A Atropine Injection, 0.5mg/ml, 1mg/ml
244
B Ferrous sulphate Tablet, 200mg
B Folic acid Tablet, 5mg
A Glyceryl trinitrate Tablet (sublingual), 500mcg
A Isosorbide dinitrate Tablet (sublingual), 5mg
B Paracetamol Tablet, 500mg
Antiarrhythmic medicines
A Adrenaline Injection, 1 mg/ml (as hydrochloride)

in ampoule
A Amiodarone Tablet, 100mg, 200mg;

injection,50mg/ml
A Atenolol Tablet, 50 mg, 100 mg
A Atropine Injection, 0.5mg/ml, 1mg/ml
A Diazepam Tablet, 2mg, 5mg
A Digoxin Tablet, 62.5 mcgs, 250 mcgs;

oral solution 50 mcgms/ml; injection
250 mcgms/ml in 2-ml ampoule.
A Imipramine Tablet, 25mg, 50mg
A Isoprenaline Tablet, 30mg, injection, 0.1mg/ml
A Lignocaine Injection, 2% (without preservative)
B Propranolol Tablet, 40mg
A Verapamil Tablet, 40mg, 80 mg (hydrochloride)
12.3 Antihypertensive medicines
A Amiloride Tablet, 5mg
A Atenolol Tablet, 50-100mg

A Captopril Tablet, 25mg, 50mg
A Dihydralazine Injection, 25mg
A Frusemide Tablet, 40mg; injection, 10mg/ml
245
A Hydralazine Tablet, 10mg, 50mg
B Hydrochlorthiazide Scored tablet, 25 mg
A Indapamide Tablet, 1.25mg, 2.5mg
A Magnesium sulphate Injection, 50%
A Methyldopa Tablet, 250 mg
A Nifedipine Tablet, 10mg sustained release
A Verapamil Tablet, 40 mg, 80 mg (hydrochloride); injection,

2.5 mg (hydrochloride)/ml in 2-ml ampoule
Medicines used in heart failure
A Adrenaline Injection, 1 mg/ml (as hydrochloride)

in ampoule
A Digoxin Tablet, 62.5 mcgs, 250 mcgs;

oral solution, 50 mcgs/ml;
injection, 250 mcgs/ml in 2-ml ampoule.
A Dobutamine Injection, 12.5mg/ml
A Dopamine Injection, 40mg/ml
B Hydrochlorthiazide Scored tablet, 25 mg
13. DERMATOLOGICAL MEDICINES
13.1 Antifungal medicines
B Benzoic acid + salicylic acid Ointment 6% + 3%
A Miconazole Ointment or cream, 2% (nitrate)
B Nystatin Ointment 100,000 iu/g
Anti-infective medicines
C Methylrosanilinium chloride Aqueous solution, 0.5%

(gentian violet)
A Neomycin sulphate + bacitracin Ointment, 5mg neomycin sulphate +
246
500 iu bacitracin zinc/g
B Potassium permanganate Aqueous solution 1:10,000
A Silver sulphadiazine Cream, 1%
Anti-inflammatory and antipruritic medicines
A Betamethasone Ointment or cream 0.1% (valerate)
C Calamine Lotion
A Hydrocortisone Ointment or cream, 1% (acetate)
A Sulphadiazine Tablet, 500mg; injection, 250mg

(HIV*) (sodium salt) in 4-ml ampoule
Medicines affecting skin differentiation and proliferation
A Benzoyl peroxide Lotion or cream, 5%
A Coal tar Solution, 5%
A Dithranol Ointment, 0.1%
A Fluorouracil Ointment, 5%
B Mepyramine Cream, 2g/100g
A Podophyllum resin Solution, 10-25%
A Urea Ointment or cream, 10%
13.5 Scabicides
B Benzyl benzoate Lotion, 25%
14. DISINFECTANTS AND ANTISEPTICS
14.1 Antiseptics
B Chlorhexidine Solution, 5% (digluconate) for dilution
C Ethanol Solution, 70% (denatured)
A Polyvidone iodine Solution, 10%
14.2 Disinfectants
A Chloroxylenol Solution, 4.8%
247
15. DIURETICS
A Frusemide Tablet, 40mg, injection, 10mg/ml
A Spironolactone Tablet, 25 mg
16. GASTROINTESTINAL MEDICINES
Antacids and other anti-ulcer medicines
B Aluminium hydroxide Tablet, 500mg; oral suspension, 320mg/5ml
A Cimetidine Tablet, 200mg, 400mg, injection
A Magnesium hydroxide Oral suspension, equivalent to 550mg magnesium

oxide/10ml
A Ranitidine Tablet, 150mg (hydrochloride); oral solution

75mg/5ml; injection, 25mg/ml in 2-ml ampoule
Antiemetics
A Metoclopramide Tablet, 10 mg (hydrochloride); injection, 5 mg

(hydrochloride)/ml in 2-ml ampoule
B Promethazine Tablet, 10mg, 25mg (hydrochloride); elixir or

syrup, 5mg (hydrochloride)/5ml
Laxatives
A Lactulose Syrup 3.3g/5ml
16.4 Antihaemorrhoidal medicines
B Haemorrhoidal suppositories Suppositories
16.5 Medicines used in diarrhoea
C Oral Rehydration Salts
17. HORMONES, OTHER ENDOCRINE MEDICINES AND CONTRACEPTIVES
17.1 Contraceptives
Hormonal
LPPA List
17.1.2 Barrier methods
C Condoms Male and Female condoms
248
Insulins and other antidiabetic agents
B Glibenclamide Tablet, 5mg
A Gliclazide (Diamicron) Tablet, 80mg
B Metformin Tablet, 500mg, 850mg
Insulin –
A Actrapid Injection
A Actraphane Injection
A Monotard Injection
Systemic hormonals, excluding sex hormones
A Carbimazole Tablet, 5mg

A Dexamethasone Tablet, 0.5mg; injection, 5mg/1ml
A Diethlylproprion Tablet 25mg (as hydrochloride)
B Hydrocortisone Injection, 100mg
A L-thyroxine Tablet, 100mcg (scored)
A Prednisone Tablet, 5mg
A Prozylthiomacil
18. VACCINES
A Human rabies immunoglobulin Injection
A Rabies vaccine Injection
A Tetanus toxoid Injection
19. MUSCLE RELAXANTS
A Suxamethonium Injection, 50mg (chloride)/ml in 2-ml ampoule
20. OPTHALMOLOGICAL PREPARATIONS
20.1 Anti-infective agents
B Chloramphenicol Eye drops, 0.5%, eye ointment, 1%
Miotics and antiglaucoma agents
A Acetazolamide Tablet, 250mg, injection, 500mg/ml
A Mannitol Infusion, 20%
A Pilocarpine Eye drops, 2%, 4%
A Timolol Eye drops, 0.5%
249
20.3 Mydriatrics
A Atropine Eye drops 0.1%, 0,5%, 1% (sulphate)
21. OXYTOCICS AND ANTIOXYTOCICS
Oxytocics
B Ergometrine Injection 0.5mg/ml (as maleate)
A Fenfluramine Tablets 20mg, 40mg; sustained release capsule

60mg
21.2 Antioxytocics
A Salbutamol Tablet, 4mg (as sulphate); injection, 50mcg (as

sulphate)/ml in 5-ml ampoule
22. PSYCHOTHERAPEUTIC MEDICINES
A Amitryptyline Tablet, 25 mg (hydrochloride)
A Artane Tablet 5mg
A Benzhexol Tablet 5mg
A Biperiden Injection 5mg/ml
A Carbamazepine Scored tablet, 100 mg, 200 mg.
A Carbidopa Tablet 25mg (in combination with

levodopa)
A Chlordiazepoxide Capsule, 10mg
A Chlormethiazole Capsule, 192mg
A Chlorpromazine Tablet, 100 mg (hydrochloride); syrup, 25

mg (HCl)/5ml; injection, 25 mg (HCl)/ml
in 2-ml ampoule.
A Clonazepam Tablets, 0.5mg, 1mg, 2mg; drops

2.5mg/ml; injection 1mg/ml
A Dihydroergotamine Injection 1mg/ml (as mesylate)
A Ergotamine Tablet 2mg (as tartrate)
A Fluphenazine Injection, 2 mg, (decanoate or enantate)

in 1-ml ampoule.
A Haloperidol Tablets, 1.5mg, 5mg; injection
250
5 mg in 1-ml ampoule
A Imipramine Tablets, 25mg, 50mg
A Levodopa Tablet 100mg, 250mg (in combination

with carbidopa)
B Phenytoin Tablet 50mg, 100mg; oral liquid

30mg/5ml
A Sodium valproate Tablet 200mg, oral liquid 200mg/5ml
A Thioridazine Tablets, 25mg, 100mg
A Tryptyline
23. MEDICINES ACTING ON THE RESPIRATORY TRACT
A Aminophylline Tablets 100mg, 200mg; injection

25mg/ml
B Hydrocortisone Injection 100mg
A Phenobabitone Tablets 8mg, 15mg; elixir 15mg/5ml;

injection 30mg/ml
A Potassium iodide Tablet 130mg; oral solution 500mg/ml;

syrup 325mg/5ml
A Prednisone Tablet 5mg
B Salbutamol Tablets 2mg, 4mg; syrup 2mg/5ml;

inhaler 100mcg/inhalation; nebuliser
solution 5mg/ml
A Theophylline Tablet, 100 mg, 200 mg, 300 mg
24. SOLUTIONS CORRECTING WATER, ELECTROLYTE AND ACID-BASE

DISTURBANCES
ORAL
A Calciferol Capsule / tablet 50,000 iu
A Magnesium sulphate Injection 0.5mg/ml
C Oral Rehydration Salts (ORS) Sachet
A Potassium chloride Powder for solution
251
A Sodium bicarbonate Injection 8.4%, infusion 4.2%
Parenteral
B Glucose Injectable solution, 5%, 10% isotonic;

50% hypertonic
24.3 Miscellaneous
B Tetanus human immunoglobulin
B Water for injection 2-ml, 5-ml, 10-ml ampoules
25. VITAMINS AND MINERALS
B Folic acid Tablet 5mg
A Folinic acid Tablet, 5mg, 10mg, 15mg, 25mg;

(HIV*) injection, 3mg/ml, 5mg/ml
B Vitamin A Tablet / capsule 100,000 iu
B Vitamin B12 Injection 1mg/ml
B Vitamin K1 Tablet 10mg; injection 1mg/0.5ml,

10mg/ml
SPECIALIST DRUGS ONLY

Antibacterials
A Ofloxacin Tablet, 200mg, 400mg
2. ANTINEOPLASTIC AND IMMUNOSUPPRESIVE MEDICINES
2.1....................................................................................Immunosuppresive medicines
A Azathioprine Tablet, 50mg; powder for injection,

100mg (as sodium salt) in vial
A Cyclosporin Capsule, 25mg;
Cytotoxic medicines
A Chlorambucil Tablet, 2mg
A Fluorouracil Injection, 50mg/ml in 5-ml ampoule
A Mercaptopurine Tablet, 50mg
A Methotrexate Tablet, 2.5mg (as sodium salt); powder

for injection, 50mg (as sodium salt) in vial
252
A Vinblastine Powder for injection, 10mg (sulphate) in
vial
A Vincristine Powder for injection, 1mg, 5mg (sulphate)

in vial
CARDIO VASCULAR MEDICINES
Antianginal medicines
3.2 Antihypertensive medicines

DIURETICS
A Spironolactone Tablet, 25 mg
5. GASTROINTESTINAL MEDICINES
Antacids and other anti-ulcer medicines
A Omeprazole Capsule, 20 mg
6. OPTHALMOLOGICAL PREPARATIONS
6.1 Miotics and antiglaucoma agents
A Timolol Eye drops, 0.5%
253

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S TA N D A R D T R E A T M E N T G U I D E L I N E S

ESSENTIAL MEDICINES LIST

1. Mrs T Khetsi Ministry of Health & Social Welfare

2. Mrs M Ntšekhe Ministry of Health & Social Welfare

3. Dr M Moteetee Ministry of Health & Social Welfare

1. Mrs T Khetsi Ministry of Health & Social Welfare

2. Mrs M Ntšekhe Ministry of Health & Social Welfare

3. Dr M Moteetee Ministry of Health & Social Welfare

4. Ms M Tiheli Ministry of Health & Social Welfare

5. Ms N Hoohlo National University of Lesotho

May God bless you all.

CHAPTER 2: NOTIFIABLE DISEASES

2.1. IMMUNISATION SCHEDULE .................................................................................................16

CHAPTER 3: TREATMENT GUIDELINES FOR SICK CHILDREN

3.1. MEASLES ..............................................................................................................................18

3.2. DIPHTHERIA .........................................................................................................................19

3.3. PERTUSSIS (WHOOPING COUGH) ........................................................................................20

3.4. TETANUS ..............................................................................................................................21

3.5. RABIES .................................................................................................................................22

3.6. TYPHOID FEVER...................................................................................................................23

3.7. POLIOMYELITIS ...................................................................................................................24

3.8. MUMPS .................................................................................................................................25

3.9. RUBELLA (GERMAN MEASLES) ...........................................................................................26

3.10. CHOLERA .............................................................................................................................26

3.11. PLAGUE ................................................................................................................................27

3.12. VIRAL HAEMORRHAGIC FEVER ..........................................................................................27

CHAPTER 4: RESPIRATORY CONDITIONS

1. CHEST PAIN ........................................................................................................................29

2. COMMON COLD AND INFLUENZA...............................................................................30

7. PULMONARY TUBERCULOSIS ......................................................................................39

CHAPTER 5: CARDIOVASCULAR CONDITIONS

1. ACUTE BREATHLESSNESS/DYSPNOEA ......................................................................45

3. HEART FAILURE IN CHILDREN....................................................................................48

4. PULMONARY EMBOLISM ...............................................................................................49

6. INFECTIVE ENDOCARDITIS ..........................................................................................52

8. CYANOTIC HEART DISEASE IN THE NEWBORN.....................................................55

9. CONGENITAL HEART DISEASE IN ADULTS..............................................................55

10. CARDIAC ARHYTHMIAS/DYSRHYTHMIAS.............................................................56

12. MALIGNANT HYPERTENSION.....................................................................................61

13. PULMONARY OEDEMA .................................................................................................62

CHAPTER 7: GASTROINTESTINAL CONDITIONS

1. GASTRO-ENTERITIS: INFECTIVE AND TOXIC.........................................................68

3. NON VIRAL HEPATITIS ...................................................................................................71

5. PEPTIC ULCER DISEASE .................................................................................................74

CHAPTER 8: GENITOURINARY CONDITIONS

1. URINARY TRACT INFECTION .......................................................................................84

4. NEPHROTIC SYNDROME ................................................................................................83

6. CHRONIC RENAL FAILURE ...........................................................................................86

CHAPTER 9: SEXUA LLY TRAN SMITT E D IN FECTION S AN D HIV/A I DS

1. SEXUALLY TRANSMITTED INFECTIONS ..................................................................88

3. MANAGEMENT OF OPPORTUNISTIC INFECTIONS ................................................94

3.1. BACTERIAL RESPIRATORY INFECTION ..............................................................................94

CHAPTER 10: CENTRAL NERVOUS SYSTEM DISORDERS

5. MOVEMENT DISORDERS-CHOREA, HEMIBALLISMUS, MYOCLONUS ANDDYSTOPIA

9. SUBACUTE MENINGITIS ..................................................................................................113

10. PERIPHERAL NEUROPATHY ........................................................................................114

11. ACUTE POST-INFECTIOUS NEUROPATHY ..............................................................115

CHAPTER 11: METABOLIC DISORDERS